Limb Ischemia Research Articles

Injectable Alginate-Based Hydrogels Encapsulating Engineered Endothelial Extracellular Vesicles for the Treatment of Critical Limb Ischemia.

Critical limb ischemia (CLI) is a peripheral arterial disease resulting from chronic inflammation of vascular systems. Recent studies have shown that inhibiting macrophage inflammation has the potential to treat CLI, and extracellular vesicles (EVs) from endothelial cells can inhibit macrophage activation. However, the limited cell-targeting capabilities and rapid clearance of EVs from the injection site limit the in vivo application of the EVs. Here, we modified endothelial EVs with platelet membranes (pM/EVs) to boost the inhibition effects on macrophage inflammation and developed an injectable alginate-based collagen composite (ACC) hydrogel for localized delivery of pM/EVs (pM/EVs@ACC) for CLI treatment. We found that pM/EVs can effectively inhibit macrophage inflammation in vitro. Furthermore, pM/EVs@ACC treatment significantly promotes the recovery of limb functions, restoring the feet' blood supply and relieving inflammation. Our findings provide compelling evidence that the pM/EVs@ACC injectable system mediating delivery of pM/EVs is a promising strategy for CLI treatment.

Extracorporeal life support for severe leptospirosis: Case series and narrative review

Introduction: Leptospirosis can be associated with multi-system organ failure (MSOF) and significant morbidity and mortality. Extracorporeal life support (ECLS) has been used as salvage therapy for severe leptospirosis complicated by acute respiratory distress syndrome (ARDS). Current knowledge in this field is limited, with no standardized treatment approaches. We aim to describe the literature to date on the use of ECLS in patients with leptospirosis, highlighting associations, outcomes, and complications. Methods: We report on the successful use of ECLS in two cases of severe leptospirosis and conduct a narrative review of the literature. Using a search strategy developed in consultation with a medical librarian and validated across pre-selected articles, several databases were searched. We included case reports, case series, cohort studies, and prospective studies of adult patients with confirmed leptospirosis undergoing ECLS. Editorials, surveys, or opinion articles without primary patient data were excluded. Overall mortality was our primary outcome. Results: Two cases of previously healthy males presenting with ARDS due to leptospiral infection are described. Literature review identified 25 articles containing 43 reported cases of patients treated with ECLS for severe leptospirosis. Patients were mostly young and male. Overall mortality was 16%. The most common complication recognized was acute renal failure requiring renal replacement therapy. Additional complications included diffuse intravascular coagulation, necrotizing pancreatitis, and limb ischemia. Conclusion: Leptospirosis should be considered in patients with epidemiologic exposure(s) presenting with critical illness, including ARDS and MSOF. ECLS is a viable rescue strategy in severe leptospirosis, even with established MSOF.

Acrocyanosis as a rare presentation of drug-induced cutaneous vasculitis: a case report

BackgroundAcrocyanosis is characterised by persistent bluish discolouration of the extremities, resulting from reduced peripheral blood flow leading to increased oxygen extraction. The aetiology can be divided into primary and secondary causes. While primary acrocyanosis is generally painless and has a benign course, secondary causes may lead to complications. This case reported acrocyanosis secondary to cutaneous vasculitis which progressed to digital gangrene, which is a rare complication of cutaneous vasculitis.Case presentationA 68-year-old man presented with a four-day history of bluish discolouration involving bilateral toes associated with pain and started to become gangrenous. Investigations for critical limb ischemia did not show evidence of critical arterial stenosis. Further history revealed history of recent administration of intramuscular injections with diclofenac, a non-steroidal anti-inflammatory agent for renal colic pain a few days prior to the onset of the. Thorough skin search showed multiple purpuric rash of his thighs, buttocks and abdomen. Skin biopsy confirmed the diagnosis of cutaneous (lymphocytic) vasculitis, which was likely to be drug-induced. The acrocyanosis initially responded to methylprednisolone, however unfortunately it progressed further to digital gangrene which required bilateral transmetatarsal amputations.ConclusionKnowledge on clinical features, aetiology and investigations of secondary acrocyanosis is crucial for early recognition and treatment of the underlying cause to prevent irreversible complications.

