Symptoms Of Limb Ischemia Research Articles

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.

Study on mid-term outcomes of atherectomy for patients with femoral popliteal artery lesions with different Global Limb Anatomic Staging System grades.

To investigate the mid-term efficacy and patency rate of TurboHawk peripheral plaque excision system in the treatment of femoral popliteal artery lesions with different Global Limb Anatomic Staging System (GLASS) grades. The clinical data of 141 patients with femoral popliteal arteriosclerosis obliterans who were treated with TurboHawk from January 2018 to July 2022 in our institution were retrospectively analyzed. There were 109 male patients and 32 female patients. Recordings were made of the patient's symptoms of limb ischemia, technical success rate, primary patency rate of target vessels, ankle brachial index (ABI), GLASS grades, postoperative complications, and a statistical analysis with the patient's preoperative treatment was conducted. All patients had improved limb ischemia symptoms to varying degrees after surgery, with a technical success rate of 100% (femoral artery puncture and superficial femoral artery recanalization) without bleeding, hematoma, pseudoaneurysm, arteriovenous fistula or other complications. The follow-up period was 1-24 months, during which the severity of claudication, resting pain, and toe ulcers significantly improved. The primary patency rate of the target vessel was 98.58% (139/141), and the ABI significantly increased on the second day, three months, and six months after surgery compared to before surgery. No major adverse events were found during follow-up. The patency rates at 1, 6, 12 and 24 months after intervention were 100%, 80%, 75% and 60% respectively. The mid-term efficacy and patency rate of TurboHawk in the treatment of femoral popliteal artery lesions with GLASS I patients have the best mid-term prognosis, the highest mid-term survival rate, and the highest vascular patency. The plaque removal system has proven to be an effective treatment for individual localized chronic total occlusion lesions. Additionally, the TurboHawk system provides a safe and minimally invasive treatment alternative for superficial femoral artery conditions, achieving significant therapeutic results within a brief period.

Efficacy of left subclavian artery revascularization strategies during thoracic endovascular aortic repair in patients with type B dissection: A single-center experience of 105 patients.

Left subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR) is necessary to reduce postoperative complications in patients with Stanford type B aortic dissection and an insufficient proximal anchoring area. However, the efficacy and safety of different LSA revascularization strategies remain unclear. Here, we compared these strategies to provide a clinical basis for selecting an appropriate LSA revascularization method. In this study, we included 105 patients with type B aortic dissection who were treated using TEVAR combined with LSA reconstruction in the Second Hospital of Lanzhou University from March 2013 to 2020. They were divided into four groups according to the method used for LSA reconstruction, namely, carotid subclavian bypass (CSB; n = 41), chimney graft (CG; n = 29), single-branched stent graft (SBSG; n = 21), and physician-made fenestration (PMF; n = 14) groups. Finally, we collected and analyzed the baseline, perioperative, operative, postoperative, and follow-up data of the patients. The treatment success rate was 100% in all the groups, and CSB + TEVAR was the most commonly used procedure in emergency settings compared with the other three procedures (P < 0.05). The estimated blood loss, contrast agent volume, fluoroscopic time, operation time, and limb ischemia symptoms during the follow-up were significantly different in the four groups (P < 0.05). Pairwise comparison among groups indicated that the estimated blood loss and operation time in the CSB group were the highest (adjusted P < 0.0083; P < 0.05). The contrast agent volume and fluoroscopy duration were the highest in the SBSG groups, followed by PMF, CG, and CSB groups. The incidence of limb ischemia symptoms was the highest in the PMF group (28.6%) during the follow-up. The incidence of complications (except limb ischemia symptoms) during the perioperative and follow-up periods was similar among the four groups (P > 0.05) The median follow-up time of CSB, CG, SBSG, and PMF groups was significantly different (P < 0.05), and the CSB group had the longest follow-up. Our single-center experience suggested that the PMF technique increased the risk of limb ischemia symptoms. The other three strategies effectively and safely restored LSA perfusion in patients with type B aortic dissection and had comparable complications. Overall, different LSA revascularization techniques have their advantages and disadvantages.

