L’ischémie critique chronique des membres : organisation de la prise en charge d’une maladie maligne

Chronic critical ischemia of the limbs (CCIL) typically raises the problem of early diagnosis and specialized treatment. The challenge is considerable since the incidence of CCIL is in the range of 500 to 1,000 patients/million inhabitants/year, with an incidence of major amputations from 100 to 300/million inhabitants/year. Mortality of these patients reaches 20% at 6 months and more than 80% at 10 years, which places the CCIL in the group of highly malignant oncological diseases. Despite therapeutic advances, the rate of amputations continues to progress especially in diabetics whose life expectancy is increasing due the excellent contribution of coronaropathy. Prequisites are summarized in the TASC consensus and in the discussions conducted during the creation of vascular centres: multidisciplinary teams, arteriopathy register (including CCIL and center audits), development of protocols (evaluation cost - efficiency of revascularization and medical treatments, evaluation of angiogenesis projects), collaboration between vascular centers and networks. CCIL is a malignant disease with an increasing incidence implying early and specialized care; means exist but efforts have to be made regarding their evaluation and coordination.

Acute mesenteric ischemia: still high mortality rate in the era of 24-hour availability of angiography

BACKGROUND

Acute mesenteric ischemia (AMI) is a serious condition with high mortality rate due to difficult and late diagnosis. Early and aggressive evaluation in high risk patients by mesenteric angiography is the key to the reduction in mortality rate. However; many physicians hesitated to perform it because of its availability, the risk of complications and high negative results. This study reviewed outcome of AMI in term of mortality rate, factors associated with mortality and the rate of angiography in high risk patients.

MATERIAL AND METHOD

The clinical data of the patients who were diagnosed as AMI were retrospectively reviewed. The clinical outcome was recorded and the factors associated with mortality were analysed.

RESULTS

Thirty-five patients were enrolled into this study during 5 years. The mortality rate was 74.3%. There were 22 high risk patients for AMI. The rate of angiography performed in this group was 4.5% (1/22). The factors associated with mortality were age more than 60 years, patients with peritonitis, hypotension, arterial cause, time interval between admission and operation or treatment more than 24 hours, bowel gangrene >100 cms. However all these factors were not statistically significant.

CONCLUSION

The mortality rate of AMI is still high even at the tertiary hospital where the angiography is available 24 hours. To decrease the mortality rate, the physicians must have the high index of suspicion in high risk patients and do not hesitate to perform early mesenteric angiography.

Inflammatory mediators are associated with 1-year mortality in critical limb ischemia

OBJECTIVE

The atherosclerotic process has inflammatory features. Patients with peripheral atherosclerosis and critical limb ischemia have a poor prognosis. This study evaluated the hypothesis that inflammatory markers are associated with mortality among patients admitted to the hospital because of critical limb ischemia.

METHODS

This was a prospective, single-center, 1-year, follow-up study of 259 consecutive patients with critical limb ischemia who were admitted to a secondary referral center of vascular diseases. Interventions included evaluation of intercurrent disease, ankle and arm blood pressures, plasma glucose and lipid levels, plasma homocysteine, cardiolipin antibodies, resistance to activated protein C, plasma endothelin-1, and the inflammatory mediators tumor necrosis factor-alpha, interleukin-6, neopterin, high-sensitivity C-reactive protein, CD40 ligand, and 8-iso-prostaglandin F alpha in plasma. The main outcome measure was total mortality and causes of death assessed 1 year after admission.

RESULTS

During the first year after admission, 61 patients (24%) died. These patients were older (P < .0001), showed a higher leukocyte count (P = .0011) and levels of serum creatinine (P < .0001), lower levels of high-density lipoprotein (HDL) cholesterol (P = .003) and frequency of active treatment (P = .014) than the 198 (76%) survivors. More nonsurvivors had gangrene (P < .0001), and fewer (P = .004) had lipid-lowering treatment. The plasma levels of interleukin-6 (P < .0001), tumor necrosis factor-alpha (P < .0001), neopterin (P < .0001), and high-sensitivity C-reactive protein (P = .002) at admission for critical limb ischemia were all significantly lower in the survivors, whereas there was no difference concerning CD40 ligand. In logistic regression adjusted for age, sex, lipid-lowering therapy, active treatment, gangrene, leukocyte count, creatinine, and serum HDL cholesterol, the inflammatory mediators tumor necrosis factor-alpha (P = .0084), neopterin (P = .0035), but not interleukin-6 (P = .585) or high-sensitivity C-reactive protein (P = .314) were independent risk variables of death within 1 year.