Anticoagulation in embolic acute limb ischaemia-an observational study.

The management of embolic acute limb ischaemia commonly involves determining aetiology and performing emergency invasive procedures. This detailed study aimed to determine the impact of manipulation of anticoagulation in the aetiology of emboli in acute limb ischaemia and determine the efficacy of primary anticoagulation therapy vs. invasive interventions. Material and methods: Data collection was conducted at a single institution on a cohort of patients presenting consecutively with embolic acute limb ischaemia over one year. Two groups were compared, one receiving anticoagulation as primary therapy with those undergoing invasive treatment as the internal comparison group. Results: A likely haematological causation was identified in 22 of 38 presentations, related to interruption of anticoagulation in cardiac conditions, the majority atrial fibrillation (n=12), or hypercoagulable states (n=10). Limb salvage was pursued in 36 patients employing anticoagulation (n=19) or surgical embolectomy (n=17) as the primary therapy in upper and lower limbs (n=17 vs n=19 respectively). Despite delays often well beyond six hours and a range of ischaemic severity in both groups, 35 of 36 patients achieved full or substantive restoration of function with improved perfusion. Regarding anatomical distribution of arterial disease and therapy, three patients with multi-level disease proceeded to embolectomy following anticoagulation. Embolectomy was undertaken most often for proximal emboli and more profound paralysis. Conclusions: Anticoagulation and coagulopathy are commonly implicated in the aetiology of arterial emboli, with omission of effective anticoagulation in atrial fibrillation being associated in almost 1/3 of presentations. Whilst more profound limb paralysis and proximal or multi-level disease tended to be managed surgically, primary anticoagulation therapy alone or with a secondary embolectomy was effective across the spectrum of ischaemia severity and despite significant delays beyond guideline recommendations.

REBOA in trauma: a life-saving intervention or a spectacular failure?

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a controversial haemorrhage control intervention often touted as the bridge to definitive haemorrhage control. This review summarizes the evolution of REBOA from its inception to the latest applications with an emphasis on clinical outcomes. This is a narrative review based on a selective review of the literature. REBOA remains a rarely utilized intervention in trauma patients. Complications have remained consistent over time despite purported improvements in catheter technology. Ischemia-reperfusion injuries, end-organ dysfunction, limb ischemia, and amputations have all been reported. Evidence-based guidelines are lacking, and appropriate indications and the ideal patient population for this intervention are yet to be defined. Despite the hype, purported technological advancements, and the mirage of high-quality studies over the last decade, REBOA has failed to keep up to its expectations. The quest to find the solution for uncontrolled NCTH remains unsolved.

Bilateral Acute Limb Ischemia due to Severe Rheumatic Mitral Stenosis and Atrial Fibrillation with Neglected International Normalized Ratio Control

Bilateral Acute Limb Ischemia due to Severe Rheumatic Mitral Stenosis and Atrial Fibrillation with Neglected International Normalized Ratio Control

Neutrophil extracellular traps and citrullinated fibrinogen contribute to injury in a porcine model of limb ischemia and reperfusion.