High Dose-rate Brachytherapy For Lower Extremity In-stent Restenosis: A 18-year, Single-center Experience

INTRODUCTION AND OBJECTIVES We present our 18-year experience of endovascular brachytherapy (EVBT), which was previously validated as a treatment for in-stent restenosis (ISR). METHODS We performed a single-center retrospective analysis of outcomes in 158 patients who underwent PTA and EVBT from 2003 to 2020. A dose of 20Gy was given at a depth of 0.5mm beyond the radius of the largest PTA balloon using iridium-192, with at least 2-cm-long margins of radiation coverage proximal and distal to the injured area. Stents were assessed for patency by duplex ultrasound imaging or angiography at 1, 3, 6, 9, 12, and 18 months and then yearly. The primary endpoint was freedom from 50% restenosis in the treated segment at 1 year, and 2 years. Patency data were estimated using the Kaplan-Meier method. Secondary endpoints were early and late thrombotic occlusion. RESULTS Of the 174 consecutive cases of EVBT, 29 (16.7%) were performed in common, external, or internal iliac, 145 (83.3%) in common femoral, superficial femoral, or popliteal arteries, or both. 142 patients (89.9%) had claudication, and 16 (10.1%) had critical limb ischemic symptoms. Preliminary analysis revealed the mean treated length to be 24.1 ± 12.3 cm over a mean duration of 16.5 ± 9.6 minutes. Median post-EVBT follow-up time was 2670 days (range, 1-4154 days). There were six (3.4%) and eighteen (10.3%) cases of early and late thrombotic occlusions, respectively. There were two deaths secondary acute coronary syndrome and stroke. Primary, assisted primary, and secondary patency in the entire cohort was 77.5%, 88.6%, and 90.6%, respectively, at 1 year and 64.8%, 79,2%, and 83.6%, respectively, at 2 years. CONCLUSIONS Our validated PTA with adjunctive EVBT protocol, followed by a consistent surveillance strategy, proves to offer a viable treatment option of ISR in centers that have the capacity to collaborate with Radiation Oncology. We present our 18-year experience of endovascular brachytherapy (EVBT), which was previously validated as a treatment for in-stent restenosis (ISR). We performed a single-center retrospective analysis of outcomes in 158 patients who underwent PTA and EVBT from 2003 to 2020. A dose of 20Gy was given at a depth of 0.5mm beyond the radius of the largest PTA balloon using iridium-192, with at least 2-cm-long margins of radiation coverage proximal and distal to the injured area. Stents were assessed for patency by duplex ultrasound imaging or angiography at 1, 3, 6, 9, 12, and 18 months and then yearly. The primary endpoint was freedom from 50% restenosis in the treated segment at 1 year, and 2 years. Patency data were estimated using the Kaplan-Meier method. Secondary endpoints were early and late thrombotic occlusion. Of the 174 consecutive cases of EVBT, 29 (16.7%) were performed in common, external, or internal iliac, 145 (83.3%) in common femoral, superficial femoral, or popliteal arteries, or both. 142 patients (89.9%) had claudication, and 16 (10.1%) had critical limb ischemic symptoms. Preliminary analysis revealed the mean treated length to be 24.1 ± 12.3 cm over a mean duration of 16.5 ± 9.6 minutes. Median post-EVBT follow-up time was 2670 days (range, 1-4154 days). There were six (3.4%) and eighteen (10.3%) cases of early and late thrombotic occlusions, respectively. There were two deaths secondary acute coronary syndrome and stroke. Primary, assisted primary, and secondary patency in the entire cohort was 77.5%, 88.6%, and 90.6%, respectively, at 1 year and 64.8%, 79,2%, and 83.6%, respectively, at 2 years. Our validated PTA with adjunctive EVBT protocol, followed by a consistent surveillance strategy, proves to offer a viable treatment option of ISR in centers that have the capacity to collaborate with Radiation Oncology.

Unexpected arterial thrombosis and acute limb ischemia in COVID-19 patients. Results from the Ibero-Latin American acute arterial thrombosis registry in COVID-19: (ARTICO-19).

Few studies have focused on arterial thrombosis and acute limb ischemia in COVID-19. This international registry intended to study the spectrum of clinical characteristics, therapeutic trends, and outcomes in a cohort of Ibero-Latin American patients with arterial thrombosis or acute limb ischemia and COVID-19. Data were retrospectively obtained from 21 centers in 9 countries. Patients with proven COVID-19 and asymptomatic or symptomatic arterial thrombosis were included. COVID-19 diagnosis was established by RT-PCR assay or IgM serology plus suggestive clinical/radiographical findings. We recorded and analyzed variables related to demography, clinical presentation, therapeutic trends, and outcomes. Eighty one patients were included in the registry. In 38.3%, acute limb ischemia symptoms were the first manifestation of COVID-19. Non-surgical management was more frequent in severe cases than surgical interventions, 11.1% vs. 88.9%, respectively (p = 0.004). Amputation rates were similar between all COVID severity groups (p = 0.807). Treatment was classified as non-surgical, open surgical, and endovascular treatment. Further analysis revealed an equal frequency of major leg amputation between treatment groups and increased mortality in patients with non-surgical management. However, multivariate regression analysis showed that treatment choices are associated with disease severity, with significant non-surgical treatment in critical patients; thus, mortality is related to the severity and confounds treatment analysis. Arterial thrombosis can be the initial symptom of a patient presenting with COVID-19. Physicians and health workers should potentially suspect COVID-19 in acute ischemia cases without a known risk factor or embolic cause. More experimental and clinical research is required to understand the complex phenomenon of arterial COVID-19 induced coagulopathy fully.