CONCLUSIONS

Increased age, leukocyte count, creatinine, and inflammatory mediators, together with gangrene, were associated with 1-year mortality despite intervention in critical limb ischemia. For tumor necrosis factor-alpha and neopterin in plasma, this association was independent of the other parameters.

Surgery for mesenteric infarction: prognostic factors associated with early death within 72 hours

OBJECTIVE

The aim of this study was to look for preoperative and postoperative prognostic factors for early mortality, likely to be of use to clinicians in decision making.

DESIGN

Prospective multicenter study.

SETTING

This study was conducted in 4 university hospitals in Northeast France.

PARTICIPANTS

One hundred thirty-one patients with mesenteric infarction confirmed by pathologic examination were included.

INTERVENTIONS

All patients underwent surgery and were hospitalized in the intensive care unit.

MAIN RESULTS

Twenty-eight patients (21.3%) underwent exploratory laparotomy only; 103 patients underwent bowel resection with/or without associated revascularization. The overall mortality rate at discharge was 74.8%. In the first 3 days, 60% of deaths occurred. The prognostic factors for death within 72 hours, obtained by logistic regression, were preoperative heart failure, lactate level over 5 mmol/L, aspartate aminotransferase over 200 IU/L, and total cholesterol level below 80 mg/dL, or procalcitonin level over 40 ng/L. From these results, a mortality prognostic score was derived. Probability of mortality within 72 hours was estimated to be 5% for patients with none of these factors and 97% for those with all 4. For deaths occurring after 72 hours, the only mortality prognostic factor was the existence of necrosed areas at the ends of bowel resections.

CONCLUSION

When patients have fewer than 3 of the prognostic factors described in the score, aggressive medical and surgical strategies could be appropriate. If necrosis is recorded at the ends of the resection, renewed surgery should be undertaken as soon as signs of new disturbances appear.

Transluminal angioplasty of isolated crural arterial lesions in diabetics with critical limb ischemia

Background: We investigated the long-term clinical results of transluminal angioplasty of isolated infrapopliteal arteries in diabetic patients with severe ischaemic foot lesions and the influence of different parameters on primary success, the long-term outcome and the survival rate. Patients and methods: Between January 2001 and May 2004 we performed 50 transluminal angioplasties in 52 (10 female, 42 male, mean age 69.3 years) diabetics with isolated lesions of crural arteries (tibio-peroneal trunk 41, anterior tibial 13, posterior tibial 5, peroneal artery 14) and limb threatening ischaemia (rest pain 12, tissue loss 40). In two patients the dilatation could not be performed due to vessel perforation and impossibility to catheter localization. The morphological classification of infrapopliteal lesions was determined according to guidelines provided by TransAtlantic Inter-Society Consensus (TASC) (17 type A, 16 type B, 13 type C, 4 type D). Results: Initial technical success after angioplasty of crural arteries could be obtained in 96%.Kaplan-Meier analysis showed a cumulative limb salvage of 92%,85% and 68, 9% after 6 months,one and two years, respectively. Patients falling in TASC group C had significantly higher risk of amputation. Overall survival at 1 year was calculated at 85% and at 2 years at 65%. Conclusion: Our results suggest that depending on the extent of lesions transluminal angioplasty of infrapopliteal artery stenoses and occlusions is considered as an effective and save therapy modality to avoid limb loss in diabetics with critical ischemia.