Ischemia/reperfusion injury (IRI) is a complex pathological process, triggered by the restoration of blood flow following an interrupted blood supply. While restoring the blood flow is the only option to salvage the ischemic tissue, reperfusion after a prolonged period of ischemia initiates IRI, triggering a cascade of inflammatory responses ultimately leading to neutrophil recruitment to the inflamed tissue, where they release neutrophil extracellular traps (NETs). NETs are web-like structures of decondensed chromatin and neutrophilic proteins, including peptidyl-arginine deiminase 2 and 4 (PAD2, PAD4), that, once outside, can citrullinate plasma proteins, irreversibly changing their conformation and potentially their function. While the involvement of NETs in IRI is known mainly from rodent models, we aimed to determine the effect of NET formation and especially PADs-mediated extracellular protein citrullination in a porcine model of limb IRI. We conducted our study on amputated pig forelimbs exposed to 1h or 9h of ischemia and then reperfused in vivo for 12h. Limb weight, edema formation, compartmental pressure were measured, and skeletal muscle was analyzed by immunofluorescence (TUNEL assay and dystrophin staining) to evaluate tissue damage. Fibrin tissue deposition, complement deposition and NETs were investigated by immunofluorescence. Citrullinated plasma proteins were immunoprecipitated and citrullinated fibrinogen was identified in the plasma by Western blot and in the tissue by immunofluorescence and Western blot. Our data consolidate the involvement of NETs in a porcine model of limb IRI, correlating their contribution to damage extension with the duration of the ischemic time. We found a massive infiltration of NETs in the group subjected to 9h ischemia compared to the 1h and citrullinated fibrinogen levels, in plasma and tissue, were higher in 9h ischemia group. We propose fibrinogen citrullination as one of the mechanisms contributing to the worsening of IRI. NETs and protein citrullination represent a potential therapeutic target, but approaches are still a matter of debate. Here we introduce the idea of therapeutic approaches against citrullination to specifically inhibit PADs extracellularly, avoiding the downstream effects of hypercitrullination and keeping PADs' and NETs' intracellular regulatory functions.

Incidence of Acute Mesenteric and Limb Ischemia in Post COVID19 Patients: A Retrospective Comparative Study

Incidence of Acute Mesenteric and Limb Ischemia in Post COVID19 Patients: A Retrospective Comparative Study

MiRNA in the Diagnosis and Treatment of Critical Limb Ischemia.

Chronic threatening limb ischemia of the inferior limbs (CLTI) is the final stage of peripheral arterial disease (PAD) and is one of the most feared atherosclerotic manifestations because if left untreated, in time, it can lead to amputation. Although there are currently numerous treatment techniques, both open and endovascular, it is a pathology that has no underlying treatment. Therefore, current studies are very much focused on new therapeutic possibilities that can be applied in the early stages of the atherosclerotic process. In numerous studies in the literature, miRNAs have been identified as important markers of atherosclerosis. The present study aims to identify the expression of three miRNAs-miR-199a, miR-20a, and miR-30c-in patients with chronic limb-threatening ischemia in the pre- and post-revascularization periods. The aim of the study is to identify whether these three markers play a role in critical ischemia and whether they have the potential for future use in new treatments of this pathology.

Progressive Acute Lower Extremity Ischemia Resulting From Cardiac Myxoma Embolization: A Case Report.

Cardiac myxomas are the most common primary benign tumors of the heart. The occlusion of peripheral arteries and complete obstruction of the abdominal aorta by a tumor embolus presents with distinct clinical manifestations. Herein, we present the case of a 38-year-old male with acute paresthesia, muscle weakness, erythematous, and violaceous changes in skin color localized to the dorsum of the left forefoot initially treated as cutaneous vasculitis. Further studies revealed the total occlusion of the terminal abdominal aorta by a saddle embolus from a cardiac myxoma. A multidisciplinary team consisting of cardiothoracic and vascular surgeons were involved in treating the patient, which resulted in full resolution of the case. This paper details the progression of acute bilateral limb ischemia to chronic limb threatening ischemia resulting from the total occlusion of the terminal abdominal aorta by a saddle embolus.

“All in one” lipid-polymer nanodelivery system for gene therapy of ischemic diseases

Gene therapy offers a promising avenue for treating ischemic diseases, yet its clinical efficacy is hindered by the limitations of single gene therapy and the high oxidative stress microenvironment characteristic of such conditions. Lipid-polymer hybrid vectors represent a novel approach to enhance the effectiveness of gene therapy by harnessing the combined advantages of lipids and polymers. In this study, we engineered lipid-polymer hybrid nanocarriers with tailored structural modifications to create a versatile membrane fusion lipid-nuclear targeted polymer nanodelivery system (FLNPs) optimized for gene delivery. Our results demonstrate that FLNPs facilitate efficient cellular uptake and gene transfection via membrane fusion, lysosome avoidance, and nuclear targeting mechanisms. Upon encapsulating Hepatocyte Growth Factor plasmid (pHGF) and Catalase plasmid (pCAT), HGF/CAT-FLNPs were prepared, which significantly enhanced the resistance of C2C12 cells to H2O2-induced injury in vitro. In vivo studies further revealed that HGF/CAT-FLNPs effectively alleviated hindlimb ischemia-induced gangrene, restored motor function, and promoted blood perfusion recovery in mice. Metabolomics analysis indicated that FLNPs didn't induce metabolic disturbances during gene transfection. In conclusion, FLNPs represent a versatile platform for multi-dimensional assisted gene delivery, significantly improving the efficiency of gene delivery and holding promise for effective synergistic treatment of lower limb ischemia using pHGF and pCAT.

