[List of diagnostic tests and procedures in leg ulcer]

Many factors contribute to the pathogenesis of leg ulcer. Most patients have venous leg ulcer due to chronic venous insufficiency. Less often, patients have arterial leg ulcer resulting from peripheral arterial occlusive disease, the most common cause of which is arteriosclerosis. Leg ulcer may be of a mixed arteriovenous origin. In diabetic patients, distal symmetric neuropathy and peripheral vascular disease are probably the most important etiologic factors in the development of diabetic leg ulcer. Other causes of chronic leg ulcers are hematologic diseases, autoimmune diseases, genetic defects, infectious diseases, primary skin diseases, cutaneous malignant diseases, use of some medications and therapeutic procedures, and numerous exogenous factors. Diagnosis of leg ulcer is based on medical history, inspection, palpation of skin temperature, palpation of arteries, fascia holes, presence and degree of edema, firm painful cords, and functional testing to assess peripheral occlusive arterial disease or identify superficial and deep venous reflux of the legs. Knowledge of differential diagnosis is essential for ensuring treatment success in patients with leg ulcer. There are many possible etiologic factors of leg ulcers and sometimes, clinical findings are similar. Additional testing should be performed, e.g., serologic testing such as blood count, C-reactive protein, HBA1c, erythrocyte sedimentation rate, differential blood count, total proteins, electrolytes, coagulation parameters, circulating immune complex, cryoglobulins, homocysteins, AT, PAI-1, APC resistance, proteins C and S, paraproteins, ANA, ENA, ANCA, dsDNA, antiphospholipid antibodies, urea, creatinine, blood lipids, vitamins and trace elements. Also, biopsy of the lesion for histopathology, direct immunofluorescence, bacteriology and mycology should be included. Other tests are Raynaud (cold stimulation) test and pathergy test. Device-based diagnostic testing should be performed for future clarification. Ankle brachial pressure index, color duplex sonography, plethysmography, MSCT and MR angiography, digital subtraction angiography, phlebography, angiography, x-ray, and capillaroscopy in lupus erythematosus are indicated. Except for bacteriologic analyses of wound biopsies, there is no test to provide specific information on the wound condition.

The angiosome concept in clinical practice: implications for patient-specific recanalization procedures

Below-the-knee (BTK) disease with the clinical presentation of critical limb ischemia is associated with a high rate of limb loss due to minor and major amputations. The main problem is to find a way to optimize blood flow to the critical limb area. BTK joint the down-stream diverges into 3 arms which supply different areas. Different concepts exist how optimal blood flow to the critical ischemic areas BTK can be achieved, either by treating as many vessels as can be reopened by an endovascular procedure, or by going for the two main BTK vessels, or in an outstanding situation also to treat the inflow of collaterals to achieve as much blood flow down the foot as possible. Derived from plastic surgery for the purpose of healing of flaps, the angiosome concept has been developed. An angiosome is an anatomic unit of tissue (consisting of skin, subcutaneous tissue, fascia, muscle and bone) fed by a source artery and drained by specific veins. From that point of view it can be presumed that revascularization of the source artery to the angiosome might result in better wound healing and limb salvage rates. The angiosome treatment concept of BTK disease refers to the concept in cardiology, where discrimination of reversible ischemia areas is made and respective vessels leading to these areas are treated in a distinctive way.

Long-term outcome of femoropopliteal stenting. Results of a prospective study

AIM

Aim of the study was to assess the long-term clinical results of primary stent placement in patients with femoro-popliteal lesions and intermittent claudication (IC) or critical limb ischemia (CLI).

METHODS

Prospectively collected data of 517 patients (543 limbs) treated for IC (N.=422; 77.5%) and CLI (N.=121; 22.5%), between September 2006 and December 2010 were evaluated. Survival, limb salvage and patency rates were analyzed and multivariate analysis was performed to evaluate possible risk factors for the development of restenosis.

RESULTS

Mean patients' age was 70.6 years (SD ±10); 64.8% of the patients (N.=335) were male. Angiography revealed TASC A or B lesions in 64.5% (N.=350), TASC C or D lesions in 35.5% (N.=193) of the patients. Two hundred thirty-two patients had evidence of occluded femoropopliteal artery (42.7%) and the remaining patients had evidence of high grade (>70%) stenosis. In total, 827 bare metal nitinol stents (1.53±0.9 per limb) were used. No early (<30-day) procedure-related death was recorded. After a mean follow-up period of 60 months (SD ±13.5), 69 patients died (13.4%). Eight (1.5%) patients underwent major amputation. The amputation rate was significantly higher in the CLI group compared to the IC group (P=0.03). Primary patency rates were 86.2%, 79.1%, 75.1% and 62.2% after 1, 2, 3 and 5 years, respectively. No difference in terms of patency rates was found between the results of the treatment of TASC A/B versus TASC C/D lesions and the patient groups with IC versus CLI.

CONCLUSION

The endovascular-first line treatment with use of nitinol stents for patients with femoropopliteal artery lesions is associated with acceptable long-term patency rates, even in patients with long lesions.