Acute mesenteric ischemia: the challenge of gastroenterology

Intestinal ischemia has been classified into three major categories based on its clinical features, namely, acute mesenteric ischemia (AMI), chronic mesenteric ischemia (intestinal angina), and colonic ischemia (ischemic colitis). Acute mesenteric ischemia is not an isolated clinical entity, but a complex of diseases, including acute mesenteric arterial embolus and thrombus, mesenteric venous thrombus, and nonocclusive mesenteric ischemia (NOMI). These diseases have common clinical features caused by impaired blood perfusion to the intestine, bacterial translocation, and systemic inflammatory response syndrome. Reperfusion injury, which exacerbates the ischemic damage of the intestinal microcirculation, is another important feature of AMI. There is substantial evidence that the mortality associated with AMI varies according to its cause. Nonocclusive mesenteric ischemia is the most lethal form of AMI because of the poor understanding of its pathophysiology and its mild and nonspecific symptoms, which often delay its diagnosis. Mesenteric venous thrombosis is much less lethal than acute thromboembolism of the superior mesenteric artery and NOMI. We present an overview of the current understanding of AMI based on reported evidence. Although AMI is still lethal and in-hospital mortality rates have remained high over the last few decades, accumulated knowledge on this condition is expected to improve its prognosis.

Antegrade revascularisation for chronic visceral ischaemia

There is no consensus of opinion on the best surgical approach for the management of chronic visceral ischaemia. The antegrade revascularisation has several advantages. It provides an excellent exposure of the supraceliac aorta, the option of originating the bypass from several areas of the distal thoracic and supraceliac aorta that is usually spared of atherosclerosis and the bypass is placed in the direction of normal blood flow (antegrade direction). The supraceliac aorta can be approached through an abdominal or a low thoracoabdominal extraperitoneal route. The results on several series indicate that it is a durable and effective technique.

Contemporary Series of Morbidity and Mortality after Lower Limb Amputation

OBJECTIVES

This study was performed in order to assess morbidity and mortality associated with major lower extremity amputation according to an extensive complication registration system used in our hospital.

METHODS

All consecutive patients who underwent lower limb major extremity amputation were included from January 1996 until December 2002. Complications were prospectively registered according to our standard complication registration system.

RESULTS

In 97 patients 122 amputations were performed including 45 above (AKA) and 77 below (BKA) knee amputations. The conversion rate from below to above knee amputation was 14%. In 65 patients 107 complications occurred (67%). The incidence of wound infection was 10% in the BKA group and 2% in the AKA group. The most frequently reported complications were pressure sores (8%) or originating from the urinary tract (13%). The hospital mortality for BKA was 9% and for AKA 18%. Long-term survival was 62% at 1 year, 50% at 2 years and 29% at 5 years.

CONCLUSIONS

An extensive registration system provides us with a detailed insight into the incidence, consequence and cause of complications. Major lower extremity amputations are still associated with considerable morbidity and mortality.

Peripheral Angioplasty as the First-choice Revascularization Procedure in Diabetic Patients with Critical Limb Ischemia: Prospective Study of 993 Consecutive Patients Hospitalized and Followed Between 1999 and 2003

OBJECTIVE

To evaluate the effectiveness of peripheral angioplasty (PTA) as the first-choice revascularisation procedure in diabetic patients with critical limb ischemia (CLI).

DESIGN

Prospective study.

METHODS

PTA was employed as first choice revascularisation in a consecutive series of diabetic patients hospitalized for CLI between January 1999 and December 2003.

RESULTS

PTA was successful performed in 993 patients. Seventeen (1.7%) major amputations were carried out. One death and 33 non-fatal complications were observed. Mean follow-up was 26+/-15 months. Clinical restenosis was observed in 87 patients. The 5 years primary patency was 88%, 95% CI 86-91%. During follow-up 119 (12.0%) patients died at a rate of 6.7% per year.

CONCLUSIONS

PTA as the first choice revascularisation procedure is feasible, safe and effective for limb salvage in a high percentage of diabetic patients. Clinical restenosis was an infrequent event and PTA could successfully be repeated in most cases.

Excimer Laser Assisted Angioplasty for Critical Limb Ischemia: Results of the LACI Belgium Study

BACKGROUND

The purpose of this study was to assess the safety and efficacy of translating into national practice methodology for infrainguinal excimer laser-assisted angioplasty, for the treatment of critical limb ischemia in poor surgical bypass candidates.