Evaluating current acute aortic syndrome pathways: Collaborative Acute Aortic Syndrome Project (CAASP)

Abstract Background Diagnosis of acute aortic syndrome is challenging and associated with high perihospital mortality rates. The study aim was to evaluate current pathways and understand the chronology of acute aortic syndrome patient care. Method Consecutive patients with acute aortic syndrome imaging diagnosis between 1 January 2018 and 1 June 2021 were identified using a predetermined search strategy and followed up for 6 months through retrospective case note review. The UK National Interventional Radiology Trainee Research and Vascular and Endovascular Research Network co-ordinated the study. Results From 15 UK sites, 620 patients were enrolled. The median age was 67 (range 25–98) years, 62.0% were male and 92.9% Caucasian. Type-A dissection (41.8%) was most common, followed by type-B (34.5%); 41.2% had complicated acute aortic syndrome. Mode of presentation included emergency ambulance (80.2%), self-presentation (16.2%), and primary care referral (3.6%). Time (median (i.q.r.)) to hospital presentation was 3.1 (1.8–8.6) h and decreased by sudden onset chest pain but increased with migratory pain or hypertension. Time from hospital presentation to imaging diagnosis was 3.2 (1.3–6.5) h and increased by family history of aortic disease and decreased by concurrent ischaemic limb. Time from diagnosis to treatment was 2 (1.0–4.3) h with interhospital transfer causing delay. Management included conservative (60.2%), open surgery (32.2%), endovascular (4.8%), hybrid (1.4%) and palliative (1.4%). Factors associated with a higher mortality rate at 30 days and 6 months were acute aortic syndrome type, complicated disease, no critical care admission and age more than 70 years (P < 0.05). Conclusions This study presents a longitudinal data set linking time-based delays to diagnosis and treatment with clinical outcomes. It can be used to prioritize research strategies to streamline patient care.

Outcomes of Patients with Critical Limb Ischemia and Chronic Kidney Disease: A National Perspective

Introduction: Studies exploring the relationship between peripheral arterial disease (PAD), critical limb ischemia (CLI), and chronic kidney disease (CKD) and its effect on in-hospital outcomes are limited. We aimed to analyze the outcomes of patients with CKD and PAD who are admitted for CLI. Methods: We utilized the National Inpatient Sample (NIS) to capture hospitalizations for CLI from 2012 to 2020 and then identified cases with concomitant CKD. The primary outcome was mortality, and secondary outcomes were cerebrovascular accident, major bleeding, vasopressor requirement, percutaneous coronary intervention, cardiac arrest, acute respiratory failure, transfusion, length of stay, and total hospital charges. Multivariable logistic regression was performed to adjust for covariates. Results: A total of 441,245 patients with CLI were identified, of which 122,370 (27.7%) reported concomitant CKD. Patients with CKD had higher in-patient mortality (odds ratio [OR] 1.68, 95% confidence interval [CI], 1.17–1.68, p < 0.001), vascular complications (OR 1.31, 95% CI, 1.17–1.48, p < 0.001), acute kidney injury requiring hemodialysis (OR 3.17, 95% CI, 2.64–3.80, p < 0.001), and major bleeding (OR 1.12, 95% CI, 1.05–1.19, p < 0.001). Patients with CKD underwent minimally invasive endovascular therapy (31.08% vs. 36.73%, p < 0.0001) and invasive procedures (14.73% vs. 23.55%, p < 0.0001) less often. PAD-CLI with CKD was associated with major (20.54% vs. 16.17%, OR 1.04; p < 0.0001) and minor (26.87% vs. 19.53%, OR 1.2, p < 0.0001) amputations more often. Conclusion: Patients admitted for PAD-CLI with concomitant CKD have significantly higher in-hospital mortality as compared to patients without CKD. Moreover, patients with CKD and PAD-CLI are less likely to receive revascularization and more likely to undergo amputation.