Experimental Modeling of the Ultra-Necrotic Stage of Critical Ischemia &#x0D; of the Lower Limbs

Objective. So far, no experimental model of the necrotic ulcerative stage of critical limb ischemia has been created. Aim. Development of a method for modeling the necrotic ulcerative stage of critical lower limb ischemia.Materials and methods. The experimental study was carried out on 120 rats - males of the "Wistar" line, divided into 4 groups of 30 animals each. In the first group (intact), the level of microcirculation in the muscles of the hind limb was determined. In the second (sham-operated) group, ischemia was not simulated, but the neurovascular bundle of the thigh was isolated and the wound was sutured. In the third group (comparison), the modeling of chronic ischemia of the leg muscles was performed by removing the femoral, popliteal, anterior and posterior tibial arteries. In the fourth (experimental) group, to simulate chronic critical ischemia of the leg muscles, the femoral, popliteal, anterior and posterior tibial arteries and veins were removed, and the peripheral nerve was damaged.In the postoperative period, the dynamics of symptoms of limb ischemia was monitored. Animals were taken out of the experiment, 10 animals in each group by an overdose of anesthesia on the 10th, 21st and 28th days. Before hatching, the level of microcirculation was determined using laser Doppler flowmetry. To study the morphological picture at the same time in the third and fourth groups, the ischemic gastrocnemius muscle of the leg was excised and a standard histological examination was performed.Results. Trophic disorders in animals of the third group developed in 13.3%, and in the experimental group - in 100%. In the experimental group, the level of microcirculation at all periods was significantly less than in the comparison group: on the 10th and 21st by 1.3 times, on the 28th day by 1.2 times, and the area of ​​muscle necrosis was greater by the same days by 21.2%, by 8.2% and by 6.8%.Conclusion. The developed experimental model corresponds to the necrotic ulcerative stage of critical ischemia in humans.

Association of arterial thromboembolism location with presence of nonvalvular atrial fibrillation.

Since nonvalvular atrial fibrillation is persistent in nature, patients with chronic nonvalvular atrial fibrillation are at life-time risk for development of thromboembolic events. Several novel oral anticoagulants have entered the market and there has been a growing body of evidence regarding their efficacy in prevention of ischemic stroke and arterial thromboembolism. The present study sought to compare the baseline characteristics between patients presenting with upper and lower extremity arterial thromboembolism developed secondary to nonvalvular atrial fibrillation. This retrospective study was made up of patients presenting with acute upper or lower extremity arterial thromboembolism as the first presentation of atrial fibrillation. Patients were included if they had acute upper or lower critical limb ischemia symptoms lasting for less than one week. Patients in whom chronic peripheral artery disease was diagnosed were also excluded to prevent potential confounding. Overall, 46.9% of patients presented with upper extremity arterial thromboembolism and 53.1% of patients presented with lower extremity arterial thromboembolism. None of the baseline characteristics showed significant difference between patients with upper and lower extremity arterial thrombosis. It was observed that there was no significant difference in the incidence of extremity involvement of acute arterial thromboembolism occurring in patients with nonvalvular atrial fibrillation in our study, and we think that acute arterial thromboembolism must be taken into consideration as one of the first signs and symptoms of atrial fibrillation.

Early experiences of intraoperative ultrasound guided angioplasty of the arterial stenosis during upper limb arteriovenous fistula creation.

