Critical Lower Limb Ischemia Research Articles

CRITICAL LIMB ISCHEMIA. A LITERATURE REVIEW (PART 2)

Critical lower limb ischemia (CLI) is the final stage of peripheral arterial disease and occurs with chronic pain at rest, loss of tissue and limb. Despite the active development of new technologies, including endovascular and open surgical methods of treatment, and the development of various guidelines, CLI still remains an unresolved burden of vascular surgery around the world. The second part of the review describes large randomized trials, open and endovascular methods of lower limb revascularization in CLI. Also, the use of deep vein arterialization technology in No-option cases for conventional methods of revascularization.

Клинический случай успешного лечения пациента с критической ишемией нижней конечности на фоне позднего дебюта антифосфолипидного синдрома

The antiphospholipid syndrome (APS) is characterized by non-inflammatory thrombotic vasculopathy with lesions of vessels of all types and localization. That is why clinical manifestations of APS are varied and patients turn to various physicians. The article describes a clinical case of a critical lower limb ischemia in AP. A 62 y. o. female patient was under outpatient observation for two years with the clinic of intermittent claudication and a diagnosis of atherosclerosis of lower limb arteries. At the same time, a history of thrombosis of the splenic artery — atypical for atherosclerosis, laboratory phenomena: a false-positive Wassermann reaction and an elongation of the phospholipid-dependent test (APTT) indicated APS. The patient was admitted into Department of Vascular Surgery of the Republic Clinical Hospital with critical lower limb ischemia and a threat of amputation. Antiphospholipid antibodies were detected. Due to the therapy pathogenetic for APS, amputation of the lower extremity was avoided. The presented clinical case shows that the APS may occur in people older than 60, and physicians of all specialties should be alert to this diagnosis.

Comparative Study between Femoro-distal Bypass Graft & Tibial Arteries Angioplasty in the Treatment of Critical Lower Limb Ischemia

Comparative Study between Femoro-distal Bypass Graft & Tibial Arteries Angioplasty in the Treatment of Critical Lower Limb Ischemia

CRITICAL LIMB ISCHEMIA. LITERATURE REVIEW (PART 1)

Critical limb ischemia (CLI) is the final stage of peripheral arterial disease which may lead tothechronic restpain, loss of tissues and limbs. Despite the active development of new technologies, including endovascular and open surgical methods of treatment, and the development of various type of guidelines, CLI still remains an unresolved burden of vascular surgery around the world. In the first part of this review, we described the problem of PAD, in particular, critical lower limb ischemia and the role of diabetes mellitus in the progression of these pathologies. In addition, we tried to reveal the statistics of «small» and «large» amputations in different regions of the world, as well as their social and economic significance.

Gas detection in the portal vein after aortobifemoral bypass: a case report

We present a case report of early surgical treatment of abdominal compartment syndrome after aortobifemoral bypass. A 73-year-old man was admitted to the I.I. Mechnikov North-Western State Medical University with critical lower limb ischemia. Aortobifemoral bypass with a synthetic prosthesis was performed via laparotomy. The postoperative period was complicated by the dynamic bowel obstruction. The patient's condition worsened (hypovolemic and septic shock, respiratory failure due to severe pneumonia). Initial tactics was conservative. Signs of bowel ischemia (pneumatosis of the intestinal wall, gas in the portal vein) were identified using “point of care” ultrasound, which led to a change in the treatment tactics. On the same day, decompression relaparotomy was performed and the intestinal decompression tube was inserted. The postoperative period proceeded with positive dynamics: early extubation with acceptable parameters of gas exchange, minimal dosages of vasopressor support. Bowel function improved and stool appeared on the 2nd day after surgery.Gas in the portal vein is an ultrasound phenomenon, which in 70 % of cases suggests necrosis of the intestinal wall. The detection of such a symptom in patients after the abdominal aorta surgery may indicate bowel ischemia, since mesenteric circulation disorders primarily develop in the inferior mesenteric artery. This condition requires urgent surgical intervention, but its differential diagnosis with postoperative paralytic ileus is not always possible, especially in the early stages. We demonstrate a case of early gas detection in the portal vein and the emergency intervention that allowed preventing irreversible ischemic damage of the bowel. “Point of care” ultrasound can help suspect this condition and determine the indications for early surgical intervention, which can positively influence the outcome. Received 19 April 2022. Revised 29 May 2022. Accepted 1 June 2022. Informed consent: The patient’s informed consent to use the records for medical purposes is obtained. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Contribution of the authors: The authors contributed equally to this article.