The comprehensive value of the modern vascular surgeon to the orthopedic surgery service

ObjectiveOrthopedic surgery is among the highest compensated specialties in modern practice. Vascular surgeons are consulted frequently during orthopedic operations, however, the comprehensive value of the vascular surgery service to the safe delivery of orthopedic care has not been characterized previously. MethodsElectronic medical records were retrospectively queried for all operations performed by orthopedic surgeons requiring operative vascular surgical consultation from June 2013 to December 2023. Data were collected on case-specific details, reasons for consultation, and total charges. Work relative value units were calculated for each primary orthopedic procedure using the Centers for Medicare and Medicaid Services physician fee schedule. ResultsA total of 952 operative vascular surgery consultations were required over the study period. Consults were requested by 56 orthopedic surgeons across all eight orthopedic subspecialties at our institution. Operative vascular consultation was requested across 108 different procedure types. A total of 94 consults (9.9%) were emergent, intraoperative requests, with the remaining 858 consults (90.1%) occurring in the preoperative setting. The most common causes for consultation included surgical exposure (n = 832 [87.4%]), inadvertent bleeding (n = 44 [4.6%]), need for bypass (n = 12 [1.3%]), and acute limb ischemia (n = 11 [1.2%]). Total charges for all operative consultations exceeded $91.5 million, and the calculated total work relative value units for all primary orthopedic procedures was 19,384.5. A total of 54 cases (5.7%) occurred after hours, on a weekend, or both. ConclusionsVascular surgeons are integral to the provision of orthopedic surgical services, inclusive of all orthopedic subspecialties, for both the prevention and treatment of iatrogenic vascular injury. The around-the-clock availability of a vascular surgeon enables the orthopedic surgery department to generate significant revenue for the hospital system. These findings are important to the ongoing discussions regarding the value and compensation of the modern vascular surgeon.

Elevation and distraction of the Tibial periosteum in the management of chronic ischemic lower limb diseases.

This study investigates the effectiveness of tibia periosteum distraction (TPD) applied to the tibial periosteum, an innovative approach grounded in Ilizarov's tension-stress theory, for the treatment of ischemic diabetic foot and vasculitic foot conditions. A retrospective analysis was conducted on 33 patients (36 limbs) who underwent TPD between June 2019 and May 2022. The study comprised 21 males (23 limbs) and 12 females (13 limbs), aged 41 to 80 years (mean age: 63.4 years). Diabetic foot accounted for 27 cases, thromboangiitis obliterans for 2 cases, and arterial occlusive disease for 4 cases. The distribution of affected limbs included 15 left feet and 21 right feet. Periosteum traction commenced on the third postoperative day at a rate of approximately 0.75mm/day, adjusted biweekly. The traction device was removed after two weeks. Evaluation included capillary refill and wound healing assessment, along with pre- and postoperative analysis of foot skin temperature, ankle-brachial index (ABI), visual analogue scale (VAS) pain scores, and peripheral blood oxygen saturation. CT angiography (CTA) was utilized to assess vascular conditions in both lower limbs. All 33 patients were successfully followed up for a duration ranging from 4 to 24 weeks (mean: 11.03 weeks). VAS pain scores significantly decreased from preoperative (5.09 ± 1.70, range: 2-8) to postoperative two weeks (2.24 ± 0.90, range: 1-4) (t = 9.44, p < .001). Oxygen saturation levels increased from 83.88% ± 11.82% (range: 58%-97%) preoperatively to 91.36% ± 5.69% (range: 76%-98%) at two weeks postoperatively (t = -4.21, p < .001). Foot skin temperature also showed a significant increase (t = -3.98, p < .001). Capillary refill test at two weeks postoperatively demonstrated notable improvement. CTA revealed evident neovascularization in the operated limbs compared to preoperative conditions. Wound improvement was significant in all 33 patients within two months postoperatively. TPD emerges as a promising technique for chronic ischemic lower limb diseases, demonstrating favorable preliminary outcomes in wound healing promotion and amputation rate reduction. Nevertheless, large-scale randomized controlled trials are essential to further validate its efficacy.