In recent years the high prevalence of diabetes and atherosclerosis in elderly uremic patients starting hemodialysis (HD) has led to the increase in the risk of vascular access (VA) failure caused by pre-existing arterial diseases, including both VA slow maturation and early failure, and upper limb ischemic symptoms. Recently, in performing radial (R), brachial (B) and ulnar (U) artery (A) percutaneous transluminal angioplasty (PTA) in HD patients affected by access thrombosis, with insufficient blood flow and severe upper limb ischemia, good outcomes have been reported. Nevertheless, these procedures were performed after arteriovenous fistula (AVF) creation. About 2 years ago, we approached an intra-operative ultrasound-guided transluminal angioplasty (IUTA) performed during AVF creation, using the arterial incision, necessary because of the anastomosis, to introduce the necessary devices for the IUTA. The arterial stenosis having undergone IUTA was diagnosed by a preliminary ultrasound examination. Ultrasound guidance during the procedure is necessary for correct balloon location in the stenosis site. We treated seven patients (four diabetics), mean age 76 + 5 yrs. In all cases, the radial arteries because of hyposphygmia, were unfit for AVF creation. Four distal radio-cephalic AVFs at the wrist were created in patients 1, 3, 4 and 5; in the other three patients (2, 6 and 7), with failure or thrombosis of previous distal AVFs, an immediately upstream anastomosis was performed. In all cases, first, the area selected to perform the AV anastomosis was exposed, then the AR was incised, and the introductory metallic guide wire and the angioplasty catheter (with dimensions decided after PUS), were introduced. The balloon was inflated to 8-13 atm for 30-35 sec. In two patients a stent was also positioned. Later, a side-to-side AVF was created, closing the distal venous vessel. Patient follow-up ranged from 6-22 months. The ultrasound evaluation after IUTA showed the correction of all the stenosis treated. AVF maturation was good, except for the stented ones, which were inadequate. In conclusion, our early experience shows IUTA could be an adequate and effective procedure allowing the use of the stenotic arteries (otherwise unsuitable) for AVF creation. In our experience, stenting after IUTA does not add any other advantages.

Determinants of long-term outcome in patients after percutaneous stent-assisted management of symptomatic subclavian or innominate artery stenosis or occlusion.

Incidence and determinants of restenosis and adverse events after endovascular management (PTA±stent) of the subclavian/innominate artery (SA/IA) stenosis/occlusion remain unclear due to the relatively short-term follow-up or limited size of prior studies. This large-scale, long-term prospective study investigated safety, efficacy, and prognosis after SA/IA PTA±stent. The study involved 411 consecutive patients with symptomatic SA/IA stenosis/ occlusion; 393 were followed annually after successful PTA±stent for up to 16 (minimum one) years. Primary outcomes were freedom from restenosis and MACCE (cardiovascular death, myocardial infarction, stroke). Angiographic success rate was 99.7% in stenoses and 76.1% in occlusions. The incidence of any periprocedural complication was 4.4% (serious - 1.2%). Symptoms of limb ischaemia, vertebrobasilar insufficiency or angina resolved in 79.1%, decreased in 19.6%. Freedom from restenosis was 82.6% and 77.9% whereas freedom from MACCE was 86.6% and 78.3% at five and 10 years, respectively. MACCE determinants (HR; 95% CI) were previous myocardial infarction (5.36; 2.9-9.91), ischaemic stroke (2.03; 1.12-3.66), hs-CRP (1.04; 1.02-1.07), concurrent atherosclerosis (1.35; 1.00-1.82). Restenosis determinants were implantation of ≥2 stents (2.65; 1.23-5.72), stent diameter (0.45; 0.34-0.59), hs-CRP (1.06; 1.02-1.1), WBC (1.2; 1.07-1.35), age (0.97; 0.94-0.99), concurrent carotid or vertebral disease (1.85; 1.07-3.18), IA intervention (2.28; 1.08-4.84). This study established long-term durability of stent-assisted PTA of symptomatic SA/IA disease and identified risk factors for restenosis and long-term MACCE. Patients at increased risk might benefit from targeted, intensified prevention measures.

Endovascular Treatment Showing Promising Short-Term Results in Patients with Total Bilateral Aortoiliac Occlusion

