[Using femoral autovein in reconstruction of the aortoiliac segment in patients with high risk of infectious complications]

AIM

To analyse the results of using a femoral vein for reconstruction of the aortoiliac segment.

MATERIAL AND METHODS

We performed a total of 10 reconstructions of the aortoiliac segment using a femoral autovien. The patients' average age amounted to 58,8±4,5 years.

RESULTS

The patients were subdivided into 2 groups, with Group 1 consisting of 5 patients operated on for complication of aortoiliac reconstruction using an artificial graft. The grafts were retrieved followed by repeat prosthetic repair with the femoral vein. All cases showed satisfactory revascularization of the limb. Venous outflow impairments after removal of the femoral vein were inconsiderable. One patient died. Group 2 comprised 5 patients initially operated on for critical ischaemia of the lower limbs with purulent necrotic lesions. Revascularization with a femoral vein was performed in all cases resulting in re-establishment of blood circulation. The procurement of the vein was followed by pronounced impairments of the lymphatic and venous outflow.

CONCLUSION

Primary autovenous reconstruction of the aortoiliac segment in patients with purulent necrotic impairments is less risky from the point of view of late complications than implantation of an artificial graft and is more advantageous from the point of view of quality of life than primary high amputation.

[Peculiarities of performing hybrid operation in a patient with atherosclerosis of lower limbs and developed critical ischaemia]

Currently, there is a tendency towards an increase in the incidence rate of cardiovascular disease. According to the data of the World Health Organization the incidence rate of obliterating diseases of peripheral arteries varies from 5 to 10%. Diseases of peripheral arteries manifest themselves by such a severe condition as lower-limb critical ischaemia. Most often lower-limb chronic critical ischaemia develops in patients with multi-level lesions of the arterial bed. Treatment of such patients constitutes a serious problem since it requires large-scope revascularization. The authors describe a clinical example of a hybrid operation in a patient with atherosclerosis of lower-limb arteries on the background of critical ischaemia of the lower extremities on the background of type 2 diabetes mellitus. The hybrid intervention was performed in the scope of balloon angioplasty and stenting of the right deep femoral artery with simultaneous loop semiclosed thromboendarterectomy from the right common femoral artery, superficial femoral and popliteal artery with balloon angioplasty of the right superficial femoral artery with mechanic recanalization and balloon angioplasty of the popliteal artery, anterior tibial artery, and peroneal artery. The next stage consisted in amputation of the anterior portion of the right foot according to the Chopart s technique with skin plasty. Resulting from the operation on the background of further angiotropic and rheological active therapy with PGE-1 preparation VAP-20 we managed to save the patient s limb and to limit to minor amputation. Hybrid operative interventions should be carried out in order to achieve maximal revascularization when it is not possible to obtain a favourable result by a reconstructive or endovascular intervention alone.

[Treatment for chronic obliterating diseases of lower limb arteries]

The work is dedicated to a new method of treatment for chronic obliterating diseases of lower limb arteries - cardiosynchronized sequential antegrade pneumocompression. The author describes the basic principles of the method, its physiological effects, and the results of treatment on volunteers.

[Age-related clinical and laboratory features of patients with occluded main arteries of lower extremities]

The study of clinical and laboratory features of patients with occluded main arteries of lower extremities included morphological characteristics of peripheral blood platelets in patients of different age in the acute period of the disease and after surgical treatment. The results were subjected to correlation analysis versus standard hemostatic parameters. Mean cell volume and enhanced anisocytosis proved the most informative morphological indicators. The mean platelet volume was increased in all patients before and after surgery especially in the elder age group. It reflected persistent activation of thrombocytopoiesis as confirmed by the studies of hemostasis. Therefore, these parameters may be used for additional testing in diagnostics of the risk of ischemic complications and repeated thrombosis. The timely prescription of auxiliary corrective therapy increases effectiveness of the treatment and the quality of life in the patients with occluded main arteries of lower extremities.

[Assessment of remote survival in patients with peripheral atherosclerosis after endured interventions on coronary arteries]

The article deals with a retrospective analysis of the risk for the development of unfavourable outcomes in vascular patients after interventions on coronary arteries versus those without them. The authors assessed remote survival in patients with atherosclerotic lesions of the coronary and vascular beds as compared with isolated coronary artery bypass grafting. All patients were at the Federal Centre for Cardiovascular Surgery from October 2008 to December 2009 and later on underwent planned examination at a polyclinic. The patients were subdivided into the following groups: Group 1 comprised a total of 131 vascular patients undergoing single-stage or stepwise operations on coronary arteries (CA) (CABG + peripheral vascular disease). They were also subjected to interventions on the abdominal aorta, carotid arteries and lower-limb arteries. Group 2 (PVD) comprised a total of 153 vascular patients without myocardial revascularization with documented indications for coronary artery bypass grafting according to the findings of coronography and noninvasive methods of examination. Group 3 (CABG) consisted of 258 patients without symptoms of peripheral atherosclerosis who underwent CABG and were examined at a polyclinic over the same period of time as the study groups. The findings of examination confirmed the world-literature discussed proposition suggesting that preventive CABG considerably improves the long-term prognosis for vascular patients. This is of special importance taking into consideration that a preventive intervention on CA brings no additional risk of operative treatment.

[Venous edema]

Findings of venous insufficiency in the lower limb can usually be detected in connection with venous edema. Realization of compression therapy requires a prescription for stockings, motivation and guidance. In specialized care, correlating the edema and venous symptoms with color Doppler ultrasonography findings is essential. In addition to the assessment of the venous status, functioning of the calf muscle pump should be assessed more profoundly. Impeding symptoms of venous insufficiency or a complicated situation are an indication for invasive treatment. Venous return found in connection with mere edema symptoms or lymphedema is not an indication for invasive treatment.

