Treatment Of Critical Ischemia Research Articles

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.

Late results of surgical treatment of critical ischemia of the lower extremities after one-staged direct revascularization

Objective. To optimize the tactics of surgical treatment in patients, suffering chronic ischemia of the lower extremities with the help of elaboration and introduction of a one-staged direct and indirect revascularization into clinical practice.
 Materials and methods. Analysis of the treatment results in 162 patients, suffering obliterating atherosclerosis of the lower extremities vessels, who were treated in stationary in Department of Vascular Surgery of Zakarpattya Regional Clinical Hospital named after Andriy Novak in 2015 - 2020 yrs. The patients were distributed in accordance to the lower extremities ischemia degree: ІІB – 7 (4.3%), ІІІA – 61 (37.7%), ІІІB – 58 (35.8%), ІV – 36 (22.2%). All the patients have had atherosclerotic affection of femoro-ankle-foot segment of the main arteries with preservation of central blood flow in aorto-iliac segment.
 Results. Occlusion of femoral artery was noted in all patients. Occlusion of anterior tibial artery was revealed most frequently – in 72% of the patients, than in fibular - in 42% of patients (p=0.00), and equally frequently with occlusion of posterior tibial artery – in 68% (p=0.61). The foot arteries were involved into the process in 51 (31.5%) patients. Affection of 2-3 arteries of the shin were registered more frequently, than occlusion of one artery – in 109 (67.3%) and 48 (26.5%) patients, accordingly. Occlusive-stenotic affection of popliteal artery have had 127 (78.4%) patients.
 Mostly frequent affection of the shin arteries was observed in basin of anterior tibial artery – in 67 (41.4%) patients, as well as in combined affection of anterior and posterior tibial arteries - in 45 (27.8%) patients. Іsolated affection of posterior artery was revealed in 36 (22.2%) patients. Combined affection of posterior tibial and fibular was observed in 14 (8.6%) patients.
 Conclusion. Efficacy of indirect revascularization after the arterial inflow restoration is more prognosticated, than efficacy of its isolated conduction in environment of chronic critical ischemia of the lower extremities. Combined application of direct and indirect revascularization guarantees more secure positive result in remote postoperative period and enhancement of the extremities preservation index.

Long term efficacy and safety of rivaroxaban plus cilostazol in the treatment of critical ischemia of the lower limbs in a frail, elderly patient with non valvular atrial fibrillation

BackgroundMany patients with critical lower limb ischemia are not eligible for revascularization procedures. Still, given the emerging role of both platelet and coagulation activation in the formation of arterial thrombi, they may benefit from the novel anticoagulant and antiplatelet drugs.Case presentationWe describe the case of a male with critical lower limb ischemia complicated by older age, frailty, polymorbidity and non valvular atrial fibrillation, who was deemed as non eligible for surgery. The patient was successfully treated with the combination of rivaroxaban and cilostazol, and the clinical benefit was maintained throughout 32 months, with no occurrence of major or minor hemorrhagic or thrombotic events.ConclusionsTo our knowledge, this is the first report on the efficacy and safety of such a combination therapy in critical lower limb ischemia. In a clinical setting in which alternative pharmacological approaches are urgently needed, the association of rivaroxaban and cilostazol warrants further investigations.

Hemodynamic and clinical effectiveness of the bone marrow cell transplantation in treatment of critical ischemia of the lower extremities

Hemodynamic and clinical effectiveness of the bone marrow cell transplantation in treatment of critical ischemia of the lower extremities

Treatment of critical limb ischemia in patients with multilevel arterial lesions

The extreme manifestation of atherosclerotic lesion of the arteries of the lower extremities is the critical ischemia of the lower extremities. The number of high amputations in such patients ranges from 120 to 500 per 1 million population in the general population annually. In order to achieve the best results in the patency of the arterial bed in the near and distant periods, revascularization of the arteries of the proximal and distal blood flow is necessary. The aim of the work was to evaluate the possibilities and effectiveness of endovascular, open and hybrid arterial interventions on the lower extremities, particularly in patients with multilevel arterial disease, by conducting a retrospective analysis of treatment of critical ischemia. The results of the preoperative ultrasound duplex scan (UDS) of the arteries of 212 patients with critical ischemia of the lower limbs (CILL) shoved, that in 78 (36.8%) were multilevel arterial lesions (MLAL). Patients were divided into two groups. The first (main group) consisted of 50 patients (64%), who have been restored to the open-end and endovascular methods of MLAL, or only endovascular. The second (control) group included 28 patients (36%) — with restoration of permeability of the proximal segment without intervention on the arteries of the distal. Installed, during the period of 16 months, postoperative observation of 78 patients with MLAL, the primary frontal area of the femoral reconstruction in the main group was 92%, and limb preservation - 96%. In the control group, the permeability of the reconstruction zone was 75%, limb preservation — 82%. Thus, it has been established that the most optimal method of recovery of inflow and outflow pathways is one-time hybrid surgical interventions performed in 88% of these patients, which allow to achieve more effectively the recurrence of ischemia and maintain limb.