Presentation, treatment, and outcome differences between men and women undergoing revascularization or amputation for lower extremity peripheral arterial disease

OBJECTIVE

Prior studies have suggested treatment and outcome disparities between men and women for lower extremity peripheral arterial disease after surgical bypass. Given the recent shift toward endovascular therapy, which has increasingly been used to treat claudication, we sought to analyze sex disparities in presentation, revascularization, amputation, and inpatient mortality.

METHODS

We identified individuals with intermittent claudication and critical limb ischemia (CLI) using International Classification of Diseases, Ninth Revision codes in the Nationwide Inpatient Sample from 1998 to 2009. We compared presentation at time of intervention (intermittent claudication vs CLI), procedure (open surgery vs percutaneous transluminal angioplasty or stenting vs major amputation), and in-hospital mortality for men and women. Regional and ambulatory trends were evaluated by performing a separate analysis of the State Inpatient and Ambulatory Surgery Databases from four geographically diverse states: California, Florida, Maryland, and New Jersey.

RESULTS

From the Nationwide Inpatient Sample, we identified 1,797,885 patients (56% male) with intermittent claudication (26%) and CLI (74%), who underwent 1,865,999 procedures (41% open surgery, 20% percutaneous transluminal angioplasty or stenting, and 24% amputation). Women were older at the time of intervention by 3.5 years on average and more likely to present with CLI (75.9% vs 72.3%; odds ratio [OR], 1.21; 95% confidence interval [CI], 1.21-1.23; P < .01). Women were more likely to undergo endovascular procedures for both intermittent claudication (47% vs 41%; OR, 1.27; 95% CI, 1.25-1.28; P < .01) and CLI (21% vs 19%; OR, 1.14; 95% CI, 1.13-1.15; P < .01). From 1998 to 2009, major amputations declined from 18 to 11 per 100,000 in men and 16 to 7 per 100,000 in women, predating an increase in total CLI revascularization procedures that was seen starting in 2005 for both men and women. In-hospital mortality was higher in women regardless of disease severity or procedure performed even after adjusting for age and baseline comorbidities (.5% vs .2% after percutaneous transluminal angioplasty or stenting for intermittent claudication; 1.0% vs .7% after open surgery for intermittent claudication; 2.3% vs 1.6% after percutaneous transluminal angioplasty or stenting for CLI; 2.7% vs 2.2% after open surgery for CLI; P < .01 for all comparisons).

CONCLUSIONS

There appears to be a preference to perform endovascular over surgical revascularization among women, who are older and have more advanced disease at presentation. Percutaneous transluminal angioplasty or stenting continues to be popular and is increasingly being performed in the outpatient setting. Amputation and in-hospital mortality rates have been declining, and women now have lower amputation but higher mortality rates than men. Recent improvements in outcomes are likely the result of a combination of improved medical management and risk factor reduction.

Prospective comparison of cartesian acquisition with projection-like reconstruction magnetic resonance angiography with computed tomography angiography for evaluation of below-the-knee runoff

PURPOSE

To compare prospectively the assessment of stenosis and radiologist confidence in the evaluation of below-the-knee lower extremity runoff vessels between computed tomography (CT) angiography and contrast-enhanced magnetic resonance (MR) angiography in a cohort of 19 clinical patients.

MATERIALS AND METHODS

The study was compliant with the Health Insurance Portability and Accountability Act of 1996 and approved by the institutional review board. Imaging was performed in 19 consecutive patients with known or suspected peripheral arterial disease; both CT angiography and a more recently developed MR angiography technique were performed within 24 hours of each other and before any therapeutic intervention. Resulting images were randomized and interpreted in blinded fashion by four board-certified radiologists with expertise in CT angiography and MR angiography. Vasculature of the lower leg was apportioned into 22 segments, 11 for each leg. For each segment, degree of stenosis and confidence of diagnosis were determined using a 3-point scale. Differences between CT angiography and MR angiography were assessed for significance using pooled histograms that were analyzed using the Wilcoxon signed rank test.

RESULTS

For assessment of stenosis, there was no difference in CT angiography compared with MR angiography for 20 of 22 segments. For confidence of diagnosis, assessment of popliteal arteries was superior on CT angiography compared with MR angiography (P<.05). Confidence in assessment of both tibioperoneal trunks and the left proximal anterior tibial artery was not significantly different between CT angiography and MR angiography. Confidence in assessment of all other 17 segments was superior with MR angiography compared with CT angiography (P<.02).

CONCLUSIONS

MR angiography using the method described here is a promising technique for evaluating lower extremity arterial runoff. MR angiography had an overall superior performance in radiologist confidence compared with CT angiography for imaging runoff vessels below the knee.