Right atrial thrombus, junctional tachycardia, and critical lower limb ischemia: three rare complications of severe acute respiratory syndrome coronavirus 2 infection

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can engender multi-system inflammatory syndrome. Its main symptoms are cardiovascular and thromboembolic problems that can develop into severe complications. The present case is about a 55-year-old patient who was admitted for critical ischemia of the right lower limb and necrosis of the right forefoot. The patient was infected with coronavirus disease 2019 (COVID-19) one month before her admission. The patient also has cardiovascular risks including type 2 diabetes and hypertension. The performance of ultrasounds revealed a thrombus in the right atrium and the pulmonary artery, and arteriography detected an occlusion of the right popliteal joint for which she had an endovascular recanalization and amputation of the right forefoot. This case highlights that SARS-CoV-2 infection could be considered a serious cardiovascular disease requiring cardiovascular explorations to initiate hospital management and avoid severe complications.

An anatomical study of the tibial nerve branches innervating the posterior tibial artery.

The arteries of the lower limbs are innervated by vascular branches (VBs) originating from the lumbar sympathetic trunk and branches of the spinal nerve. Although lumbar sympathectomy is used to treat nonreconstructive critical lower limb ischemia (CLLI), it has limited long-term effects. In addition, the anatomical structure of tibial nerve (TN) VBs remain incompletely understood. This study aimed to clarify their anatomy and better inform the surgical approach for nonreconstructive CLLI. Thirty-six adult cadavers were dissected under surgical microscopy to observe the patterns and origin points of VBs under direct vision. The calves were anatomically divided into five equal segments, and the number of VB origin points found in each was expressed as a proportion of the total found in the whole calf. Immunofluorescence staining was used to identify the sympathetic nerve fibers of the VBs. Our results showed that the TN gave off 3-4 VBs to innervate the posterior tibial artery (PTA), and the distances between VBs origin points and the medial tibial condyle were: 24.7± 16.3 mm, 91.7± 66.1 mm, 199.6± 52.0 mm, 231.7± 38.5 mm, respectively. They were mainly located in the first (40.46%) and fourth (31.68%) calf segments, and immunofluorescence staining showed that they contained tyrosine hydroxylase-positive sympathetic nerve fibers. These findings indicate that the TN gives off VBs to innervate the PTA and that these contain sympathetic nerve fibers. Therefore, these VBs may need to be cut to surgically treat nonreconstructable CLLI.

Rare presentation of Waldenström’s macroglobulinaemia requiring bilateral above-knee amputations: a case report

BackgroundWaldenström’s macroglobulinaemia is a rarely encountered B-lymphocytic malignancy. Waldenström’s macroglobulinaemia-associated paraproteinaemia is linked to an increase in serum viscosity, which results in a hypercoagulable state. Burning bilateral foot pain in a man with alcohol dependence and controlled atrial fibrillation presenting to the emergency department was attributed to peripheral neuropathy, given satisfactory angiographic evidence of bilateral foot arterial blood supply. Subsequently, his presentation as an emergency with acute bilateral critical lower limb ischemia that was managed by bilateral above-knee amputations, prompted a wider search for other etiologies. We present a hitherto unreported case of Waldenström’s macroglobulinaemia-related acute bilateral lower limb ischemia, which required bilateral above-knee amputations.Case presentationA 50-year-old Caucasian man, who was an alcohol dependent heavy smoker, presented with burning pain in his right foot that was deemed to be related to alcoholic neuropathy. A computerized tomographic angiogram demonstrated an occluded right distal anterior tibial artery but a patent posterior tibial artery supplying the foot arch, findings that were associated with noncritical ischemia. After multiple presentations within a week, he was admitted following sudden clinical deterioration with acute confusion, hyponatremia, and bilateral foot pain. Over the course of 24 hours, the patient deteriorated rapidly, with bilateral lower limb ischemia requiring bilateral above-knee amputations. Subsequent investigations revealed a diagnosis of Waldenström’s macroglobulinaemia.ConclusionsTo the best of our knowledge, this is the only reported case of Waldenström’s macroglobulinaemia-induced bilateral lower limb ischemia requiring major bilateral amputations.