Background: Endovascular treatment (ET) is a treatment option for aortoiliac occlusive disease in patients with critical symptoms. ET is the choice for the transatlantic inter-society consensus for the management of peripheral arterial disease (TASC II) type A and B lesions. However, its use for type C and D lesions is getting more popular due to its less invasive nature and feasibility for more patients than open surgery. Objectives: To describe short term results of ET in the treatment of total bilateral aortoiliac occlusion and discuss its role in the treatment of such lesions. Patients and Methods: Patients with total bilateral aortoiliac occlusion with either life disturbing claudication or critical limb ischemia symptoms, including rest pain or limb ulcer, who were unresponsive to exercise and medical treatment were chosen and underwent ET and were followed up. Their demographic data and possible risk factors were recorded. Activity level before and after the procedure was compared using paired sample T test. Satisfaction mean and standard error was calculated and three months, six months, and twelve months patency rates were calculated and 95% confidence interval (CI) was made using binomial exact test. Results: Fifteen patients met the inclusion criteria and underwent ET. Technical success was achieved in all cases. There were two cases of early mortality due to concomitant coronary artery disease (CAD) and prior poor medical condition. Patients satisfaction mean was 7.9 out of 10 (SE: 0.5) and activity level after procedure was significantly higher than before (1.53 and 2.58; P < 0.001). Primary patency rates at 3, 6, and 12 months were respectively 92.3% (24 of 26 limbs, CI = [74.7, 99.0]), 90.9% (20 of 22 limbs, CI = [70.8, 98.9]), and 83.3% (15 of 18 limbs, CI = [58.6, 96.4]). For 12 months follow-up, secondary patency rate increased to 88.9% (16 0f 18 limbs, CI = [65.3, 96.4]). Conclusion: When comparing patency rates for ET and open surgery no significant difference is seen (CI [58.6, 96.4], 93.6) and since re-intervention after ET with no delay is possible, it sounds a good treatment choice for total bilateral aortoiliac occlusions. Endovascular treatment of total bilateral aortoiliac occlusions can be a valid option with promising results and fewer complications that especially can be considered in high-risk patients. Further studies are recommended.

Efficacy of endovascular interventional minimally invasive techniques in treatment of acute brachial artery injury

Objective To evaluate the efficacy of endovascular interventional minimally invasive techniques in treatment of acute brachial artery injury. Methods A retrospective case series study was designed to analyzed data of 16 cases (11 males and 5 females) sustaining acute brachial artery injury treated from March 2011 to August 2016. Mean age was 47.9 years (range, 27-66 years). Left upper extremity vascular injury occurred in 7 cases and right upper extremity vascular injury occurred in 9. There were 13 cases of arterial intima injury and 3 of arterial pseudoaneurysm. All patients underwent endovascular therapy including stent implantation and balloon dilatation. Angiography was used to evaluate the repair of brachial artery and the operation time was recorded. Improvements of distal limb arterial pulse and limb ischemic symptoms were observed, and the patients who were followed up with stent lumen stenosis more than 50% received endovascular treatment again. Results The procedures was successful in all patients, with operation time of 30-75 minutes (mean, 45 minutes). After the insertion of a stent, recovered brachial artery blood flow and disappeared pseudoaneurysm were observed on angiography, without occurrence of stent stenosis or contrast extravasation. Symptoms of local pain and numbness were alleviated, and blood supply of the distal brachial artery was improved after operation. All patients were followed up for 3-36 months(mean, 16.7 months). The false aneurysm did not recur. Two cases of stent stenosis more than 50% had a second balloon dilation procedure and the blood flow returned to normal. Stent patency was found in 14 cases with stent stenosis of less than 50%. During the follow-up period, no ischemic necrosis, displacement of the stent or stent fracture were found. Conclusion For acute brachial artery injury, endovascular management exhibits higher technical success rate and good clinical outcome with a low incidence of complications. Key words: Brachial artery; Stents; Vascular system injuries

Nonatherosclerotic limb ischemia: Prompt evaluation and diagnosis.

Limb ischemia is most often associated with atherosclerosis and older age. When a younger patient without risk factors for atherosclerosis presents with symptoms of limb ischemia, vascular occlusion may not be suspected initially, thus delaying diagnosis and treatment. Delayed diagnosis can lead to a poor outcome. Here, we describe several uncommon causes of limb ischemia and their initial presentations, workup, and treatment to help guide the practitioner in making a timely diagnosis in this unusual patient population.

Cilostazol Can Increase Skin Oxygen Supply Assessed by Transcutaneous Oxygen Pressure Measurement in Type 2 Diabetes With Lower Limb Ischemic Disease: A Randomized Trial.