Diagnosis and treatment of limb fractures associated with acute peripheral ischemia

Acute Peripheral Ischemia (API) is the most severe acute complication after both open and closed fractures, as ischemia compromises not only the vitality of the affected limb, but also the patient's life, because metabolic anaerobic changes following ischemia have serious local and general consequences. These explain why early diagnosis of API is very important for the prognosis of the traumatized limb.The authors analyse cases when API was not diagnosed immediately after trauma, but some time after the first examination, due to either low systolic BP or to late onset of API. The patients were analysed concerning the type of the fracture, the reason for delayed diagnosis of API, the moment of API diagnosis and the arterial injury. In all those cases, surgery was performed immediately after API diagnosis, in order to identify and treat the complex injuries(bone and vascular).

[Optimization of the treatment of the patients presenting with chronic venous insufficiency in the lower extremities with the use of the modern methods of thalassotherapy]

The introduction of thalassotherapy (seaweed wraps cold) into the standard drug therapy and elastic compression techniques increases the effectiveness of conservative treatment of the patients presenting with chronic venous insufficiency due to the influence of biologically active components of brown algae that help to improve microcirculation, lymphatic drainage function, and peripheral hemodynamics. These effects lead to a decrease in the severity of hypoxia, enhancement of tissue trophism, promotion of inflammatory processes, reduction of the clinical manifestations of the disease, and improvement of the patients' quality of life.

[The hybrid operations for the critical ischemia of the lower extremities]

In the work there was adduced the analysis of the examination and treatment results in 35 patients, suffering occlusion-stenotic affections of the lower extremities arteries, in whom reconstruction-restoration operations were joined with endovascular interventions, performed simultaneously or in two stages. Complex clinic-instrumental examination of patients have included ultrasound duplex scanning and dopplerography, roentgencontrast angiography, multispiral computeric tomography with intravenous contrast, radionuclide angiography permitting to substantiate the surgical tactics algorithm. In early postoperative period up to one year of follow-up in 28 (80%) patients good and satisfactory results were observed, also preservation of the open reconstruction zone in 25 (71.4%) and of the endovascular reconstruction zone in 28 (80%) patients were registered accordingly. In two patients, suffering the balloon angioplasty site reocclusion, the stenting was accomplished with the main vessels blood flow restoration. In 5 (14.3%) patients after performance of transcutaneous transluminal balloon angioplasty a progress of atherosclerotic affection of the shin arteries was observed through one year, leading to high amputation of the lower extremity. Thus, due to application of the hybrid technologies during one year of follow-up there was saved the support capacity of the extremity in 30 (85.7%) patients.

Interventional radiology in the diabetic lower extremity

Most of what we know today for interventional techniques for revascularization in patients with DF disease is derived from our knowledge on CLI in patients with PAD. There are today no dedicated randomized controlled trials on interventional treatment of DF. It is, however, clear that huge progress in interventional techniques has been obtained during the past decade. In most institutions, the nonsurgical option is the current first choice. As the aim of treatment is ulcer healing through temporary increase in blood flow, it is still unclear what the contribution of new stent and drug-eluting technologies will have on the clinical outcome of DF treatment. Long-term follow-up studies, dedicated to patients with an arterial DF problem, have to be performed before we can evaluate all these new technologies.

[Relationship between serum β2-microglobulin and lower extremity atherosclerotic occlusive disease]

OBJECTIVE

To explore the relationship between fasting serum level of β2-microglobulin (β2-M) and the development of lower extremity atherosclerotic occlusive disease (LEAOD).

METHODS

A total of 59 LEAOD patients at our hospital from March 2011 to August 2012 were recruited into the LEAOD group while another 32 non-LEAOD patients into the control group. Their clinical profiles and the parameters of ankle brachial index (ABI),β2-M and high-sensitivity C-reactive protein (hsCRP) were recorded and analyzed.

RESULTS

The patients had higher serum levels of β2-M (5.3 ± 3.2 vs 2.6 ± 1.3) and hsCRP (15.1 ± 14.8 vs 8.0 ± 6.7) according to the severity in the LEAOD group than those in the control group (P < 0.05).β2-M was correlated with smoking (β 1.248, odds ratio[OR] 0.020, 95% confidence interval [CI] 1.221-9.942), diabetes (β 1.524,OR 4.591, 95%CI 1.493-14.118) and ABI (β-4.091,OR 0.017, 95%CI 0.002-0.136) . The receiver operating characteristic (ROC) curve showed that β2-M level had some value of predicting the occurrence of LEAOD (ROCAUC 0.821, 95%CI 0.731-0.912, P < 0.01).

CONCLUSION

Serum level of β2-M may play a role in pathologic process of LEAOD. And further studies are needed to validate its value as a biomarker for LEAOD.

[Efficacy comparison of interventional thrombectomy versus thrombolysis in the treatment of acute mixed-type lower extremity deep venous thrombosis]

OBJECTIVE

To compare the clinical efficacy of interventional thrombectomy versus thrombolytic treatment for acute mixed-type lower extremity deep venous thrombosis (LEDVT).

METHODS

The clinical data of 458 patients with acute mixed type LEDVT were analyzed retrospectively.Group A: 327 patients underwent mechanical aspiration thrombectomy; Group B: 131 patients received systematic thrombolysis and anticoagulation with urokinase and heparin.

