Critical Ischemia Of Lower Extremities Research Articles

The application of cell products for the treatment of critical limb ischemia in patients with diabetes mellitus: a review of the literature

The number of patients with diabetes mellitus (DM) has been progressively increasing worldwide over the past decades, and many international organizations consider DM as a public health emergency of the 21st century.Critical limb ischemia (CLI) is the most severe stage of peripheral arterial disease (PAD) in DM and is characterized by a high risk of limb loss without revascularization. Traditional treatment tactics include open and endovascular revascularization surgical techniques. However, in patients not eligible for revascularization and in cases where performed surgical treatment performed has been ineffective, there are almost no therapeutic alternatives, often leading to amputations and death. As of today, one of the newest non-surgical treatment options is cell therapy. Among different cells, mesenchymal stromal cells (MSCs) are potentially one of the most prospective for use in this patient population.This article provides an overview of clinical trials using cell therapy in patients with CLI.To analyze publications, electronic databases PubMed, SCOPUS, ClinicalTrials, and ScienceDirect were searched to identify published data from clinical trials, research studies, and review articles on cell therapy for critical lower extremity ischemia. After the search, 489 results were received.As a result of systematic selection, 22 clinical trials were analyzed.According to the analyzed literature data, the use of cell products in this category of patients is effective and safe. Cell therapy can stimulate the formation of new vessels and enhances collateral circulation; it is also reported improved distal perfusion, increased pain-free walking distance, decreased amputation rates, and increased survival rates.Nevertheless, further study of the potential use of this category of drugs is needed.

Predictive model for novel subtypes of patients undergoing lower extremity amputation for peripheral artery disease: An unsupervised machine learning study

BackgroundPeripheral artery disease (PAD) represents the frequently seen circulatory condition related to a risk of critical limb ischemia and amputation. Critical lower extremity ischemia may require amputation, and the outcomes vary. In this study, we developed an artificial intelligence (AI)-driven predictive model for PAD subtypes to assess risk among patients more precisely and accurately to predict disease progression. MethodsThe present retrospective study examined clinical data in PAD patents undergoing lower extremity amputation. The data were analyzed using an unsupervised machine learning algorithm (UMLA) for subgroup identification and risk stratification. The clustering result accuracy was validated by analyzing the follow-up data of clusters. Finally, we built the prediction model with binary logistic regression. ResultsIn total, we enrolled 507 cases into this work. Two distinct subgroups, consisting of Clusters 1 and 2, were identified by UMLA; those from Cluster 1 showed markedly poorer conditions and prognostic outcomes compared with those from Cluster 2. With regard to the new PAD subtype, we established a nomogram with eight predictive factors, including gender, age, smoking history, diabetes and coronary heart disease history, albumin levels, endovascular intervention, and amputation level. The nomogram could accurately categorize patients into two identified clusters, and the area under receiver operating characteristic curve was 0.861 (95 % confidence interval: 0.830–0.893). ConclusionIn this study, UMLA was used to identify new phenotypic subgroups among PAD cases who showed different risks of amputation. Our constructed AI-driven predictive model for PAD subtypes showed that it can be used for risk stratification and clinical management with high accuracy and reliability.

Balloon angioplasty and stenting of lower extremity arteries in patients with critical limb ischemia

Lower extremity peripheral vascular disease is a typical, rapidly progressive, and disabling condition. In most patients, limb ischemia is detected at late stages of the disease. As a result, they are at high risk of limb loss, which makes a complete conventional treatment ineffective. In this situation, balloon angioplasty and stenting of lower extremity ar- teries are considered the optimal modern method of treating patients with critical limb ischemia. This study aims to evaluate the effectiveness of endovascular techniques to improve revascularization during the treatment of critical lower extremity ischemia. The research involved a comprehensive examination and endovascular treatment of 170 patients with occlusive-stenotic lesions of the lower extremity arteries. The patients were operated for critical ischemia between January 2016 and December 2022, and the effectiveness of the measures taken was analyzed. It was found that the pathology under the study requires timely diagnosis and identification of the severity of limb ischemia and circulatory disorders, with the subsequent preparation of an appropriate treatment plan. The authors discussed the main problems accompanying balloon angioplasty and stenting of the lower extremity arteries in patients with critical limb ischemia. Also, the experience of developed countries in the optimization and improvement of the studied tech- nique was studied. It has been proven that the diagnosis of lower extremity vascular disease is related to specific difficulties. However, it can be made on an outpatient basis by analyzing medical examination data and simple labor- atory methods. The authors also examined the feasibility and prospects of balloon angioplasty and stenting of the lower extremity arteries in patients with critical limb ischemia. The re-search findings have a practical value for improving the treatment of patients with occlusive and stenotic lesions of the lower extremities, as well as for improving the effec-tiveness of balloon angioplasty and stenting.