The purpose of this study was to compare the efficacy and safety of cilostazol versus acetylsalicylic acid (ASA) for amelioration of lower limb ischemia in type 2 diabetes. Prospective, randomized positive-controlled open clinical trial. Eighty-nine patients with type 2 diabetes mellitus and symptoms of lower limb ischemia (perceptions of coldness of the lower limbs, numbness, intermittent claudication, or pain at rest) present for 6 months or more that had not significantly changed within the past 3 months participated in the study. All subjects had an initial transcutaneous oxygen pressure (TcpO2) of less than 40 mm Hg in the foot when measured in the supine position. Subjects included 46 males and 43 females; their ages ranged from 35 to 80 years. Participants were randomly allocated to 2 groups, one was treated with cilostazol 100 mg taken twice daily (n = 48), and a second group took 100 mg of ASA daily (n = 41) for 8 weeks. Clinical assessment included measurement of transcutaneous oxygenation, and symptoms associated with lower limb ischemia. Blood analyses included a full blood panel, coagulation screen, renal function tests, hepatic function tests, and lipid profiles. All tests were performed at baseline and repeated at 8 weeks. Age, duration of diabetes, diabetic complications, lower limb ischemic symptoms, TcpO2, and smoking status did not differ between the 2 groups. In contrast, TcpO2 significantly improved from 37.1 ± 11.9 mm Hg to 42.0 ± 9.7 mm Hg in the cilostazol-treated group (P < .05), whereas no significant change was observed in the ASA-treated group (P > .05). Ischemic symptoms such as intermittent claudication (P = .009), perception of limb coldness (P = .008), and pain at rest (P = .017) showed greater improvement in the cilostazol-treated group when compared to subjects treated with ASA. Approximately 10% of patients treated with cilostazol experienced adverse side effects (palpitations, headache, diarrhea). Cilostazol was not found to have significant detrimental effects in hematologic or biochemical indices, including renal, hepatic, and blood coagulant function tests. We found that 8 weeks of treatment with cilostazol 100 mg daily was safe and well tolerated for the treatment of type 2 diabetes with lower limb ischemic disease.

Umbilical Cord-Derived Mesenchymal Stem Cells Relieve Hindlimb Ischemia through Enhancing Angiogenesis in Tree Shrews.

Hindlimb ischemia is still a clinical problem with high morbidity and mortality. Patients suffer from consequent rest pain, ulcers, cool limbs, and even amputation. Angiogenesis is a promising target for the treatment of ischemic limbs, providing extra blood for the ischemic region. In the present study, we investigated the role of umbilical cord-derived mesenchymal stem cells (UC-MSCs) in regulating angiogenesis and relieving hindlimb ischemia. UC-MSCs were isolated from the umbilical cord of tree shrews. Angiography results showed that UC-MSCs injection significantly promoted angiogenesis in tree shrews. Moreover, the ankle brachial index, transcutaneous oxygen pressure, blood perfusion, and capillary/muscle fiber ratio were all markedly increased by the application of UC-MSCs. In addition, the conditioned culture of human umbilical vein endothelial cells using medium collected from UC-MSCs showed higher expression of angiogenic markers and improved migration ability. In short, the isolated UC-MSCs notably contributed to restoring blood supply and alleviating the symptoms of limb ischemia through enhancing angiogenesis.

Limb ischemia: cardiovascular diagnosis and management from head to toe.

Peripheral arterial disease (PAD) affects an estimated 27 million people in Europe and North America. Limb ischemia, defined as ischemic rest pain, ischemic ulcerations, or ischemic gangrene, represents the most severe manifestation of PAD and is associated with significant cardiovascular and limb morbidity and mortality. Critical limb ischemia (CLI), defined as limb ischemia symptoms for greater than 2weeks, is characterized by a cascade of hemodynamically significant macrovascular atherosclerotic obstruction and microvascular changes culminating in decreased muscle perfusion, disrupted muscle energy metabolism, and inflammation. In contrast, acute limb ischemia (ALI) is defined as limb ischemia symptoms characterized by sudden onset of less than 2weeks duration resulting in hemodynamically compromised limb perfusion. Diagnosis of both ALI and CLI is dependent on history, physical examination, and a combination of anatomic and hemodynamic assessment of the limb. Given that the risk factors for ALI and CLI overlap with risk factors for atherosclerotic coronary and neurovascular disease, the management of limb ischemia is focused on both endovascular or surgical limb salvage and cardiovascular risk factor control. Despite advancements in endovascular and surgical revascularization techniques, limb morbidity remains high; clinical trials of angiogenic and cell-based therapies are ongoing. Cardiovascular risk reduction in patients with limb ischemia also remains suboptimal and future studies will focus on novel antiplatelet agents.