RESULTS

Complete thrombus removal (Grade I): Group A was was better than group B (65.44% vs 37.4%) (P = 0.000). The circumference differences of healthy and affected limbs of knee-joints' below and above 15 cm at discharge were (1.34 ± 0.57) and (0.93 ± 0.32) cm in group A were better than (1.72 ± 0.69) and (1.29 ± 0.43) cm in group B (both P = 0.000). Among them, 411 patients had a median follow-up period of 35 (16-70) and the follow-up rate was 89.83%. At 36 months postoperation, the circumference difference of affected limbs of knee-joints' below 15 cm for group A (0.53 ± 0.22) cm was better than that for group B (1.42 ± 0.65) cm (P = 0.000) . And the sequelae occurrence rates of edema, pigmentation and ulceration of group A (29.64%, 14.01%,0%) were lower than those of group B (55.77%, 83.65%, 9.62%) (both P = 0.000). Color Doppler flow imaging revealed that the vein patency rate of group A was 90.23% and normal valve function rate 71.34%. And both were better than group B (37.50%, 15.38%) (P = 0.000; P = 0.000). The total effective rate of group A (100%) was better than that of group B (71.15%) (P = 0.000). Excellency rate: group A (88.93%) was higher than group B (29.81%) (P = 0.000).

CONCLUSION

Interventional thrombectomy is better than simple thrombolysis in the treatment of acute mixed-type lower extremity deep venous thrombosis. And the former offers better protection of normal valve function.

[Analyses of risk factors for deep vein thrombosis in lower extremities]

OBJECTIVE

To explore the risk factors of deep vein thrombosis (DVT) in lower extremities.

METHODS

Retrospective data analyses were performed for a total of 1264 DVT patients at our department from January 2010 to December 2012.

RESULTS

Among them, 984 cases (77.85%) were over 40 years old, no overt cause was found for 642 cases (50.79%), 142 cases (11.23%) had a clear history of trauma before onset (without surgery). Among 316 recurrent postoperative cases, there were the surgical histories of orthopedics (n = 142, 11.23%), gynecology (n = 90, 7.12%), general practice (n = 42, 3.32%), vascular (n = 23, 1.82%), urological (n = 12, 0.94%) and others (n = 7, 0.55%). Ten cases (0.79%) occurred after suffering bedridden chronic diseases. And 20 cases (1.58%) were caused by conditions during pregnancy or postpartum period.had Malignant tumors were found in 25 (1.98%) patients. After long-term uses of hormones, 10 patients (0.79%) of rheumatoid arthritis had a recurrence.Owing to varicose veins, 27 patients (2.14%) recurred. Eight patients (0.63%) had a history of drug abuse, 2 cases (0.16%) suffered depression and 62 cases (4.9%) were recurrent.

CONCLUSION

There are many causative factors of DVT so that prevention is of great importance. We should pay more attention to the prevention and treatment of high-risk DVT patients.

Chronic lower limb ischemia and advanced renal failure. Do we possess sufficient therapeutic knowledge?

Chronic lower limb ischemia diminishes the quality of life and is associated with a higher risk of limb amputation and cardiovascular mortality. Coexisting chronic renal disease can modulate the response to pharmacotherapy and revascularization, and thus influence prognosis. This paper reviews current literary evidence regarding therapeutic problems observed in patients with obliterative atherosclerosis and renal failure. We reviewed articles from peer-reviewed medical journals which were published between 2000 and 2011. The poorer clinical response in the discussed patients is not only connected with the direct failure of surgical and endovascular procedures, but first of all with the high mortality of the patients. There is still a lack of sufficient evidence on the effectiveness of currently used anti-atherosclerotic agents in patients with end-stage renal failure. A certain priority is the search for an effective therapeutic strategy that would reduce mortality associated with cardiovascular conditions in this particular group of patients. Identifying patients who can benefit most from costly endovascular procedures is another vital issue.

Superficial femoral artery TASC D Registry: twelve-month effectiveness analysis of the Pulsar-18 SE nitinol stent in patients with critical limb ischemia

AIM

Single center observational study analyzing the primary patency rate and freedom from target lesions revascularization rate of the Pulsar-18 nitinol stent after recanalization of long superficial femoral artery (SFA) occlusions (TASC D) in 22 patients with critical limb ischemia (CLI).

METHODS

Between 1/2011 and 7/2011, 22 consecutive patients (9 male, 13 female) with chronic total occlusions (CTO) of the femoro-popliteal arteries presenting with CLI (17 patients with Rutherford 4 score, and 5 patients with Rutherford 5 score) were enrolled and successfully recanalized using the Pulsar-18 self-expanding (SE) nitinol stent (BIOTRONIK AG, Buelach, Switzerland). Primary patency at 12 months was defined as no binary restenosis (>50%) on Duplex ultrasound (PSVR<2.5) and respectively no target lesion revascularization performed within 12 months. The average lesion length of the treated femoro-popliteal segment was 315 mm. Performing spot stenting average stent length in all patients was 245 mm (minimal 215 mm, maximal 315 mm).