Femorodistal bypasses using venous “cuffs”

Background/Aim. Although distal venous patch and cuff techniques are recommended to improve the patency of by-pass in the lower extremities, the advantage of these techniques remains unproven. Autovenous bypass graft remains the method of choice, but when there is no possibility of using the great saphenous vein, the venous cuff method may have an advantage. The aim of this study was to evaluate the results of femorodistal bypass procedures with a venous cuff in critical lower extremity ischemia. Methods. The study described the results of femorodistal bypass procedures after a follow-up period of 6 to 24 months. We followed 28 patients with distal composite anastomosis of femorodistal arterial reconstruction. Indications for surgical treatment were set on the basis of the clinical exam and morphological criteria based on multidetector computed tomographic angiography. Three types of distal graft-arterial anastomoses were applied: Miller?s cuff, Taylor?s patch, and St. Mary?s vein boot anastomosis. Results. After 6 months of surgery, all bypasses were passable; after one year, 2 (7%) patients had graft occlusion and above-knee amputation, and 8 (28%) patients died; after 24 months, 18 (64%) patients had primary bypass patency. Conclusion. Femorodistal bypass procedures using a synthetic graft and venous cuff have good long-term results. The optimal anastomosis type is St. Mary?s boot. A longer follow-up period and comparison with the autovenous bypass are necessary for a more detailed assessment of the final conclusion.

Dynamika pokaznykiv yakosty zhyttia u khvorykh na infarkt miokarda z krytychnoiu ishemiieiu nyzhnikh kintsivok pid vplyvom kompleksnoho likuvannia z vykorystanniam arhinin-karnitynovoi sumishi ta standartnoho protokolnoho likuvannia

Introduction. The presence of critical lower extremity ischemia (CLEI) in patients with acute coronary syndrome (ACS) limits the possibility of early invasive interventions and determines the tactics of medical preparation for surgery and prevention of complications. The aim of the study. To assess the dynamics of life quality using the EQ-5D-5L questionnaire in patients with myocardial infarction (MI) in combination with obliterative atherosclerosis of the main vessels at the stage of critical lower extremity ischemia and high risk of cardiac complications in the inpatient phase of treatment under the influence of metabolic therapy. Materials and methods. 67 patients with ACS (MI) in combination with CLEI due to stenotic atherosclerosis of the iliac-femoral arterial segment were examined: 35 patients of the main group who underwent emergency balloon angioplasty and infarct-dependent coronary artery stenting in addition with L-arginine/L-carnitine complex (“TIVOR-L”; “Yuri-Pharm”; in the form of intravenous infusions for seven days of 100.0 ml once / day). 32 patients in the comparison group received only standard protocol treatment. All patients, in addition to general clinical, laboratory and instrumental methods, were additionally assessed for quality of life according to the EQ-5D-5L questionnaire. Statistical processing of indicators was performed by the method of variation statistics. Samples were checked for normality of data distribution according to the test of S. Shapiro – M. Wilk, parametric (t-test, Student’s test) methods were used. Confidence interval (CI) and relative risk (RR) were used to more accurately assess the accuracy. Results. In patients of both groups, the severity of the clinical condition did not differ significantly and was due to typical manifestations of ACS and CLEI. In patients of the main group, the use of intravenous infusions of arginine-carnitine mixture against the background of the standard protocol treatment program led to the elimination of anginal syndrome in all patients and reduced functional class of acute heart failure. When evaluating the effectiveness of the proposed combination treatment and its subjective perception by patients, it was found that initially patients of both groups evaluated their quality of life with similar relatively low scores: an average of 26.14 ± 10.15 and 25.68 ± 9.74 points (p-value more than 0.05). We note a significantly higher assessment of quality of life in patients after a course of comprehensive treatment, whose quality of life index improved by an average of 160.9 % and reached the level of 86.5 ± 8.3 points. During the standard treatment program in patients with ACS in combination with CLEI there was a significant improvement in well-being, the total quality of life index increased by 40.2 %. Сonclusions. Patients in the experimental group with acute coronary syndrome and critical lower extremity ischemia who received arginine-carnitine mixture in addition to complex standard protocol drug treatment had significantly reduced feelings of chest pain/discomfort and anxiety / depression and tended to increase motor activity.