Influence of the patency of the plantar arch on the results of the treatment of critical ischemia based on the angiosome concept

Influence of the patency of the plantar arch on the results of the treatment of critical ischemia based on the angiosome concept

Endovascular Treatment of Critical Ischemia in the Diabetic Foot

This review discusses the role of endovascular treatment in diabetic patients with critical limb ischemia (CLI). Angioplasty of the femoropopliteal region achieves similar technical success and limb salvage rates in diabetic and nondiabetic patients. Angioplasty in as many as possible tibial vessels is accompanied by more complete and faster ulcer healing as well as better limb salvage rates compared to isolated tibial angioplasty. Targeted revascularization of a specific vessel responsible for the perfusion of a specific ulcerated area is a promising new approach: it replaces revascularization of the angiographically easiest-to-access tibial vessel, even if this is not directly responsible for the perfusion of the ulcerated area, by revascularization of area-specific vascular territories. In conclusion, the endovascular approach shows very high efficacy in ulcer healing for diabetic patients with CLI. Larger prospective studies are now needed to estimate the long-term results of this approach.

THE PLACE OF VASCULAR SURGERY IN TREATMENT OF DIABETIC PATIENTS

This article is dedicated to diagnostics, prevention and surgical treatment of vascular complications of diabetes mellitus, particularly prevention of ischemic strokes and treatment of critical ischemia of lower limbs. The main tendency in treatment of brachiocephalic artery lesions nowadays is a surgical intervention in the latent stage of the disease. X-ray endovascular surgical techniques are being increasingly used to treat lesions of lower limbs arteries. Limb preservation is impossible without cooperation of many specialists. It's essential to perform careful out-patient follow up of the patient after vascular reconstructive surgery.

Revascularization of ischemic limbs after transplantation of human bone marrow cells with high aldehyde dehydrogenase activity

AbstractThe development of cell therapies to treat peripheral vascular disease has proven difficult because of the contribution of multiple cell types that coordinate revascularization. We characterized the vascular regenerative potential of transplanted human bone marrow (BM) cells purified by high aldehyde dehydrogenase (ALDHhi) activity, a progenitor cell function conserved between several lineages. BM ALDHhi cells were enriched for myelo-erythroid progenitors that produced multipotent hematopoietic reconstitution after transplantation and contained nonhematopoietic precursors that established colonies in mesenchymal-stromal and endothelial culture conditions. The regenerative capacity of human ALDHhi cells was assessed by intravenous transplantation into immune-deficient mice with limb ischemia induced by femoral artery ligation/transection. Compared with recipients injected with unpurified nucleated cells containing the equivalent of 2- to 4-fold more ALDHhi cells, mice transplanted with purified ALDHhi cells showed augmented recovery of perfusion and increased blood vessel density in ischemic limbs. ALDHhi cells transiently recruited to ischemic regions but did not significantly integrate into ischemic tissue, suggesting that transient ALDHhi cell engraftment stimulated endogenous revascularization. Thus, human BM ALDHhi cells represent a progenitor-enriched population of several cell lineages that improves perfusion in ischemic limbs after transplantation. These clinically relevant cells may prove useful in the treatment of critical ischemia in humans.

Successful bosentan treatment of critical ischaemia induced by vasculitis in an SCLE patient

Successful bosentan treatment of critical ischaemia induced by vasculitis in an SCLE patient

Subintimal Angioplasty as a Treatment of Femoropopliteal

The authors describe their experience with treating 109 patients with intermittent claudication (78) and critical ischemia (46) by the use of subintimal recanalizations of above-knee femoropopliteal occlusions. Data was entered into a computerized registry and all cases were reviewed. Comorbidities, indication, runoff, and occlusion length was compared with patency by statistical analysis. The authors report technical success rate of 90% but a low assisted patency rate of 37% by 12 months of follow-up. They conclude that subintimal angioplasty is an alternative to open surgery for patients with femoro-popliteal occlusions and intermittent claudication but is contraindicated in the treatment of critical ischemia except in cases where the patient is not able to have surgical treatment.