RESULTS

Technical success, with establishing an antegrade straight line flow to the foot through a reopened SFA, was achieved in all 22 patients. Subintimal and intraluminal recanalization techniques were used. Two patients with Rutherford 5 score had a minor amputation shortly after the recanalization procedure. All other patients had a complete wound healing of their lesions during a 6 month follow-up. After 12 month follow-up the primary patency rate of the Pulsar-18 SE nitinol stent was 77% with a per protocol restenosis in 5 of 22 patients. Seventeen patients showed a walking capacity on treadmill test >300 meters (Rutherford II). Two patients with a documented restenosis were Rutherford, these patients were treated conservatively. Three patients with restenosis and a Rutherford III score were scheduled for an endovascular target lesion revascularization leading to a freedom from target lesion revascularization rate of 86%.

CONCLUSION

Endovascular intervention of long SFA occlusions using subintimal or intraluminal recanalization technique with implantation of the Pulsar-18 SE nitinol stent in CLI patients is safe and clinically effective with a primary patency rate after 12 months of 77% and a freedom from target lesion revascularization rate of 86%.

[Revascularization for lower limbs thromboangiitis obliterans-early and mid-term outcome report]

OBJECTIVES

To summarize the outcome of revascularization for lower limbs thromboangiitis obliterans (TAO) and evaluate risk factors affected outcomes.

METHODS

Between January 2008 and December 2011, a consecutive series of 24 TAO patients with lower limb ischemia were underwent revascularization. All the patients were male. The mean age was (33 ± 6) years (24-43 years). All patients presented with history of heavy smoking.Fifteen patients (62.5%) presented with ulcer or gangrene, 7 cases (29.2%) presented with rest pain, the rest 2 cases (8.3%) presented with severe intermittent claudication.Eight cases underwent bypass, including 6 autogenous vein graft, 1 prosthesis graft and 1 hybrid graft; 7 cases underwent catheter-directed thrombolysis combined with angioplasty; 3 cases underwent angioplasty and stenting directly; the rest 6 cases underwent thromboectomy and/or endarterectomy. The technical success, amputation and patency of target vessel were reported.Some risk factors were evaluated by multi-factors regression analysis to identify whether influenced outcomes.

RESULTS

Seventeen cases (70.8%) harvested primary technical success. Three cases (12.5%) suffered with major amputation due to failure of revascularization.Eight cases with bypass all were successful, 4 cases with thrombolysis got success, 2 cases with primary angioplasty and stenting got success, while the 3 cases with thromboemctomy and/or endarterectomy got success. Among the 7 failed cases, 3 cases needed major amputation, 2 cases underwent re-operation, and the rest 2 cases got conservation treatment. All the patients had effective follow-up between 1 and 40 months (mean (17 ± 11) months).No death occurred during the follow-up. Primary patency, secondary patency and limb salvage rate were 45.8% (11/24), 62.5% (15/24), and 79.2% (19/24), respectively.Risk factors regression analysis showed patients with ulcer or gangrene before revascularization got significant worse outcomes (Wald = 4.018, P = 0.043) . Bypass could improve outcomes significantly (Wald = 4.016, P = 0.045) .

CONCLUSIONS

Outcomes of revascularization for TAO with lower limb severe ischemia are acceptable. Autogenous vein graft bypass should be first choice. Thrombolysis with angioplasty could be a reasonable choice for those had no satisfied autogenous vein graft.

[Lower body ischemia due to bending of the stent after hybrid treatment for chronic stanford type B aortic dissection]

Lower body ischemia due to bending of a stented graft at the thoracic aorta was rare, particularly when it occurred in several days after surgery. We experienced this complication and performed the 3rd-time thoracic endovascular repair( TEVAR).A 49-year-old man with a chronic aortic dissection of Stanford type B underwent TEVER;however we failed to close the entry because of the tortuously bended distal arch of the aorta. Then it was decided the patient undergo a hybrid treatment with arch replacement and frozen elephant trunk. Seventeen days after the surgery, the blood pressure of the patient's lower limb was reduced rapidly and his renal function deteriorated. Bending of the stent was revealed by computed tomography( CT). The patient underwent the 3rd-time emergency TEVAR, and his symptoms improved.

[Effect of intermittent pneumatic compression on coagulation function and deep venous hemodynamics of lower limbs after rectal cancer resection]

OBJECTIVE

To investigate the effects of intermittent pneumatic compression (IPC) on coagulation function, deep venous hemodynamics and prevention of deep venous thrombosis (DVT) of lower limbs in patients after rectal cancer resection.

METHODS

A total of 120 patients undergoing rectal cancer resection were randomly divided into non-IPC group (control group, n=60) and IPC group (n=60). The control group received routine treatment after resection and the IPC group received IPC based on the routine treatments. Prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB), international normalized ratio (INR) and volume of D-dimer (D-D) were detected before operation and 1-, 3-, 5- and 7-day after operation. Meanwhile, blood flow velocity and caliber of external iliac vein, femoral vein and popliteal vein were examined by color Doppler ultrasound, then the average blood flow velocity and blood flow volume were calculated.