Prevention of erosive and ulcerative gastroduodenal bleeding in patients after endovascular surgery on the arteries of the lower extremities for critical ischemia

The OBJECTIVE was to evaluate methods for the prevention of gastrointestinal bleeding in patients after endovascular surgery on the arteries of the lower extremities for critical ischemia.METHODS AND MATERIALS. The study included 188 patients treated in the vascular surgery department of A. A. Polyantsev General Surgery Clinic of Volgograd State Medical University for obliterating atherosclerosis of the arteries of the lower extremities in the period from 2017 through 2021.RESULTS. There was a relationship between the indicator that the patient indicated independently – the number of painkillers taken per day to reduce pain, and erosive and ulcerative lesions of the stomach and duodenum in both groups. The increasing number of operations with critical lower extremity ischemia (СLEI) and the expected decrease in the number of amputations indicates the increased capabilities of vascular and X-ray endovascular surgeons in preserving the extremity and ultimately the life of patients with decompensated forms of obliterating lesions of the extremities. This group of patients had a large number of perioperative complications from various organs and systems, including a high probability of gastrointestinal bleeding.CONCLUSION. An increased risk group for the occurrence of gastrointestinal bleeding (GIB): patients with repeated reconstructions, surgical corrections of complications or amputations at various levels, as well as taking anticoagulants in therapeutic dosage. Long-term routine prevention of acute erosive and ulcerative lesions of the stomach and duodenum, gastrointestinal bleeding with proton pump inhibitors is not acceptable for this group of patients. It is necessary to have a complex effect on the factors of aggression – the exclusion of the use of NSAIDs, total eradication.

Development of a Fuzzy Diagnostic Model of Ischemic Disease of the Lower Limbs for Different Stages of Patient Management.

Ischemic disease has severe impact on patients which makes accurate diagnosis vital for health protection. Improving the quality of prediction of patients with ischemic extremity disease by using hybrid fuzzy model allows for early and accurate prognosis of the development of the disease at various stages. The prediction of critical ischemia of lower extremity (CLI) at various disease stages is complex problem due to inter-related factors. We developed hybrid fuzzy decision rules to classify ischemic severity using clinical thinking (natural intelligence) with artificial intelligence, which allows achieving a new quality in solving complex systemic problems and is innovative. In this study mathematical model was developed to classify the risk level of CLI into: subcritical ischemia, favorable outcome, questionable outcome, and unfavorable outcome. The prognosis is made using such complex indicators as confidence that the patient will develop gangrene of the lower extremity (unfavorable outcome), complex coefficient of variability, and reversibility of the ischemic process. Model accuracy was calculated using representative control samples that showed high diagnostic accuracy and specificity characterizing the quality of prediction are 0.9 and higher, which makes it possible to recommend their use in medical practice.

Auto-venous femoral-popliteal bypass in patients with critical lower extremity ischemia and coronary heart disease associated with diabetes melitus

Аim — to improve the results of treatment of patients with atherosclerotic lesions of the arteries of femoral-popliteal segment, who underwent auto­venous femoral-popliteal bypassgrafting.Materials and methods. During the period of years 2018 to 2021, 34 patients with critical ischemia of the lower extremities underwent autovenous shunting with a reversed great saphenous vein with treatment of the inner surface of the vein with a solution of cytostatics (paclitaxel). Besides, the treatment was analysed in two control groups, who underwent autovenous reverse vein shunting (30 patients) and autovenous in-situ shunting (33 patients). The follow-up periods lasted for 24 months. The evaluation criteria included the cases of shunt thrombosis, shunt stenosis, mortality, serious ischemic events — acute lower extremity ischemia, myocardial infarction, ischemic stroke, cases of high amputations of the lower extremities.Results. In the postoperative period, no deaths were observed; absence of complicationswas registered in 96 (98 %) patients. In the main group, the frequency of shunt thrombosis was 5 (14.7 %), hemodynamically significant restenosis was diagnosed in 6 patients (17.6 %), acute myocardial infarction in 1 patient (2.9 %). In the comparison group, 11 cases of autovenous shunt thrombosis were defined.Conclusions. Our clinical experience showed promising short- and medium-term results. The chosen surgical approach and topical application of cytostatic drugs enabled to achieve long-term patency of venous shunt, which is of particular importance for patients with diabetes mellitus.