METHODS

A prospective five centre Belgian registry enrolled 48 patients, who presented with 51 chronic critically ischemic limbs (Rutherford category 4, 5 or 6) and were poor candidates for bypass surgery. Treatment included crossing the occlusion or stenosis by conventional guidewire followed by excimer laser angioplasty with, or without, adjunctive balloon angioplasty or stenting. A step-by-step technique was used in cases where the guidewire could not pass the occluded site. The primary endpoint was limb salvage, at 6 months, of the treated limb.

RESULTS

Initial treatment was successful in all 51 limbs. By 6 months there had been six deaths, six minor and four major amputations and further intervention was required in four patients. Among survivors, limb salvage rate at 6 month was 38/42 (90.5%), with freedom from critical limb ischemia in 86%.

CONCLUSIONS

This Belgian study of excimer laser assisted angioplasty, in high-risk patients who were poor candidates for surgical re-vascularisation, had a low incidence of surgical re-interventions and limb salvage rate in excess of 90%.

Safety and efficacy of superselective angioembolization in control of lower gastrointestinal hemorrhage

BACKGROUND

We evaluated the safety and efficacy of angioembolization to control lower gastrointestinal hemorrhage.

METHODS

Retrospective chart review of patients undergoing angiography for lower gastrointestinal hemorrhage from January 2000 to December 2002.

RESULTS

Seventy-seven patients with lower gastrointestinal hemorrhage underwent mesenteric angiography. Angioembolization was performed in 11 patients. Sixty-six patients were not embolized; 47 of these were treated medically and 19 surgically. Mortality rate was not significantly different in patients treated surgically (3 of 19, 16%) versus those managed medically (6 of 47, 13%; P = 0.746). Of the 11 patients who were embolized, 10 had immediate cessation of hemorrhage, 7 had gastrointestinal ischemia, and 6 died (55%). Overall mortality in non-embolized patients was 9 of 66 (14%; P = 0.002 versus mortality in embolized patients).

CONCLUSIONS

Angioembolization, though effective at controlling hemorrhage, is associated with ischemic complications and a high mortality rate. Our data support surgical or medical management for lower gastrointestinal hemorrhage.

Critical appraisal of femorofemoral crossover grafts

Background

The aim of this study was to determine how often femorofemoral crossover grafting for critical ischaemia or intermittent claudication gives an ideal result. An ideal result is an uncomplicated operation with primary wound healing, relief of ischaemic symptoms without recurrence and no need for further intervention.

Methods

All patients undergoing primary femorofemoral crossover grafting between January 1988 and December 2003 were studied.

Results

Some 144 operations were analysed; 51 patients had critical ischaemia and 93 claudication. There was one postoperative death (0·7 per cent). Complications occurred within 30 days in 32 patients (22·2 per cent), including graft occlusion in three (2·1 per cent); six patients (4·2 per cent) required early reoperation. Primary patency for patients with critical ischaemia was 88, 82 and 74 per cent at 1, 3 and 5 years respectively. Respective figures for those who presented with claudication were 93, 92 and 90 per cent (P = 0·034). Late symptoms included graft occlusion (20 patients), disease progression (25), ongoing ulceration (six), graft infection (nine), false aneurysm formation (two) and late donor-site stenosis (two).

Conclusion

When obtaining informed consent, simply describing patency and limb salvage rates does not provide an accurate picture of the outcome of femorofemoral grafting.

Vascular complications of the intra-aortic balloon counterpulsation

From September 1994 to December 2002, 6,274 cardiosurgery operations were performed at the Department of Cardiac Surgery, University Hospital, Hradec Kralove, Czech Republic. Intra-aortic balloon counterpulsation (IABP) was applied in 192 cases (3.1%). From this group of 192 counterpulsated patients 103 were successfully treated (53.6%); 89 counterpulsated patients (46.4%) died from the surgical procedure (30-day mortality rate). In 5 cases (2.6%) from the group of 192, the IABP was introduced before the operation. Ischemic changes of the limb were observed in 11 cases (5.7%). Significant bleeding occurred at the site of puncture in 6 cases (3.1%). Dissection of the femoral and iliac arteries was found in 2 patients (1.0%), perforation of the iliac artery in 1 case (0.5%). In 2 cases (1.0%) the balloon was led into the venous system. In case report No. 1 an introduction of the balloon under a sclerotic plaque of the descending aorta and iliac artery is described. In case report No. 2 a placement of the balloon in the venous bloodstream is reported.