Two-Stage Gene Therapy (VEGF, HGF and ANG1 Plasmids) as Adjunctive Therapy in the Treatment of Critical Lower Limb Ischemia in Diabetic Foot Syndrome.

One of the most serious problems in people with diabetes is diabetic foot syndrome. Due to the peripheral location of atherosclerotic lesions in the arterial system of the lower extremities, endovascular treatment plays a dominant role. However, carrying out these procedures is not always possible and does not always bring the expected results. Gene therapy, which stimulates angiogenesis, improves not only the inflow from the proximal limb but also the blood redistribution in individual angiosomes. Due to the encouraging results of sequential treatment consisting of intramuscular injections of VEGF/HGF bicistronic plasmids followed by a month of ANG1 plasmids, we decided to use the described method for the treatment of critical ischemia of the lower limbs in the course of diabetes and, more specifically, in diabetic foot syndrome. Twenty-four patients meeting the inclusion criteria were enrolled in the study. They were randomly divided into two equal groups. The first group of patients was subjected to gene therapy, where the patients received intramuscular injections of pIRES/VEGF165/HGF plasmids and 1 month of ANG-1 plasmids. The remaining patients constituted the control group. Gene therapy was well tolerated by most patients. The wounds healed significantly better in Group 1. The minimal value of ABI increased significantly in Group 1 from 0.44 ± 0.14 (± standard deviation) to 0.47 ± 0.12 (with p = 0.028) at the end of the study. There were no significant differences in the control group. In the gene treatment group, PtcO2 increased significantly (from 28.71 ± 10.89 mmHg to 33.9 ± 6.33 mmHg with p = 0.001), while in Group 2, no statistically significant changes were found. The observed resting pain decreased significantly in both groups (Group 1 decreased from 6.80 ± 1.48 to 2.10 ± 1.10; p < 0.001; the control group decreased from 7.44 ± 1.42 to 3.78 ± 1.64 with p < 0.001). In our study, we evaluated the effectiveness of gene therapy with the growth factors described above in patients with CLI in the course of complicated DM. The therapy was shown to be effective with minimal side effects. No serious complications were observed.

Treatment of critical ischemia of the lower extremities

Chronic ischemia of the lower extremities (CLLI) remains one of the main socio-economic problems modern medicine. The problem of treating patients with intermittent claudication, despite the rapid development of medical technologies, remains one of the most significant in medicine. The progression of the disease leads to the development of complications such as major cardiovascular events, the development of critical lower limb ischemia (CLLI), as well as amputations, which are disabling diseases. In this article broad notion are summarized on critical limb ischemia, scope of the problem, its treatment and modern approaches for the management of this disorder. Besides, latest clinical trials and study results are stated in order in depth understand the management of the disease.

Appraisal of Ilio-popliteal Bypass Surgery for Limb Salvage (In Patients with Critical Lower Limb Ischemia and Infected Femoral pseudoaneurysms)

Appraisal of Ilio-popliteal Bypass Surgery for Limb Salvage (In Patients with Critical Lower Limb Ischemia and Infected Femoral pseudoaneurysms)

EE307 Orbital Atherectomy System (OAS) with Angioplasty for Critical Lower LIMB Ischemia Treatment. Budget IMPACT Analysis: From a Modelling Approach to a Hospital Reality in Italy

Critical limb ischemia (CLI) is a clinical syndrome of ischemic pain at rest or tissue loss, such as non-healing ulcers or gangrene, related to Peripheral Artery Disease (PAD). CLI has a high short-term risk of limb amputation.Mortality after amputation is extremely high and is increased in diabetic patients. An Endovascular first approach is recommended based on a lower procedural risk.