Treatment of patients with occlusive-stenotic diseases of the arteries by endovascular method

Annotation. The case of successful treatment of a patient with critical lower extremity ischemia illuminates the possibilities of different approaches of the endovascular surgical method. The results of treatment of patients with occlusive-stenotic diseases of the lower extremities arteries as a result of obliterating atherosclerosis were analyzed. 243 patients underwent endovascular surgery. 14 (5.76%) patients were previously operated on. The multi-storey lesions were found in 35 (14.4%) cases. Most patients were ranged in age from 46 to 86 years. There were 175 men (72.0%) and 68 women (28.0%). The right lower extremity was affected more often – 148 (60.9%) patients than the left ones – 95 (39.1%). The thrombosis was diagnosed in 21 (10.6%) individuals as the most common complications in the early postoperative period. Limb amputation was performed in 12 patients. Mortality rate in the early postoperative period was 2.56% (4 patients died). It is established that the methods of choice in the reconstruction of stenotic-occlusive lesions of the arteries are: balloon angioplasty (and stenting), rotor-mechanical thromboaspiration, regional thrombolytic therapy. These methods are performed mainly under local anesthesia, they are minimally invasive and can be used in patients with severe comorbidities.

The state of lipid exchange, hemostasis, inflammatory reaction and potentials for their correction in indirect revascularization in patients with critical ischemia of lower extremities (a correlation statistical analysis)

Aim:to study the state of lipid metabolism, hemostasis, inflammatory reaction and the potential for their correction after indirect revascularization in patients with distal steno-occlusion of arteries and critical ischemia of lower extremities (critical ILE).Material and methods.Changes in hemostasis and dynamics of its parameters during the complex surgical treatment in 131 patients with critical ILE and distal arterial stenoocclusion were analyzed. To achieve the targeted goals, patients were divided into the following groups: 34 patients had traditional care (control group); 32 patients had intravenous laser blood irradiation in combination with standard therapy (Group I); 32 patients had cytokine therapy with roncoleukin in combination with standard therapy (Group II); 33 patients had intravenous laser blood irradiation combined with cytokine therapy and standard therapy (Group III). Parameters of lipid metabolism were studied in dynamics (total cholesterol, very low density lipoproteins, high density lipoproteins, triglycerides); products of lipid peroxidation (malondialdehydes, conjugates, superoxide dismutase); inflammatory mediators (C-reactive protein, sialic acids, seromucoids, fibrinogen A, circulating immune complexes); hemostatic parameters (fibrinogen, fibrinolytic activity, fibrin degradation products, antithrombin III activity). Hemostatic indices were compared with identical parameters of 48 apparently healthy individuals (reference group).Results.On admission, patients with critical ILE and distal wall occlusion had sharp changes in their lipid metabolism, inflammatory reaction, and hemostasis. Conclusion. The inclusion of intravenous laser blood irradiation and cytokine therapy separately and in combination in a set of therapeutic measures led to the leveling of the studied homeostasis indicators. The best results were obtained in the group where patients had combined perioperative intravenous laser blood irradiation with cytokine therapy in indirect revascularization.

Correction of hemostasis and hemorheology with intravenous laser blood irradiation and cytokinotherapy in indirect revascularization at the perioperative period in patients with critical ischemia of their lower extremities