RESULTS

Incidence of lower limb DVT was 13.3% (8/60) and 1.7% (1/60) in control group and IPC group respectively with significant difference (P<0.05). The differences in PT, APTT and INR were not significant (P>0.05) at 1-day after operation as compared to the preoperative level, while FIB and D-D both increased (P<0.05), all presented no significant difference among the two groups (P>0.05). PT shortened gradually (P<0.05), APTT and INR did not change significantly (P>0.05), FIB and D-D increased gradually (P<0.05), and no significant differences were found between the two groups at the same time point (all P>0.05). All the above parameters in the control group were significantly lower than those in IPC group (all P<0.05).

CONCLUSIONS

IPC can improve hemodynamics indexes of deep veins of lower limb in patients after rectal cancer operation, and prevent the lower limb DVT. IPC is a safe, simple and convenient physical therapy.

Therapeutic angiogenesis in critical limb ischemia

Critical limb ischemia (CLI) is a severe form of peripheral artery disease associated with high morbidity and mortality. The primary therapeutic goals in treating CLI are to reduce the risk of adverse cardiovascular events, relieve ischemic pain, heal ulcers, prevent major amputation, and improve quality of life (QoL) and survival. These goals may be achieved by medical therapy, endovascular intervention, open surgery, or amputation and require a multidisciplinary approach including pain management, wound care, risk factors reduction, and treatment of comorbidities. No-option patients are potential candidates for the novel angiogenic therapies. The application of genetic, molecular, and cellular-based modalities, the so-called therapeutic angiogenesis, in the treatment of arterial obstructive diseases has not shown consistent efficacy. This article summarizes the current status related to the management of patients with CLI and discusses the current findings of the emerging modalities for therapeutic angiogenesis.

Deep vein thrombosis and/or pulmonary embolism concurrent with superficial vein thrombosis of the legs: cross-sectional single center study of prevalence and risk factors

AIM

The aim of this paper was to assess the prevalence of concurrent deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in the patients with superficial vein thrombosis (SVT) of the legs and to find factors significantly and independently associated with coincident DVT/PE.

METHODS

In the setting of a tertiary referral hospital, patients with SVT, attending vascular clinic, underwent physical examination, laboratory testing and leg vein ultrasound (in the case of clinically suspected PE also perfusion/ventilation lung scan or/and helical CT pulmonary angiography). In statistical analysis, we used unpaired t-test, non-parametric Wilcoxon rank sum test, stepwise logistic regression and multivariable logistic regression model.

RESULTS

We examined 138 patients (age 61.4 ± 13.9 years, 36.2% men), with ST mostly on varicose veins (89.9%). The prevalence of concurrent DVT/PE was 34.1%. Neither the clinical manifestation nor SVT localization differed significantly between the group with isolated SVT and that with coincident DVT/PE. Of all the assessed patients characteristics (age and sex, BMI, history of SVT, DVT or PE, hypercoagulable states, cardiovascular risk factors) only two factors were significantly and independently associated with the presence of concurrent DVT/PE. Log BMI was significantly higher in the patients with isolated SVT. Factor V Leiden (FVL) was proved as an independent risk factor for concomitant DVT/PE with odds ratio 2,531 (95% CI 1,064-6,016).

CONCLUSION

The prevalence of concurrent DVT/PE in patients with SVT, referred to hospital vascular clinic was 34.1%. Lower BMI (log BMI, respectively) and the presence of FVL were significantly and independently associated with concurrent DVT/PE. Our results should be further investigated in a larger prospective study.

The effect of revascularization procedures on healing of mixed arterial and venous leg ulcers

AIM

The optimal management of venous leg ulcers in patients with concomitant peripheral artery disease (PAD) remains unclear. The aim of the present study was to evaluate the effectiveness of revascularization procedures in healing of the ulcers of mixed etiology.

METHODS

During a 6-year period a total of 20 patients with evidence of chronic venous insufficiency, impaired arterial perfusion (ABI<0.75) and active leg ulcer were treated. Patients with moderate PAD (0.5<ABI<0.75) were treated conservatively with modified compression and were considered for revascularization if the ulcer did not heal, while those with severe PAD (ABI<0.5) underwent revascularization.

RESULTS

Eleven out of seventeen (64.7%) limbs with moderate arterial disease showed a significant healing progress after modified compression and healed at an average time of 24.7±3.1 weeks, while the other 6 limbs (35.3%) failed to improve underwent revascularization and healed at an average time of 16±2.6 weeks. Three limbs with severe arterial disease underwent revascularization and healed at an average time of 17.6±2.5 weeks. Overall the nine arterial interventions had a 100% technical success rate, while ABI improved from 0.54±0.07 to 0.94±0.04 after the intervention. The 30-day mortality was null. Healing time in patients treated with revascularization was significantly lower compared to those treated conservatively (16.6±2.6 weeks vs. 24.7±3.2 weeks, P<0.001). During the follow-up period (48.7±14.3 months), there were 9 ulcer recurrences, 6 in the group of conservative treatment and 3 in the group of revascularization. No significant difference in recurrences between the two groups (log rank=0.772, P=0.38) was demonstrated.