Outcome of Surgical Management for Abdominal Aortic Pseudoaneurysm in Behçet Disease: A Shift From Open Surgery Towards Endovascular Repair

Objectives: Remote endarterectomy (RE) is a minimally invasive procedure conceived as an alternative to an above-the-knee bypass for patients with symptomatic limb ischemia. Successful RE outcome is frequently hampered by adherent plaque within and beyond the adductor canal and the insertion of a stent. We present a case series of modified RE enhanced by the addition of a distal leg incision to accomplish a longer segment plaque excision without the need for a distal stent. Methods: A retrospective record review identified RE procedures performed from May 2010 through March 2012. Adjunctive patch angioplasty was used to close the arteriotomies. Demographics, lesion characteristics, procedural details, andoutcomedatawere collected. Study endpointsweredeath, occlusion, reoperation, or last office follow-up visit. Results: REwas performed in 11 patients (5men;mean age, 68 years, 3 diabetics, 11 tobacco users). Indication for operation was claudication in 6, rest pain in 3, and gangrene in 2.REwas technically successful in all patients.Distal arterial exposure was above knee in 7 (64%), below knee in 2 (18%), and combined above-knee and below-knee exposures in 2 patients (18%). Two patients underwent concomitant balloon angioplasty in either the popliteal or anterior tibial vessels. Mean postoperative ankle-brachial index increase was .43 (P 1⁄4 .001). Operative complication of above-knee popliteal artery perforation occurred in one patient but was successfully repaired with covered stent deployment. Average procedure duration was 162 6 69 minutes (standard deviation) and average hospital stay was 4 days. All patients reported symptom resolution; both patients with tissue ulceration healed. During the 12-month follow-up period, a femoropopliteal reocclusion developed in four patients, resulting in one patient who underwent a successful femoral-popliteal bypass operation. Limb salvage rate was 100%. Conclusions: When endovascular therapies are exhausted, and should autologous saphenous vein be unavailable, the dual incision RE technique of long segment femoropopliteal occlusive lesions accomplishes effective revascularization. Symptom relief or limb salvage was achieved in all patients; the need for a subsequent bypass was rare and not adversely affected by having undergone the dual incision RE.

Dual Incision Remote Endarterectomy Is a Novel Treatment Option for Long-Segment Superficial Femoral-Popliteal Artery Occlusive Disease

Objectives: Remote endarterectomy (RE) is a minimally invasive procedure conceived as an alternative to an above-the-knee bypass for patients with symptomatic limb ischemia. Successful RE outcome is frequently hampered by adherent plaque within and beyond the adductor canal and the insertion of a stent. We present a case series of modified RE enhanced by the addition of a distal leg incision to accomplish a longer segment plaque excision without the need for a distal stent. Methods: A retrospective record review identified RE procedures performed from May 2010 through March 2012. Adjunctive patch angioplasty was used to close the arteriotomies. Demographics, lesion characteristics, procedural details, andoutcomedatawere collected. Study endpointsweredeath, occlusion, reoperation, or last office follow-up visit. Results: REwas performed in 11 patients (5men;mean age, 68 years, 3 diabetics, 11 tobacco users). Indication for operation was claudication in 6, rest pain in 3, and gangrene in 2.REwas technically successful in all patients.Distal arterial exposure was above knee in 7 (64%), below knee in 2 (18%), and combined above-knee and below-knee exposures in 2 patients (18%). Two patients underwent concomitant balloon angioplasty in either the popliteal or anterior tibial vessels. Mean postoperative ankle-brachial index increase was .43 (P 1⁄4 .001). Operative complication of above-knee popliteal artery perforation occurred in one patient but was successfully repaired with covered stent deployment. Average procedure duration was 162 6 69 minutes (standard deviation) and average hospital stay was 4 days. All patients reported symptom resolution; both patients with tissue ulceration healed. During the 12-month follow-up period, a femoropopliteal reocclusion developed in four patients, resulting in one patient who underwent a successful femoral-popliteal bypass operation. Limb salvage rate was 100%. Conclusions: When endovascular therapies are exhausted, and should autologous saphenous vein be unavailable, the dual incision RE technique of long segment femoropopliteal occlusive lesions accomplishes effective revascularization. Symptom relief or limb salvage was achieved in all patients; the need for a subsequent bypass was rare and not adversely affected by having undergone the dual incision RE.