Sympathectomy and Neuromodulation in the Treatment of Critical Lower Limb Ischemia

INTRODUCTION Critical lower limb ischemia is a widespread disease that occurs due to atherosclerotic lesions of the arteries with progressive narrowing of their lumen. Clinically critical ischemia is manifested by pain at rest, resistant to narcotic analgesics, and/or ulcerative necrotic process on the legs. In the absence of treatment, patients undergo amputation of the lower limb. Almost all patients die 10 years after amputation of the lower limb at the level of the thigh. Currently, there are following methods of treatment of critical ischemia: conservative therapy, direct revascularization, lumbar sympathectomy and neurostimulation.AIM OF STUDY To present the data of modern scientifi c literature on the use of lumbar sympathectomy and epidural spinal cord stimulation in the treatment of critical lower limb ischemia.MATERIAL AND METHODS This review presents the latest data obtained as a result of studying domestic and foreign literature on the treatment of critical lower limb ischemia with lumbar sympathectomy and epidural spinal cord stimulation. Currently, lumbar sympathectomy is performed by surgical (open, mini-access and endoscopic) and percutaneous (chemical or radiofrequency) methods. Percutaneous access is becoming widespread due to its minimally invasiveness, maximum accessibility, ease of performance and low cost. Epidural spinal cord stimulation is performed for resistant pain syndrome. The mechanism of action of spinal stimulation is to block the transmission of nerve impulses at the level of the gelatinous substance of the posterior horns of the spinal cord during stimulation of afferent fi bers of a larger diameter (type A-alpha and A-beta fi bers).CONCLUSION Spinal neurostimulation and lumbar sympathectomy are promising methods of treatment for critical lower limb ischemia in case of impossibility of direct revascularization. Lumbar sympathectomy can reduce the intensity of pain and improve the quality of life of patients. According to a number of studies, epidural spinal cord stimulation signifi cantly reduces the likelihood of amputation of the lower limb, and also reduces the intensity of pain in patients refractory to conservative therapy, as well as in those who are not indicated for direct revascularization of the arteries of the lower extremities. More large-scale studies are needed to determine the indications for the above methods.

Therapeutic Angiogenesis in the Experimental Ulcerative-Necrotic Stage of Critical Lower Limb Ischemia

Introduction. The effectiveness of therapeutic angiogenesis in the ulcerative-necrotic stage is insufficient to preserve the limb.The aim of research was to study the effectiveness of therapeutic angiogenesis with "Udenafil", mononuclear fraction of autologous bone marrow and their combination in the experimental ulcerative-necrotic stage of critical lower limb ischemia.Materials and methods. Lower leg muscle ischemia was simulated on Wistar rats. All animals were divided into 4 groups, 20 animals in each group: with simulated critical ischemia without treatment (control group); with critical ischemia and monotherapy with udenafil (udenafil, orally, 8.6 mg/kg for 28 days, the first experimental group); with critical ischemia and monotherapy with mononuclear fraction of autologous bone marrow (a single paravasal injection of a mononuclear fraction of autologous bone marrow in 7 days after critical ischemia simulation, the second experimental group); with critical ischemia and combined therapy (udenafil orally, 0.86 mg/kg, once a day, for 28 days, and a single paravasal injection with a mononuclear fraction of autologous bone marrow, similar to the group with monotherapy, the third experimental group). The level of blood microcirculation in the lower leg muscles was measured in 21 and 28 days; after that, histological examination was performed.Results. In the control group, the regional blood flow rate in the ischemic shin muscle was 2.1 times less than in intact animals in 21 days and 1.8 times less in 28 days after simulated critical ischemia. In the first experimental group, the regional blood flow rate increased by 1.6 times in 21 days and 28 days after udenafil administration; in the second experimental group, the regional blood flow rate increased by 1.6 times and 1.7 times, respectively, after the mononuclear fraction of bone marrow was administered to animals; and in the third experimental group, the regional blood flow rate increased 1.8 times, compared with the animals of the control group after the combined use of bone marrow cells and udenafil. In 28 days after the start of the experiment, histological tests detected foci of necrosis with perifocal inflammation in the ischemic muscles of the lower leg in animals of the control group. In the first and second experimental groups, a decreased size and number of necrosis sites was registered due to formation of young connective tissue and new capillaries. None of newly formed microcirculatory bed was detected. In the third experimental group, the severity of necrotic changes was minimal, a large number of newly formed blood vessels (arterioles) were visualized in wide layers of the connective tissue (capillaries, venules); this was a new microcirculatory bed.Conclusion. Application of udenafil combined with the mononuclear fraction of the bone marrow results in an increased perfusion of ischemic tissues and development of a new microcirculatory bed.