CONCLUSION

A protocol-driven therapeutic strategy that includes a revascularization procedure as a therapeutic option in patients with ulcers of mixed etiology may be beneficial. Based on the current data, it is essential the therapeutic strategy to be individualized by including an overall risk assessment accounting for comorbidities of the patient and the risk of the procedure.

Plaque excision in the management of lower-limb ischemia of atherosclerosis and in-stent restenosis with the SilverHawk atherectomy catheter

AIM

Aim of the present study was to compare the effectiveness of plaque excision in management of lower limb ischemia of atherosclerosis and in-stent restenosis with the SilverHawk atherectomy catheter.

METHODS

From November 2010, to August 2011, 43 patients were involved and completed follow-up. They were divided into two groups: group A is the atherosclerotic plaque group (16 cases, 37.2%) and group B is the in-stent restenosis/occlusion lesion group (27 cases, 62.8%). The average age of group A was 68.3 years and group B was 72 years, the mean duration was 27.4 months and 26 months, respectively. Intermittent claudication was 8 cases and 16 cases respectively, and rest pain both was 4 cases, foot ulcer was 1 case and 4 cases, toe gangrene both was 3 cases. Ankle Brachial Index (ABI)≤0.4 was 2 in group A and 8 in group B, ABI>0.4 was 12 and 16, ABI=0 was 2 and 3, respectively. Excision with protective devices in 6 cases. Nine cases and 17 cases received treatment for proximal and distal lesions over the same period, respectively, included the proximal iliac artery stenting 1 case in group A and 5 cases in group B, distal calf arteries stenting 6 cases in group A and 11 cases in group B, balloon angioplasty 2 in group A and 1 in group B. Endpoints included postoperative mortality or amputation of target limb.

RESULTS

Forty-one operations were successful, the technical success rate was 95.3%, one case in group B suffered above-knee amputation. The target vessels of 41 patients maintain patency after discharge. Postoperative claudication distance increased to 500 meters except for one case in each group, all 4 rest pain patients got alleviated, reduced toe ulcer area happened in 1 and 2 cases respectively, all 3 cases of gangrene dried up/infection controlled in each group. Postoperative ABI result 0.7-0.8: 4 in group A and 5 in group B; 0.81-0.9 was 5 and 8; >0.91 was 6 and 13, respectively. Symptom improvement result had no significant difference between the two groups (P>0.05). Follow-up covered 41 patients, average 17.5±3.3 months. Group A patients stayed in good condition, 7 claudication patients's walking distance above 500 meters remains; rest pain no recurrence, one ulcer healing, 2 of 3 toe gangrene self-shedding and stump healing, 1 toe gangrene removed by surgery and wound healing. Group B, 4 of 15 claudication cases recurrence, and received plaque excision again. Rest pain no recurrence. 3 of 4 ulcer healing, 1 ulcer area reduced significantly. One out of 3 gangrene received below knee amputation (toe osteomyelitis), wound healing. One recurrence, angiography showed in-stent severe restenosis, received plaque excision again. One toe gangrene removed by surgery and wound healing.

CONCLUSION

Plaque excision with "SilverHawk" treatment for lower limb ischemia of atherosclerosis or in-stent restenosis is safe and effective. No significant difference for these two lesions in efficacy. Long term follow-up and larger randomized study is needed for further information on treatment.

Nitinol stents with polymer-free paclitaxel coating for stenosis of failing infrainguinal bypass grafts

AIM

This study was designed to investigate the immediate and one-year outcomes of polymer-free paclitaxel coated drug-eluting stent (DES) implantation in a consecutive series of patients presenting with stenosis of infrainguinal bypass grafts.

METHODS

Between January 2011 and January 2012, 11 patients with failing infrainguinal bypass grafts were treated in two institutions. Clinical status and Duplex scan parameters were recorded at baseline and over a follow-up period of one year.

RESULTS

DES implantation was successfully performed in all patients. Ten patients received a single stent and one patient received two stents. At one year, one patient showed total bypass graft occlusion (9%). In all the remaining patients, Duplex scan examination documented patency of the treated grafts.

CONCLUSION

DES implantation in failing infrainguinal bypass grafts can be safely performed and provides satisfactory clinical outcomes. The patency rate of 91% favourably compares with those obtained with other endovascular treatments such as plain balloon or cutting balloon angioplasty.

The use of the GORE® TIGRIS® Vascular Stent with dual component design in the superficial femoral and popliteal arteries at 6 months

AIM

The aim of this study was to collect procedural and clinical data assessing safety and performance of the GORE® TIGRIS® Vascular Stent, a novel dual component stent, made of a nitinol wire frame combined with a fluoropolymer-interconnecting structure.