Sharp liver transection versus clamp crushing technique in liver resections: A prospective study

BACKGROUND

Parenchymal liver transection constitutes an important phase of liver resection. Serious intraoperative bleeding, together with injuries to vital structures of the liver remnant, can occur during this stage. A method of sharp liver parenchymal transection with scalpel is compared in a prospective randomized manner with the widely used clamp crushing technique.

METHODS

Patients scheduled for hepatectomy under selective hepatic vascular exclusion (N = 82) were allocated randomly to either the sharp transection group (n = 41) or the clamp crushing group (n = 41). Warm ischemic time, blood loss and transfusions, postoperative morbidity and mortality, and tumor-free margins were recorded in both groups and analyzed.

RESULTS

When the sharp transection group was compared with the clamp crushing group, the two groups were similar in warm ischemic time (median 36 vs 34 minutes), total operative time (median 205 vs 211 minutes), intraoperative blood loss (median 500 vs 460 mL), blood transfusion requirements (median value 0 in both groups), and overall complication rate (44% vs 39%). However, sharp transection yielded better tumor-free margins compared with the clamp crushing technique (12 +/- 1.4 mm vs 8 +/- 1.5 mm, mean +/- SD, P < .05).

CONCLUSION

Sharp liver parenchymal transection with a scalpel is equally safe in terms of blood loss and mortality compared with the clamp crushing method. Although it is a technically demanding method, requiring selective hepatic vascular occlusion, it may be recommended when the tumor-free margins are anticipated to be narrow.

Management of Peripheral Vascular Disease

The management of patients with peripheral arterial occlusive disease (PAD) has to be planned in the context of natural history, epidemiology, and apparent risk factors that predict deterioration. The ankle-brachial index to date has proved to be the most effective, accurate, and practical method of PAD detection. Given that PAD is a powerful indicator of systemic atherosclerosis and (independent of symptoms) is associated with an increased risk of myocardial infarction and stroke, as well as a six times greater likelihood of death, the prevalence and demographic distribution of measurable PAD becomes particularly relevant. Reliable information on interventions to confer symptom relief is much weaker and reflects discrepancies between published reports from centers of excellence and the experience of patients routinely treated in communities around the world. The impact of newer treatment modalities, such as complex endovascular procedures and therapeutic angiogenesis, has been a subject of recent controversy.

Leukocytosis and ischemic vascular disease morbidity and mortality: is it time to intervene?

The association between leukocytosis and increased morbidity and mortality of ischemic vascular disease has been observed for more than half a century, and recent studies in >350,000 patients confirm the robustness of the association and the dramatically higher relative and absolute acute and chronic mortality rates in patients with high versus low leukocyte counts. Although there is reason to believe that the association is not causal (that is, that leukocytosis is simply a marker of inflammation), there is also reason to believe that the leukocytosis directly enhances acute thrombosis and chronic atherosclerosis. Leukocytosis also is associated with poor prognosis and vaso-occlusive events in patients with sickle cell disease, and experimental data suggest a direct role for leukocytes in microvascular obstruction. The only way to test whether leukocytes contribute directly to poor outcome in ischemic cardiovascular disease is to assess the effect of modifying leukocyte function or number. Because selective blockade of leukocyte integrin alphaMbeta2 and P-selectin have thus far been disappointing as therapeutic strategies in human cardiovascular and cerebrovascular disease, I discuss the potential risks and benefits of short-term treatment with hydroxyurea to decrease the leukocyte count in select populations of patients at the highest risk of short-term death.

Pancreatic ischemia associated with vasospasm in the early phase of human acute necrotizing pancreatitis

OBJECTIVES

The angiographic appearance of acute necrotizing pancreatitis (ANP) demonstrates ischemic change with vasospasm in and around the pancreas. We investigated the role of vasospasm in pancreatic ischemia and necrosis in the early phase of human ANP.

METHODS

The relationship between the angiographic abnormalities and the perfusion status of the pancreas documented by contrast-enhanced computed tomography (CE-CT) was examined in 102 patients with ANP who were admitted during the early phase of the disease.