Clinical characteristics and short-term outcomes in patients with cardiogenic shock undergoing mechanical circulatory support escalation from intra-aortic balloon pump to impella: From the J-PVAD registry.

An escalation strategy from intra-aortic balloon pump (IABP) to Impella (AbioMed, Danvers, MA, USA) is proposed in patients with cardiogenic shock (CS) refractory to IABP therapy, but its clinical data are lacking. This study aimed to elucidate the clinical characteristics and short-term outcomes in patients undergoing IABP-Impella escalation. From the Japanese nationwide registry of Impella (J-PVAD), a total of 2578 patients with CS receiving Impella support were classified into the IABP-Impella group (n = 189) or the Primary Impella group (n = 2389). We applied 1:3 propensity score (PS) matching, selecting 185 patients and 555 patients, respectively. Before matching, the IABP-Impella group presented longer shock-to-Impella time, worse laboratory data, and more frequent inotropes and pulmonary artery catheter use than the Primary Impella group. After matching, the baseline characteristics were well-balanced. Regarding the 30-day clinical outcomes in the PS-matched cohort, there were no significant differences in the rates of mortality and major complications (a composite of bleeding, hemolysis, infection, stroke, myocardial infarction, limb ischemia, and vascular injury) between the groups. However, The IABP-Impella group showed a significantly higher rate of infection (10.3 % vs. 5.6 %, p = 0.042) and additional mechanical circulatory support use (34.1 % vs. 23.8 %, p = 0.008) than the Primary Impella group. Compared to patients with primary Impella support, those undergoing IABP-Impella escalation showed similar 30-day mortality and major complications despite poorer clinical conditions before Impella support and a more complicated clinical course after Impella insertion.

Role of Antiplatelet Therapy in Patients Managed for Complex Aortic Aneurysms using Fenestrated or Branched Endovascular Repair

Despite the increasing number of fenestrated/branched endovascular aortic repair (f/bEVAR) procedures, evidence on post-operative antiplatelet therapy is lacking. This study aimed to investigate the role of single antiplatelet therapy (SAPT) vs. double antiplatelet therapy (DAPT) after f/bEVAR on 30 day and follow up outcomes. A multicentre retrospective analysis was conducted, including f/bEVAR patients managed from 1 January 2018 to 31 December 2022. Comparative outcomes were assessed according to post-operative antiplatelet therapy. The cohort was divided into the SAPT group (acetylsalicylic acid [ASA] or clopidogrel) and DAPT group (ASA and clopidogrel). The duration of SAPT or DAPT was one to six months. Primary outcomes were 30 day death, and cardiovascular ischaemic and major haemorrhagic events. Secondary outcomes were survival and target vessel (TV) patency during follow up. A total of 1 430 patients were included: 955 under SAPT and 475 under DAPT. The 30 day mortality was similar (SAPT 2.1% vs. DAPT 1.5%; p = .42). Cardiovascular ischaemic events were lower in the DAPT group (SAPT 11.9% vs. DAPT 8.2%; p = .040), with DAPT being an independent protector for acute mesenteric (p = .009) and lower limb ischaemia (p = .020). No difference was found in 30 day major haemorrhagic events (SAPT 7.5% vs. DAPT 6.3%; p = .40). The mean follow up was 21.8 ± 2.9 months. Cox regression showed no cofounders on survival, with similar rates between groups (log rank p = .71). DAPT patients presented higher TV patency (SAPT 93.4%, standard error [SE] 0.7% vs. DAPT 96.6%, SE 0.7%; log rank p = .007) at thirty six months. Cox regression revealed bEVAR as a predictor of worse TV patency (hazard ratio 2.03, 95% confidence interval 1.36 - 3.03; p < .001). DAPT was related to higher patency within bEVAR patients (SAPT 87.2%, SE 2.1% vs. DAPT 94.9%, SE 1.9%; p < .001). DAPT after f/bEVAR was associated with lower risk of cardiovascular ischaemic events and higher TV patency, especially in bEVAR cases. No difference in major haemorrhagic events was observed at 30 days.