METHODS

This retrospective analysis included 32 consecutive patients (20 men, mean age 72.8 years) with 40 atherosclerotic femoropopliteal lesions (occlusions in 5%) who underwent angioplasty and implantation of a GORE® TIGRIS® Vascular Stent. The patients were scheduled for follow-up at 3, 6 and 12 months after stent implantation for Duplex ultrasound and assessment of Rutherford Becker class (RBC) and Ankle-Brachial Index (ABI) RESULTS: The mean implanted stent length was 62.3 mm (range 30-100 mm). Procedural success (residual stenosis <30%) was achieved in 100% of the lesions. At 6 months 2 restenosis in 2 patients were observed, resulting in a cumulative primary patency rate (±standard error) of 91.7±8.0%. Between baseline and 6 months the ABI increased from 0.65±0.18 to 0.96±0.12 (P<0.0001) and the median of RBC increased from 3 to 1.5 (P<0.0005). No stent thrombosis was found.

CONCLUSION

In this retrospective collection of patients all lesions could be successfully treated with this novel hybrid TIGRIS stent. These preliminary results show promising primary patency rates at 6 months. In addition, significant improvements were observed in symptom classification and hemodynamics.

Neuraxial anaesthesia for lower-limb revascularization

BACKGROUND

Lower-limb revascularization is a surgical procedure that is performed to restore an adequate blood supply to the limbs. Lower-limb revascularization surgery is used to reduce pain and sometimes to improve lower-limb function. Neuraxial anaesthesia is an anaesthetic technique that uses local anaesthetics next to the spinal cord to block nerve function. Neuraxial anaesthesia may lead to improved survival. This systematic review was originally published in 2010 and was first updated in 2011 and again in 2013.

OBJECTIVES

To determine the rates of death and major complications associated with spinal and epidural anaesthesia as compared with other types of anaesthesia for lower-limb revascularization in patients aged 18 years or older who are affected by obstruction of lower-limb vessels.

SEARCH METHODS

The original review was published in 2010 and was based on a search until June 2008. In 2011 we reran the search until February 2011 and updated the review. For this second updated version of the review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, CINAHL and Web of Science from 2011 to April 2013.

SELECTION CRITERIA

We included randomized controlled trials comparing neuraxial anaesthesia (spinal or epidural anaesthesia) versus other types of anaesthesia in adults (18 years or older) with arterial vascular obstruction undergoing lower-limb revascularization surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed data extraction and assessed trial quality. We pooled the data on mortality, myocardial infarction, lower-limb amputation and pneumonia. We summarized dichotomous data as odds ratio (OR) with 95% confidence interval (CI) using a random-effects model.

MAIN RESULTS

In this updated version of the review, we found no new studies that met our inclusion criteria. We included in this review four studies that compared neuraxial anaesthesia with general anaesthesia. The total number of participants was 696, of whom 417 were allocated to neuraxial anaesthesia and 279 to general anaesthesia. Participants allocated to neuraxial anaesthesia had a mean age of 67 years, and 59% were men. Participants allocated to general anaesthesia had a mean age of 67 years, and 66% were men. Four studies had an unclear risk of bias. No difference was observed between participants allocated to neuraxial or general anaesthesia in mortality rate (OR 0.89, 95% CI 0.38 to 2.07; 696 participants; four trials), myocardial infarction (OR 1.23, 95% CI 0.56 to 2.70; 696 participants; four trials), and lower-limb amputation (OR 0.84, 95% CI 0.38 to 1.84; 465 participants; three trials). Pneumonia was less common after neuraxial anaesthesia than after general anaesthesia (OR 0.37, 95% CI 0.15 to 0.89; 201 participants; two trials). Evidence was insufficient for cerebral stroke, duration of hospital stay, postoperative cognitive dysfunction, complications in the anaesthetic recovery room and transfusion requirements. No data described nerve dysfunction, postoperative wound infection, patient satisfaction, postoperative pain score, claudication distance and pain at rest.

AUTHORS' CONCLUSIONS

Available evidence from included trials that compared neuraxial anaesthesia with general anaesthesia was insufficient to rule out clinically important differences for most clinical outcomes. Neuraxial anaesthesia may reduce pneumonia. No conclusions can be drawn with regard to mortality, myocardial infarction and rate of lower-limb amputation, or less common outcomes.

Successful catheter directed thrombolysis in postpartum deep venous thrombosis complicated by nicoumalone-induced skin necrosis and failure in retrieval of inferior vena caval filter

Venous thromboembolism is an important cause for maternal morbidity and mortality in postpartum period. Though catheter-directed thrombolysis (CDT) is now considered as a safe and effective therapy for the management of deep venous thrombosis (DVT) but still it is not indicated in postpartum DVT. We are presenting a case of 22-year-old female patient who presented with post-partum lower limb DVT and managed successfully with CDT by using injection streptokinase and temporary inferior vena caval filter was inserted as prophylactic for pulmonary embolism as she had extensive DVT extending into inferior vena cava (IVC). During follow-up, she developed large skin necrosis in left lower limb which was managed by adding injection low-molecular-weight heparin. IVC filter also could not be retrieved even after trying all manoeuvres during follow-up after 2 weeks.