Purpose . To study potentials for correcting hemostasis and hemorheology with intravenous laser blood irradiation (ILBI) and cytokine therapy (CT) in indirect revascularization at the perioperative period in patients with critical ischemia of lower extremities. Material and methods . A prospective controlled clinical trial included 162 patients with critical lower limb ischemia (CLLI) having distal arterial steno-occlusion who had indirect revascularization surgery. CLLI etiological factors were: obliterating atherosclerosis in 108 (66.7%) patients and obliterating thromboangiitis in 54 (33.3%) patients. 56 patients had chronic ischemia of degree III; 106 patients – chronic ischemia of degree IV. All patients were divided into 5 groups who had various curative modalities at their perioperative period: Group I (n = 34) –standard treatment; Group II (n = 32) – standard treatment + ILBI; Group III (n = 32) – standard treatment + CT with Roncoleukin; Group IV (n = 33) – standard treatment + ILBI + CT; patients from Group V (n = 31) in revascularizing osteotrepanation had intraosseous marrow laser irradiation (IOLI) – standard treatment + ILBI + CT. The researchers also studied dynamics of hemostatic parameters (fibrinogen – F, fibrinolytic activity – FA, fibrin degradation products – PDF, activity of antithrombin-III, plasminogen – P) and hemorheology (erythrocyte deformability – DE, von Willebrand factor – WF, ADP induced platelet aggregation). The obtained hemostasis and hemorheology findings were compared with identical parameters of 48 practically healthy subjects («reference group»). Results . On admission, patients with CLLI in distal steno-occlusion had a sharp change in their hemostasis formula shifting towards hypercoagulation and deterioration of hemorheology. ILBI and CT techniques applied either separately or in combination with other therapeutic measures in the perioperative period of indirect revascularization normalized parameters of blood coagulation system (for all parameters – p < 0.05; r = 0.4) and of hemorheology (for DE – p < 0.05; r = 0.4; for WF and ADP-induced platelet aggregation – p < 0.05; r = 0.3). The best results were obtained under the combination of ILBI and CT at the perioperative period of indirect revascularization, especially in revascularizing osteotrepanation with IOLI. Conclusion . ILBI and CT applied in combination with standard treatment at the perioperative period in indirect revascularization reliably correct hemostasis and hemorheology in patients with CLLI and distal arterial steno-occlusion.

Evaluation of the Efficacy of Surgical Treatment of Patients With Chronic Critical Ischemia of Lower Extremities at the Stage of Trophic Complications

Relevance. Chronic critical ischemia of the lower extremities (CCILE) in the stage of trophic complications is the final stage of diseases of the arteries of the lower extremities, leading to disability of patients and having a poor prognosis in terms of preservation of the lower extremities and mortality.Aim of study. Objective assessment of the efficacy of lower limb revascularization in trophic disorders.Material and methods. The analysis of treatment of 52 patients with stage IV CCILE (according to the classification of R. Fontaine and A.V. Pokrovsky) was carried out. Of these, 42 patients underwent three-phase scintigraphy combined with X-ray computed angiography on a hybrid apparatus. After the operation, this study was conducted in 37 patients.Results. Out of 52 patients, surgery for revascularization of the lower extremities was performed in 37 patients, 15 were not operated on. Out of 37 operated patients, improvement of blood circulation occurred in 32 (86.5%). Circulatory decompensation was observed in 5 patients (9.7%). Among non-operated patients, improvement of blood circulation occurred in 9 patients (17.3%), no effect or decompensation — in 5 (9.7%). Subjective improvement in the condition and decrease in the degree of ischemia corresponded to the improvement of microcirculation according to the data of three-phase scintigraphy.Conclusion.1. Revascularization of the lower extremities in patients with trophic disorders is an effective method of treating this pathology. Therefore, all patients with chronic ischemia threatening limb loss should be considered as candidates for revascularization.2. If the leg arteries or short occlusive or stenotic lesions of the main arteries are affected, such patients should be discussed together with specialists in endovascular surgery for endovascular treatment or joint intervention.3. Hybrid radiation method (three-phase scintigraphy and single-photon emission computed tomography, combined with X-ray computed angiography) is an objective method that reflects the state of peripheral circulation and microcirculation, and allows you to objectively assess the effectiveness of the treatment.

Results of surgical treatment in patients, suffering diabetes mellitus and chronic critical ischemia of lower extremity, taking into account the data of intraoperative debitometry