Hybrid technique with endovascular privilege in management of critical lower limb ischemia

Hybrid technique with endovascular privilege in management of critical lower limb ischemia

Evaluation of long-term treatment results of patients with critical limb ischemia and diabetes mellitus with different management approaches

Background. In all cases of critical lower limb ischemia revascularization should be performed. However, the overlay of diabetic angiopathy significantly worsens the prognosis of the surgery, and the conservative therapy also frequently turns out to be ineffective even in the nearest future. Therapeutic stimulation of angiogenesis in this group of patients is an additional application point for the possible improvement of treatment results.&#x0D; Aim. Evaluating treatment results of patients with critical ischemia and underlying diabetes after 5 years from the beginning of supervising, as well as assessing the benefits of additional angiogenesis as a part of treatment.&#x0D; Material and methods. The study included data from 140 patients with critical ischemia and diabetes mellitus, divided into 4 groups, who received surgical [groups IA (n=45) and IB (n=30)] or therapeutic [groups IIA (n=40) and IIB (n=25)] treatment. Additional angiogenic therapy was also carried out in two groups (groups IB and IIB). Treatment outcomes were assessed over a 5-year period. Efficacy criteria were evaluated in the form of limb preservation and patient survival. The results were studied using descriptive statistics methods. Qualitative data were analyzed by constructing 22 contingency tables and using the xi-square method.&#x0D; Results. The best indices of limb preservation and the lowest mortality of patients were obtained in the group after revascularization with additional angiogenic therapy. Gene therapy induction significantly improved the course of disease in limb preservation for periods from 6 months to 2 years (30% amputations by 2 years of follow-up, p=0.045). Angiogenic induction of angiogenesis also made it possible to improve the treatment results in the groups of conservative therapy but reliably better indicators of limb preservation were obtained in two groups with surgical interventions.&#x0D; Conclusion. The optimal management tactic for patients with critical lower limb ischemia and underlying diabetes mellitus is direct revascularizing intervention on the lower limb arteries with additional angiogenic therapy in the postoperative period. Additional gene therapy induction of angiogenesis makes it possible to reduce the number of amputations both as part of combined surgical or therapeutic treatment , but it cannot be an alternative to surgery.

Tratamento híbrido para revascularização de membro inferior em paciente com infecção de prótese vascular: relato de caso

Patients with severe arterial obstructive disease and critical limb ischemia associated with vascular graft infection have elevated morbidity and mortality rates and are at high risk of limb loss. We present the case of a 76-year-old male patient with left lower limb critical ischemia and a femoropopliteal vascular graft infection. We used a hybrid treatment approach with an open surgical approach to the inguinal and popliteal regions and used the vascular prosthesis as endovascular access for direct recanalization of the superficial femoral artery, because the long occlusion and extensive calcification had frustrated initial attempts at endovascular treatment. After endovascular recanalization, the infected graft was removed. Used in conjunction with open surgery, advances in endovascular techniques and materials offer new solutions for patients when usual procedures fail.