Clinical outcomes of acute limb ischaemia caused by femoropopliteal stent thrombosis.

Although femoropopliteal-specific stents have durable patency, stent thrombosis (ST) may occur, which can lead to acute limb ischaemia (ALI). We aimed to investigate the clinical features and outcomes of ALI caused by femoropopliteal ST in patients with lower extremity artery disease. This multicentre retrospective study included 499 patients with ALI - of whom 108 patients had ALI caused by femoropopliteal ST (ST-ALI) and 391 patients had ALI caused by other aetiologies (de novo ALI) - who underwent treatment between September 2011 and March 2023. Clinical features and outcomes were compared between the two groups. The primary outcome measure was 12-month amputation-free survival; factors associated with amputation or death were investigated using multivariate Cox proportional hazards regression analysis. Patients with ST-ALI were significantly more likely to exhibit conventional atherosclerotic risk factors, including diabetes mellitus (63% vs 26%) and haemodialysis (51% vs 10%) compared to patients with de novo ALI, whereas patients with de novo ALI were older (80 years vs 74 years) and more likely to have atrial fibrillation (49% vs 18%) than patients with ST-ALI. The 12-month amputation-free survival rate was significantly lower in the ST-ALI group than that in the de novoALI group (51% vs 76%; p<0.001). Multivariate analysis revealed that ST-ALI, older age, haemodialysis, atrial fibrillation, the presence of a wound, peak C-reactive protein level, and non-ambulatory status all have an independent, positive association with death or major amputation. The current study revealed that patients with ST-ALI had worse clinical outcomes than those with de novo ALI, highlighting the need to maximise ST prevention.

Comparison of Duplex Ultrasound and Digital Subtraction Angiography for Assessing Tibial Vessel Disease.

Background Duplex ultrasonography (DUS) is readily available and often used as the first diagnostic test for patients with peripheral artery diseases (PADs). PAD is a disease that affects the general population but more commonly affects diabetics.To date, the role of DUS in the assessment of tibial vessel disease is inconclusive at best. The goal of our study is to assess the validity of DUS in characterizing the presence and severity of tibial diseasesvia comparison with digital subtraction angiography (DSA) findings. Methods This is a single-center retrospective cohort study analyzing three arterial segments (anterior tibial, posterior tibial, and fibular arteries) in patients who received a duplex study followed by DSA within a 30-day period. All arterial segments were graded from normal (Grade 0) to occluded (Grade 4), based on duplex interpretationand directly compared to direct visualization findings from DSA. Using statistical methods, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of DUS were determined. Results A total of 171 tibial vessel segments from 57 enrolled subjects with critical limb ischemia symptoms were analyzed in this study. The agreement between both modalities was poor (Kappa=0.19, p < 0.05), with DUS demonstrating a significant underestimation of vessel pathologies. This is also reflected by the overall sub-optimal sensitivity (23%), specificity (84%), PPV (69%), and NPV (41%) in DUS when compared to DSA results as the gold standard. Conclusion Significant disagreements were noted in this study between DUS and DSA findings, primarilysignificant underestimation of tibial vessel disease by the DUS when compared with the DSA. Caution is advised in the clinical application of DUS in patients with chronic limb-threatening ischemia (CLTI) symptoms and multi-segment tibial vessels due to its demonstrated limitations in this study.

Elevated Composite Inflammatory Markers are Associated with Clinical Severity and Long-term Amputation Risk in Patients with Critical Limb Ischemia after Percutaneous Transluminal Angioplasty

Elevated Composite Inflammatory Markers are Associated with Clinical Severity and Long-term Amputation Risk in Patients with Critical Limb Ischemia after Percutaneous Transluminal Angioplasty