RESULTS

Ischemic change with vasospasm on angiography of the intrapancreatic and extrapancreatic arteries was observed and corresponded with the poorly perfused area of the pancreas detected by CE-CT done at admission. Resultant pancreatic necrosis was confirmed on follow-up CE-CT examination consistent with the location where angiography demonstrated ischemic change with vasospasm. Severe ischemic change on angiography was primarily observed in patients in whom more than 50% of the pancreas was poorly perfused. The extent of the ischemic change was correlated with the extent of the poorly perfused area of the pancreas and the mortality rate.

CONCLUSION

These results suggest that vasospasm is involved in the development of pancreatic ischemia and necrosis in the early phase of ANP.

Prognostic factors for amputation or death in patients submitted to vascular surgery for acute limb ischemia

OBJECTIVE

To investigate the risk profile of patients with thrombosis and emboli, and prognostic factors for death or amputation in patients presenting with acute limb ischemia in a tertiary care regional hospital in Brazil.

METHODS

A prospectively planned cohort study was carried out in which 83 patients with acute limb ischemia, secondary to thrombosis, or embolism, classified in stages II and III of severity were evaluated. Univariate analysis and logistic regression models were used to explore the relationship between anthropometric and demographic characteristics, comorbidities, cardiovascular risk factors, duration of occlusion, and type of surgery with the incidence of amputation or death, which were evaluated in 30 days and 1 year thereafter.

RESULTS

Male gender, smoking, and comorbidities were more frequent among patients with thrombosis, and atrial fibrillation was more common among patients with embolism. Occlusion longer than 24 hours (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.1-7.6) and a trend for diabetes (RR 2.6, 95% CI 0.9-7.5) were the characteristics associated with death or amputation in the multivariate analysis, which occurred in 15 (18.1%) and 24 (28.9%) of the participants, respectively. Reperfusion injury was a risk factor for death but not for amputation (OR 16.9, 95% CI 1.1-232.9) after adjustment for age, duration of occlusion, and diabetes.

CONCLUSIONS

Traditional and avoidable risk factors explain the occurrence of thrombosis and embolism in our region. Access to medical care is the most important and modifiable prognostic factor for death or amputation.

[Prevention of intestinal ischemia after abdominal aortic reconstructive surgery]

The aim of this study was to estimate rate of intestinal ischemic complications after abdominal aortic reconstructive surgery, to evaluate risk factors and to provide means of prevention of complication.

MATERIAL AND METHODS

Study group consisted of 172 patients who underwent aortic reconstruction in 2000-2003 in the Department of Vascular Surgery of Kaunas University of Medicine Hospital. Six patients underwent intestinal ischemia in the postoperative period, i. e. 3.5%; four of them died. This indicated that 13% of patients died after abdominal aortic surgery. Ninety-four patients underwent operation for aortoiliac occlusive disease, colon ischemia occurred in 1 case (1.1%). Seventy-eight patients underwent abdominal aortic aneurysm; 33 patients -- ruptured aneurysm, and 45 -- aneurysm without rupture. In ruptured abdominal aortic aneurysm group with III degree colon ischemia there were 3 cases (9.1%); 2 of them died, which formed 11% of all deaths in this group. In the group of non-ruptured abdominal aortic aneurysm with III degree colon ischemia there were 2 cases (4.4%). Both patients died, which formed 50% of all deaths in this group. For all patients operated for abdominal aortic aneurysm, a. mesenterica inferior stump pressure was evaluated. In case of stump pressure 50 mmHg and more a. mesenterica inferior was ligated. If pressure was lower than 50 mmHg a. mesenterica inferior was reimplanted into vascular graft. Forty-nine reconstructions of a. mesenterica inferior were made in abdominal aortic aneurysm group: 25 in ruptured cases, and 24 in non-ruptured cases. Despite the fact that a. mesenterica inferior was reconstructed, 2 patients had colon ischemia after this reconstruction in the group of ruptured aneurysm. In the group of non-ruptured aneurysm, colon ischemia developed only after ligation of a. mesenterica inferior. We conclude that a. mesenterica inferior is very important for normal circulation of left colon. Correct evaluation of preoperative aortography, correct operative strategy, and reimplanted a. mesenterica inferior if it is necessary -- are the main means of colon ischemia prevention after abdominal aortic surgery.