Objective. To analyze the results of surgical treatment of patients, suffering diabetes mellitus, ischemic form of diabetic foot syndrome and chronic critical ischemia of the lower extremity, caused by stenotic-occlusive affection of femoral arterial and popliteo-tibial segments, taking into account the data of intraoperative debitometry.&#x0D; Materials and metods. Results of surgical treatment were analyzed in 67 patients, suffering diabetes mellitus Type II, ischemic form of diabetic foot syndrome and chronic critical ischemia of the lower extremity, caused by stenotic-occlusive affection of femoral arterial and popliteo-tibial segments in 1 and 12 mo. In all the patients a femoro-popliteal shunting without intervention on the popliteo-tibial segment was performed. In accordance to the results obtained during intraoperative debitometry, the patients were distributed into three Groups: Group I - 22 patients with the shunt debit more than 60 ml/min, Group II - 25 patients with the shunt debit 30-60 ml/min, and Group III - 20 patients with the shunt debit lesser than 30 ml/min. In thrombosis of primary zone of arterial reconstruction a reoperation was conducted - a hybrid arterial reconstruction of the popliteo-tibial (thrombectomy from shunt and the balloon angioplasty) segment arteries.&#x0D; Results. In a Group I (n=22) a primary passability of the arterial reconstruction zone in 1mo was observed in 20 (90.9%), and in 12 mo - in 17 (77.3%) patients; in Group II (n=25) - accordingly, in 19 (76%) and 14 (56%) patients; in Group III (n=20) - accordingly, in 9 (45%) and 4 (20%).&#x0D; Thronbosis in the arterial reconstruction zone was diagnosed during a year in 32 patients, of them during first month after primary shunting - in 19 (59.4%), during further 11 mo - in 13 (40.6%) patients. After reoperation for thrombosis of the arterial reconstruction zone, consisting of a hybrid arterial reconstruction, secondary passability of the arterial reconstruction zone during 12 mo was observed in 24 (75%) of 32 patients. While restoration of outflow from popliteal artery into one tibial artery (n=23) during 12 mo a rethrombosis of the arterial reconstructive zone have occurred in 7 patients, secondary passability of the arterial reconstruction zone during 12 mo was observed in 16 (69.6%) patients. While restoration of outflow from popliteal artery into two tibial arteries (n=9) during 12 mo rethrombosis of the arterial reconstruction zone have occurred in 1 patient, secondary passability of the arterial reconstruction zone during 12 mo was observed in 8 (88.9%) patients.&#x0D; Conclusion. In combined stenotic-occlusive affection of femoral arterial segment and arteries of popliteo-tibial segment the isolated restoration of passability and femoral arterial segment without intervention on arteries of popliteo-tibial segment necessitates taking into account the intraoperative debitometry data with determination of the shunt debit constitutes an effective diagnostic method, the data of which may help to adjust a differentiated approach to tactics of surgical treatment in patients, suffering diabetes mellitus, chronic critical ischemia of the lower extremity, caused by stenotic-occlusive affection of femoral arterial segment and arteries of popliteo-tibial segment.&#x0D; The shunt debit bordering value, in presence of which the isolated restoration of the femoral arterial segment passability is possible, constitutes the indices higher than 60 ml/min, further intervention on the popliteo-tibial segment arteries is indicated only in the patients with the shunt thrombosis; while in the shunt debit 30-60 ml/min a reconstruction stage of the popliteo-tibial segment arteries after restoration of the femoral arterial segment passability may be postponed and performed on second stage of the procedure; while the shunt debit lesser than 30 ml/min - a simultaneous reconstruction of femoral segment and of the popliteo-tibial arteries, using performance of a hybrid arterial reconstruction, is necessary. The last is effective method of restoration of blood circulation in patients, suffering diabetes mellitus and chronic critical ischemia of the lower extremity, caused by stenotic-occlusive affection of femoral arterial segment and arteries of popliteo-tibial segment, and in accordance to the results adduced (index of the arterial reconstruction zone passability during 12 mo have constituted 75%) do not differ trustworthily from result of reconstruction of arterial segment in patients of Group I: the shunt debit more than 60 ml/min, while index of the arterial reconstruction zone passability during 12 mo constitutes 77.3% (p&gt;0.05).&#x0D; While thrombosis of primary zone of arterial reconstruction the addition of thrombectomy from the shunt by restoration of the main blood flow from popliteal into two tibial arteries, using the balloon angioplasty, demonstrates a trustworthy best index of secondary passability of the arterial reconstruction zone in 12 mo - 88.9%, comparing with index of secondary passability of the arterial reconstruction zone in 12 mo after restoration of the main blood flow from popliteal artery into one tibial artery - 69.6% (p&lt; 0.05).