Комплексный подход к лечению неоперабельных пациентов с критической ишемией нижних конечностей и сахарным диабетом: результаты и перспективы

INTRODUCTION: The question of the optimal methods of conservative treatment of patients with critical lower limb ischemia (CLLI) and diabetes mellitus (DM) is still open. AIM: To evaluate the long-term results of therapeutic treatment of patients with CLLI and DM whose peripheral vascular bed is unsuitable for reconstruction, or who refused surgical treatment for different reasons, and to determine effectiveness of additional angiogenesis in this group of patients. MATERIALS AND METHODS: The work involved 65 patients with CLLI and DM who were divided to 2 groups. The control group of patients (40 individuals) received a course of conventional therapy. In the study group (25 individuals), additional exogenous stimulation of angiogenesis was used with angiogenic vascular endothelial growth factor. Subsequently, instrumental parameters of limb perfusion were assessed within 6 months, and in the long-term period (5 years), limb preservation and mortality in this group. RESULTS: Exogenous stimulation of angiogenesis permits to improve the following 6-month treatment results (8% of deaths and 20% of amputations in the study group versus 15% of deaths and 42.5% of amputations in the same period in the control group), and permits to maintain this trend within 5 years of follow-up (64% of deaths and 72% of amputations in the study group versus 80% of deaths and 87.5% of amputations in the control group). Reliable differences between the groups in the frequency of amputations were observed on visits in 6 months (p = 0.041) and in 1 year of follow-up (p = 0.048). According to instrumental data, the best parameters in terms of the painless walking distance (p = 0.032) and transcutaneous oxygen tension were obtained in the study group by 6 months of follow-up (p = 0.028). CONCLUSIONS: Therapeutic angiogenesis improves the results of treatment of patients with CLLI and diabetes mellitus, especially in 6 months — 2 years interval, however, conservative therapy still demonstrates unsatisfactory results of treatment in the near and in the long terms.

Psychological determinants of the attitude towards vascular interventions in patients with lower limb ischaemia

BackgroundCritical lower limb ischaemia is associated with a 20% annual risk of amputation and death. It is necessary to activate pa-tients’ personal resources which comprise mental dispositions needed to effectively cope with the disease. The objective of the study was to evaluate the correlation between the attitude toward the vascular reconstruction and self-efficacy (SE), health locus of control (HLoC) and own life quality (QOL) assessment in patients with critical lower limb ischaemia.Participants and procedureThe study involved 64 patients with critical lower limb ischaemia (Rutherford 4 and 5), 26 women and 38 men. Four scales were applied during primary admission: the Generalized Self-Efficacy Scale; the Satisfaction with Life Scale; the Multidimensional Health Locus of Control Scale; and the visual scale revealing attitude to vascular reconstruction.ResultsThe attitude to the vascular reconstruction was positive (M = 8.50). The lowest grades were given by those hospitalised several times during follow-up (M = 8.30); women expressed low grades (M = 7.71). An overall positive correlation was found between the positive attitude to the surgery and self-efficacy (p = .012), internal HLoC (p = .041) and external locus (p = .026). In the patients who died within six months from baseline assessment, no correlations were found. In subjects with no readmission, a correlation was found between positive attitude to surgery and the external personal HLoC (p = .023). In patients with subsequent readmissions, a correlation was found between the originally positive attitude to the surgery and poor self-efficacy (p = .009).ConclusionsPatients with weak mental dispositions cannot cope with difficult situations and show a tendency to experience strong emotions, concentrating on their deficiencies, resulting in decreased motivation and feeble engagement in treatment. Poor mental disposition influences the final outcome of the vascular reconstruction.

Gender peculiarities of critical lower limb ischemia

BACKGROUND: Development of critical ischemia of lower limbs in patients with atherosclerosis causes negative consequences due to the high probability of detecting multilevel changes, as well as identifying coronary and carotid pools.&#x0D; АIM: The aim of the study was to investigate gender differences in critical lower limb ischemia of atherosclerotic genesis following reconstructive interventions.&#x0D; MATERIALS AND METHODS: Arterial reconstructions have been performed in 261 patients with peripheral atherosclerosis (95 women and 166 men). The specific features of reconstructive interventions have been taken into account; complications and the number of amputations have been analyzed in the early period.&#x0D; RESULTS: Higher pulse pressure has been registered in the female group; tibial arteries have been affected significantly more frequently (p 0,05). Thrombosis of the operated segment has been observed more frequently in the male patients at the stage of critical ischemia; in the case of claudication the complications were sporadic.&#x0D; CONCLUSIONS: The best results of reconstructive care in men and women with peripheral atherosclerosis at the claudication stage determine the vector of active tactics in the absence of conservative treatment results.