Outcomes of patients with atherosclerotic upper extremity tissue loss

Severe ischemia of the upper extremity causing tissue necrosis occurs much less frequently than in the lower extremity. The clinical outcome of patients diagnosed with digital nonhealing ulcer or gangrene is largely unknown. A retrospective review of patients with upper extremity tissue loss was performed. Patients with ischemia from embolic disease, steal syndromes, and vasospastic or connective tissue disorders were excluded. Thirteen patients with upper extremity ischemic gangrene and/or nonhealing ulcers were treated from January 1995 to June 2002. Comorbid conditions included diabetes mellitus in 10 patients and renal failure in 11 patients. Five patients developed bilateral upper extremity ischemia during the period of evaluation, while 8 had unilateral involvement. Nine patients had dry gangrene of a digit, 5 had nonhealing ulcers, and 1 patient developed wet gangrene from an ischemic ulcer. All 13 patients received local wound care and medical treatment with anticoagulants, calcium channel blockers, or antiplatelet agents. Ischemic lesions healed in 3 of the 5 patients with conservative management. Surgical intervention was performed on 6 patients with dry gangrene, and the patient with wet gangrene underwent amputation of the hand (53.8%). Two patients underwent sympathectomy without improvement. In the remaining 3 patients, tissue loss remained stable. Seven patients died within 2 years of presentation with upper extremity ischemia, with a survival at 24 months of only 14% by lifetable analysis. The local outcome of severe upper extremity ischemia is generally favorable, with good response to either medical management or digit amputation. However, the life expectancy of the patients with upper extremity ischemia from true atherosclerotic disease is dismal. Therefore, surgical intervention should be reserved for infection control or pain relief only.

Warum wird die mesenteriale Ischämie zu spät erkannt?

Survival of patients with acute mesenteric ischaemia is decisively dependent upon early diagnosis and non-delayed treatment. Maximum shortening of the admission-to-treatment-time is the main task, as the prehospital phase (e. g. symptom-to-admission-interval) varies considerably and is hardly to be influenced. "Acute mesenteric ischaemia" should early be considered as a possible diagnosis in patients presenting with abdominal symptoms of unknown cause bearing risk-factors for intestinal ischaemic disorders. In such cases an immediate angiography is the method of choice to confirm the diagnosis. To avoid irreversible intestinal damage, immediate laparotomy is induced if competent conducted angiography is not available within one hour after suspicion of intestinal ischaemia.

Is it possible to improve outcome in patients undergoing surgery for acute limb ischemia? Can iloprost, a prostacyclin analogue, be helpful?

Acute limb ischaemia (ALI) is a serious medical emergency leading to high rate of complications, being not only limb- but even life-threatening, often in spite of early successful revascularization. Concomitant underlying diseases, the metabolic derangement that seems a result of the acute insult and a possible reperfusion injury following revascularization may account for this severe prognosis. Only anticoagulation, fasciotomy and perioperative supportive treatment are established strategies in ALI patients. Possible benefit from chronic therapies active on vascular and cardiac side has been suggested. Moreover, several categories of compounds, potentially acting on pathophysiological mechanisms of ischemia-reperfusion syndrome, have been tested in experimental models, but none of them has as yet been proven effective in clinical studies. Prostanoids are drugs traditionally utilized in critical chronic limb ischaemia, and their pharmacological properties support a potential usefulness as adjuvant treatment in ALI. In a pilot double-blind placebo-controlled study it has been evaluated the effect of perioperative iloprost, a synthetic prostacyclin analogue, in 30 patients with ALI undergoing Fogarty's thromboembolectomy. The encouraging results of iloprost in this study (lower incidence of major clinical events, more evident metabolic improvement by means of transcutaneous tensiometry--statistically significant reduction in TcpCO2--suggested the opportunity of performing a larger, multicenter trial (ILAILL). In comparison with the pilot study, ILAILL included patients undergoing various types of surgical revascularization, and a longer period of experimental treatment and post-operative follow-up. Preliminary data from this study confirm the high morbidity and mortality of ALI (overall incidence of major events, 29%). Results of ILAILL trial, as for comparison of effects between iloprost and control group, will be available at the beginning of 2005.