Changes in homeostasis and some aspects of its correction after indirect revascularization in patients with distal wall-occlusion of the artery with critical ischemia of lower extremities

Changes in homeostasis and some aspects of its correction after indirect revascularization in patients with distal wall-occlusion of the artery with critical ischemia of lower extremities

Early outcomes of therapy and indirect revascularization surgery in patients with critical ischemia of lower extremities

To study the immediate results of therapy and indirect revascularization in patients with critical ischemia of the lower limbs. The results of medication and surgical treatment were analyzed in 210 patients with critical ischemia of the lower limbs. Atherosclerosis obliterans was diagnosed in 142 patients, thromboangiitis obliterans - in 68 patients. Lesion of femoropopliteal segment was observed in 32 (15.2%) cases, popliteal-tibial segment - 68 (32.8%) patients, tibial and foot segment - 62 (29.5%) cases, foot - 31 (14.8%) cases, multiple-level lesion - 17 (8.1%) cases. Survey consisted of Doppler ultrasound, CT angiography, rheovasography with analysis of rheographic index (RI) and pulse oximetry. Circulatory parameters were compared with identical values in 48 almost healthy persons ("reference group"). The results of medication and surgical treatment were evaluated by using of the scale of Rutherford R.B. et al. (1997). Conservative treatment was performed in 48 patients (control group). The following types of indirect revascularization operations were performed to stimulate regional circulation: bone trepanation in 42 patients, lumbar sympathectomy in 51 patients, bone trepanation + lumbar sympathectomy in 38 patients, bone trepanation with intraosseous irradiation in 31 cases. Indirect revascularization improves early postoperative outcomes, ensures maintaining support function of the limb and active lifestyle in patients with critical ischemia of the lower limbs. Technical simplicity of these procedures facilitates widespread introduction of indirect revascularization in multi-field hospitals.

The analysis of database of registered diseases of peripheral arteries in Yekaterinburg

The study was carried out to analyze database of registered diseases of peripheral arteries in patients of Yekaterinburg during 2009-2013. The database of the territorial foundation of mandatory medical insurance of the Sverdlovsk region in 2009-2013 was used as study material. The number of registered cases of treatment of diseases of peripheral arteries was analyzed. The sampling of patients with diseases of peripheral arteries taking treatment in twenty-four-hours and day-time hospitals. The statistical processing was applied to all cases ranged by years: patients with compensated blood circulation, critical ischemia of extremities and mortification. The audit was applied to randomly selected 40 medical records of patients with diseases of peripheral arteries, receiving treatment in twenty-four-hours and day-time hospitals during 2014 and 50 medical records ofpatients with diseases ofperipheral arteries against the background of diabetes mellitus from register of the oblast podiatry consulting room. The total number of treated patients with diseases ofperipheral arteries in Yekaterinburg during five years made up to 31,309, including 19% ofpatients with diabetic affection of lower extremities. In twenty-four-hours hospital 12,716 (40.6%) patients were treated and 18,593 (59.4%) were treated in day-time hospital. The study established increasing in day-time hospitals number of patients with arteriosclerosis obliterans up to 1.8 times, with diabetic angiopathy up to 3.6 times. At increasing of number of treated patients number ofpatients with critical ischemia of lower extremities during 5 years decreased insignificantly and number of large amputations have a certain trend to decreasing (up to 2.5%). The study established deviations under application of medicinal therapy in patients with diseases of peripheral arteries at pre-specialized stage and absence of achievement of target values of main laboratory parameters. The database of registered diseases of peripheral arteries can be used as a tool for data analysis and further management decision making with purpose of enhancing quality of medical care of patients residing in municipality.

Pathogenetic justification and clinical significance of using arginine for prevention of critical ischemia of lower extremities and fatal manifestations of multifocal atherosclerosis

The aim — to investigate the results of treatment with L‑arginine of patients with intermittent claudication for prevention of critical stages of limb ischemia.Materials and methods. 86 patients with intermittent claudication were randomly divided into two groups of 43 patients each. Patients of the first group received 8 g of L‑arginine (Tivortin) twice a day, patients of the second group — 40 mg of prostaglandin E1 (PGE1) twice a day.Results and discussion. Administration of L‑arginine contributed to an increase in the distance of painless walk by 230 ± 63 %, the absolute walk distance — by 155 ± 48 % (p < 0.05), the administration of PGE1 — by 209 ± 63 % and 144 ± 28 %, respectively (p < 0.05). Treatment with L‑arginine increased the value of the coefficient of L‑arginine/asymmetric dimethylarginine in plasma and the excretion of nitrates and cGMP in the urine, which indicated the normalization of the biosynthesis of endogenous NO. PGE1 therapy did not significantly affect endothelium‑dependent vasodilation parameters. The coefficient of quality of life, estimated in an analog scale, increased from 3.51 ± 0.18 to 8.3 ± 0.4 in the arginine group and to 7.0 ± 0.5 in the PGE1 group (all p < 0.05).Conclusions. Arginine is a drug of choice to prevention of severe forms of lower limbs ischemia and other manifestations of multifocal atherosclerosis.