Can we treat lower limb critical ischaemia with chemical sympathectomy?

Chemical lumbar sympathectomy was first introduced into medical practice in the 1920s. It has been used to treat a variety of conditions from muscular spasm to hyperhydrosis, although it has been used most widely in the treatment of complex regional pain syndrome and also in the treatment of critical ischaemia of the lower limb.

Subintimal angioplasty as a treatment of femoropopliteal artery occlusions

Objectives: to report the results of subintimal PTA of femoropopliteal occlusions above the knee. Design: a retrospective study. Patients: in the period from January 1997 to January 2002, 109 patients were submitted to 124 interventions. The indication for treatment was intermittent claudication in 78 cases and critical ischaemia in 46. Methods: all cases of subintimal angioplasty were prospectively registered. A review of all cases treated with subintimal PTA for above-knee femoropopliteal occlusions were done. Primary assisted haemodynamic patency rate was calculated on intention to treat basis and for successfully treated cases. Comparison of patency with respect to comorbidities, indication, runoff and occlusion length was done with univariate and multivariate analysis (Cox' regression). Results: technical success rate was 90%. Primary assisted patency rates at 6, 12 and 18 months were 43, 37 and 31% calculated on basis of intention to treat and 48, 42 and 35% for successfully treated cases. Diabetes mellitus and critical ischaemia were found to be independent risk factors for re-occlusion. Conclusion: subintimal angioplasty is an alternative to open surgery for patients with femoropopliteal occlusions and intermittent claudication. The treatment is relatively atraumatic, complications are rare and in most cases treated with endovascular techniques. Patency rates are low. In cases of critical ischaemia, time can be important for outcome with respect to limb salvage. We therefore find that the poor patency rates of subintimal angioplasty of femoropopliteal occlusions contraindicate its use in the treatment of critical ischaemia with exception of cases unsuitable for surgical treatment.Eur J Vasc Endovasc Surg 25, 578-582 (2003)

Polytetrafluoroethylene (PTFE) femorodistal grafts with a distal vein cuff for critical ischaemia

To analyse the results of PTFE femorodistal bypass grafts using a distal anastomotic vein cuff in the treatment of critical ischaemia. Prospective study of consecutive patients under the care of a single Vascular Surgeon. A dedicated Vascular Surgical Unit in a University teaching hospital. Fifty-one consecutive femorodistal PTFE grafts were performed on 50 patients (median 74 years, range 58-94 years, 25 men; median ankle:brachial index 0.4). In 28 (55%) a common ostium arteriovenous fistula (AVF) was fashioned at the distal anastomosis. The 30-day postoperative mortality was 8%, with 10 (21%) major complications. The 1 and 2 year primary patency was 64% and 51%, respectively, with corresponding limb salvage rates of 85% and 80%. The presence of an AVF did not significantly affect graft patency or patient survival, but appeared to hinder limb salvage. The latter effect may be due to bias in patient selection. PTFE femorodistal grafts with a distal vein cuff are a suitable alternative to autogenous saphenous vein in distal reconstructions for critical ischaemia. No conclusions can be made about the efficacy of an AVF in this context.

The role of percutaneous transluminal angioplasty in the treatment of critical ischaemia

In an attempt to establish the overall role played by percutaneous transluminal angioplasty in the treatment of critical ischaemia we studied 101 consecutive patients (110 limbs) who presented to one vascular unit over an 18 month period with this diagnosis. All patients underwent assessment with Doppler waveform analysis and arteriography and decisions about further management were made jointly by the surgical team and vascular radiologist. Results showed that only 24/110 limbs (22%) had lesions that were suitable for treatment with angioplasty alone. In addition one patient underwent angioplasty in conjunction with a distal bypass. Forty-one of the 110 limbs (37%) underwent reconstructive surgery, 18/110 (16%) primary amputation and 26/110 (24%) conservative treatment. Of those 24 limbs undergoing angioplasty, four were technically unsuccessful, and six were technically successful but without clinical improvement and all required alternative treatment. Only 12/110 limbs (11%) showed clinical improvement during their admission following angioplasty. We conclude that although angioplasty can be used successfully to treat critical ischaemia the overall numbers of patients who are suitable for treatment and who gain benefit from it is small.