Long-Term Effects of Beraprost Sodium on Arteriosclerosis Obliterans: a Single-Center Retrospective Study of Japanese Patients

Arteriosclerosis obliterans (ASO) causes ischemic symptoms of the lower limbs, reducing quality of life (QOL), and has a poor prognosis. Early diagnosis and treatment are necessary. In this study, the effects of long-term administration of beraprost sodium (beraprost) to treat ASO were investigated. One hundred and eighty eight patients treated with beraprost for ≥1 year were retrospectively identified. Outcomes were lower limb ischemic symptoms, carotid intima/media thickness (IMT), and cardiovascular events. Patients reported visual analog scale scores for major symptoms at baseline and after 3, 6, and 12 months of treatment. Overall, 188 patients (mean age 70.8 ± 10.15 years, Fontaine classification: grade I 14.4%, grade II 85.6%) treated with beraprost for 2.4-10.7 years (mean 6.5 years) were included in this study. Administration of beraprost significantly reduced patient-reported severity of lower limb ischemic symptoms in all patients at 12 months, including those with diabetes, hypertension, or dyslipidemia. IMT decreased from 1.09 ± 0.09 mm at baseline to 1.04 ± 0.11 mm at 12 months (P < 0.001). Decreases in IMT were similar in patients with diabetes, hypertension, or dyslipidemia. Overall, 26 (13.8%) events occurred during a mean follow-up of 6.5 years, including 23 cardiovascular events (unstable angina in three patients, myocardial infarction in six patients, cerebral infarction in eight patients, and transient cerebral ischemic attack in six patients) and non-cardiovascular death in three patients. Beraprost at 120 μg/day significantly reduced the risk of ischemic symptoms compared with <120 μg/day (adjusted hazard ratio: 0.17; 95% confidence interval: 0.06, 0.45; P < 0.001). No severe adverse events or adverse events requiring dose reductions/discontinuation occurred during long-term administration of beraprost. Beraprost reduced lower limb ischemic symptoms, IMT, and the incidence of cardiovascular events in patients with ASO.

Upper limb ischaemia after formation of dialysis fistula

Limb ischaemia caused by formation of dialysis fistula is rare but serious complication. The severity of symptoms may vary but rest pains and necrotic lesions are observed in most advance cases. In these patients different invasive procedures for treatment are performed - from simplest dialysis fistula ligation to complicated vascular reconstructions. The aim of the study was to evaluate treatment results of upper limb ischaemia triggered by dialysis fistula. We have analysed methods and results of treatment of 14 patients with symptomatic upper limb ischaemia caused by dialysis fistula treated in our department between 1st January, 2006 and 30th June, 2013. Treatment was subject to anatomical situation and clinical symptoms. In three patients the ligation of dialysis fistula was performed, four patients underwent inflow reconstruction - in one case by ligation of ligation of vein branch, in three patients by cephalic transfer of arterial anastomosis. In 2 patients hyperkinetic fistula aneurysm was excised and replaced by PTFE bypass, in three patients fistula reconstruction with DRIL method (distal revascularization - interval ligation) was performed, in one patient surgical operation of brachial artery stenosis was conducted. One patient underwent brachial artery angioplasty. Rest pains occurred in all patients (100%), regressive changes in 10 patients (71.4%). Eight patients (57.2%) had concomitant diabetes, seven (50%) ischaemic heart disease, five (35.5%) chronic lower limb ischemia and hyperparathyroidism was observed in fivepatients (35.5%). The imaging studies in all patients revealed pathological steal syndrome (stealing blood to the fistula), in majority concurrent with other pathologies - obstruction stenosis of peripheral artery, defects in blood out flow from the limb. As a result of the surgical treatment, symptoms of limb ischaemia subsided in all patients. Critical limb ischaemia caused by dialysis fistula is a dangerous complication. In most cases there are several causes of ischaemia. Treatment methods should be selected individually for each patient and clinical situation. Clinical symptoms should subside as a result of optimal choice of treatment and, if possible, maintaining of dialysis access.

Comparison of Embolic Load in Femoropopliteal Interventions

To compare the incidence of distal emboli occurring during percutaneous transluminal angioplasty (PTA) and primary stent on the superficial femoral artery (SFA) METHODS: A total of 50 consecutive patients were entered in a prospective, randomized trial. Inclusion criteria were the presence of symptomatic limb ischemia due to stenosis or occlusion of the SFA. An embolic protection device was placed in the popliteal artery. The patients were then randomly assigned to undergo primary stent implantation or PTA. The filters were retrieved and sent for histologic examination. Stenting in the SFA produced more emboli (1.44 mm(3)) than PTA (0.772 mm(3)), P = .031. Reanalyzing the patients according to actual treatment performed, volume of debris in the stent group was 1.271 mm(3) and in the PTA group was 0.191 mm(3), P = .00087. Volume of embolized material during endovascular interventions in the SFA-above-knee popliteal artery is higher when a stent is used.