Features of selection of anticoagulant therapy in patients with critical ischemia of lower extremities after reconstructive operations

Objective : to improve the results of treatment of patients with obliterating atherosclerosis with critical ischemia of the lower extremities by individual selection of anticoagulant therapy for the prevention of thrombosis aft er reconstructive surgery on the arteries of the lower extremities. Materials and methods: 82 patients were divided into 2 groups: 1 group (48 patients) - reconstructive surgery on the arteries of the lower extremities and anticoagulant therapy under the control of the coagulogram. 2 group (34 patients) - reconstructive operations with the selection of anticoagulant therapy with the help of hemostasiogram indicators and the T-2 thrombodynamics test. Results: Out of 48 patients in the 1 study group, a good eff ect was observed in 36 patients (75.00%), in 9 (18.75%) - satisfactory, and in 3 cases (6.25%) - unsatisfactory. In the 2nd group: good results - 33 (97.06%) patients, and in 1 (2.94%) patients - satisfactory. Unsatisfactory results were not. Th e number of repeated operations within 1 year, performed in the 1st group, was statistically signifi cantly 2 times greater than in the second group. All the second operations are associated with the development of thrombotic complications. With a combination of the majority of hemostasiogram and «Trombodynamics T-2» tests, the dose of heparin therapy was adjusted, increasing by 2500 units, i.е. the patient received 7500ED 4 p / day. If during the «T-2 thrombodynamics» and coagulogram on the 6th day aft er surgery, hypercoagulation was determined, then the dose of heparin increased again by 2500 units. Conclusions: Comparative analysis of hemostasiogram indices in the fi rst hours aft er the performed operative treatment is not very useful for predicting the frequency of thrombotic complications, while 6 days aft er operative treatment it indicates the presence of statistically signifi cant diff erences between the two study groups. Th at indicates a more adequate selection of a dose of heparin in the second group.

Microfibrillar-associated protein 4 variation in symptomatic peripheral artery disease

BackgroundSymptomatic peripheral artery disease (PAD) is an atherosclerotic occlusive disease affecting the lower extremities. The cause of symptomatic PAD is atherosclerosis, vascular dysfunctions, impaired angiogenesis and neointima formation. Microfibrillar-associated protein 4 (MFAP4) is an extracellular matrix protein, which is highly expressed in the heart and arteries and recently introduced as a potential mediator of pathological vascular remodeling and neointima formation. We aimed to investigate the relationship between serum MFAP4 (sMFAP4) and symptomatic PAD outcomes.MethodsA total of 286 PAD patients were analyzed if they had either intermittent claudication or critical lower-extremity ischemia (CLI) and followed for 7 years. The level of serum MFAP4 (sMFAP4) was measured by alphaLISA. Kaplan–Meier, Cox proportional hazard and logistic regression analysis were used to analyze the associations between upper tertile sMFAP4 and symptomatic PAD outcomes.ResultsPatients with upper tertile sMFAP4 had an odds ratio (OR) of 2.65 (p < 0.001) for having CLI diagnosis. Further analysis indicated that patients with upper tertile sMFAP4 had a hazard ratio (HR) of 1.97 (p = 0.04) for cardiovascular death during the 7-years follow-up. However, analysis of 2-year primary patency showed that patients with upper tertile sMFAP4 had decreased risk of vascular occlusion after reconstructive surgery with HR of 0.15 (p = 0.02).ConclusionssMFAP4 has potential as a prognostic marker for cardiovascular death, primary patency of reconstructed vessels and CLI diagnosis in symptomatic PAD patients. Confirmation of observations in larger cohorts is warranted.

A clinical case of endovascular treatment of a patient with chronic arterial insufficiency of the brain with critical ischemia of lower extremities

A clinical case of endovascular treatment of a patient with chronic arterial insufficiency of the brain with critical ischemia of lower extremities