[Surgical and conservative treatment of the ischemic form of the diabetic foot syndrome]

The efficacy of the prolonged intraarterial infusion (PIAI) of the suspendized hydrocortisole for the correction of the distal angiitis of the lower limbs in patients with the diabetic foot syndrome was analyzed. The 1st group involved 51 patients, who received the hydrocortisole PIAI alone during 3-4 days. The 2nd group of 48 patients received distal autovenous by-pass surgery. The 3rd group of 13 patients received the combination of the surgical treatment and the PIAI. 95.5% patients of the 1st group showed remission of the disease during the first follow up year. Among patients of the 2nd group by-passes were active in 88%. After 4 years of follow up the cumulative by-pass permeability and limb preservation were registered in 45 and 50.9%, respectively. 90% of the patients from the 3rd group, who had received the complex treatment, showed by-pass permeability and limb preservation.

Identification of optimal control compartments for serial near-infrared spectroscopy assessment of lower extremity compartmental perfusion

Near-infrared spectroscopy (NIRS) has shown promise in detecting ischemic changes in acute compartment syndrome. The objectives of this study were to 1) assess the correlation in NIRS values between upper and lower extremity control sites for bilateral lower extremity trauma and 2) investigate the effect of skin pigmentation on NIRS values. Forty-four volunteers (14 male, 30 female) were monitored over separate 1-hour sessions. NIRS leads were placed over leg and upper extremity compartments. Colorimeters were used to document skin pigmentation. NIRS values between corresponding contralateral compartments were extremely well correlated (r = 0.76-0.90). Upper extremity NIRS values were correlated to leg values in the following order: volar (r = 0.65-0.71), dorsal (r = 0.36-0.60), and deltoid (r = 0.42-0.51). A negative correlation was observed between melanin and NIRS values. Analogous leg compartments are the optimal site of control for each other. The volar forearm may be the best upper extremity control. Skin pigmentation may affect absolute NIRS values.

[Complications after reconstructive operations on major arteries of lower limbs and methods of correction thereof]

The present study was aimed at revealing and examining the causes of specific complications after reconstructive vascular operations in the aortic-iliac-femoral zones. The study comprised a total of 155 patients, with the period of postoperative follow up amounting to 3 years. Thirty-nine patients were operated on for various specific complications within the terms from 1 to 3 years. The results of the study showed clear-cut relationship between the development of complications and progression of the underlying disease. Satisfactory results after secondary interventions were obtained in patients with good state of the distal bed and operated on at early terms after complications.

[Experience with hybrid techniques of surgical treatment of patients with lower limb critical ischaemia]

The authors present their original experience with the use of hybrid techniques of surgical treatment in a total of 19 patients with lower limb critical ischaemia (LLCI) on the background of complex lesions of the arteries of lower extremities. They describe various types of hybrid techniques of surgical treatment of patients with critical ischaemia on the background of chronic obliterating diseases of lower-limb arteries. Also discussed are 3 varieties of clinical situations in which it is appropriate to employ the hybrid method: thrombosis of the bypass graft, multi-storey lesions of lower-limb arteries, and the use of a hybrid technique in order to decrease the size of the surgical wound. The period of follow up varied from 2 to 36 months. The limbs were saved in all the patients during the whole follow-up period. Two patients were found to have thrombosis of the reconstructed segment after 1.5-5 months.

[Phlebotrophic therapy with venarus in patients suffering from lower limb chronic venous insufficiency]

The article deals with medicamentous therapy of lower limb chronic venous insufficiency (LLCVI). The authors analysed herein the results of treating patients suffering from LLCVI using Venarus whose basic components are diosmin and hesperidin. The obtained findings demonstrated that clinical administration of this phlebotonic agent is effective in the given cohort of patients during the whole therapeutic course, with a maximum positive effect observed within the first 4 weeks. The parameters of quality of life of the patients with LLCVI improved significantly on the background of taking the phlebotonic Venarus.

A critical analysis on the impact of antiplatelet therapy in the patency of infrainguinal bypass grafts

Antiplatelet therapy plays an important role in the management of atherosclerotic disease and numerous studies have shown their efficacy in the reduction of cardiovascular mortality and morbidity. Antiplatelets are given in patients subjected to lower limb bypass aiming not only to reduce cardiovascular mortality and morbidity but also improve graft patency. Various antiplatelet agents have been used for this purpose. The aim of this review article is to critically evaluate the existing evidence on the impact of antiplatelet therapy for maintaining infrainguinal graft patency and highlight the mechanisms involved along these lines.

[Angiographic characteristics of the lesion, influencing the choice to perform either direct or indirect endovascular revascularization for critical ischaemia of the lower limbs]

AIM

to determine which angiographic characteristics of a lesion of lower limb arteries are independent predictors of the possibility to re-establish the direct blood flow along the angiosomic (in relation to the trophic defect) artery.

MATERIAL AND METHODS

we carried out a retrospective analysis of angiograms of 192 patients with degree IV peripheral arterial disease according to A.V. Pokrovky's classification, with restored free blood flow to the foot at least along one femoral artery by means of balloon angioplasty. All patients were subdivided into two groups: the group of direct revascularization (84 patients) and the group of indirect revascularization (108 patients). The compared groups reliably did not differ by the clinical characteristics and the stage of the trophic lesion (male gender, prevalence of diabetes mellitus and mean age amounted to: 45%, 73% and 71 years versus 39%, 77% and 69 years, respectively). However, in the group of direct revascularization more frequently were encountered lesions of the toes (75% vs 55%, p = 0.005), while in the group of indirect revascularization prevailing were lesions of the heel region (7% vs 29%, p=0.0002).

RESULTS

the statistical analysis showed that independent predictors for a possibility of performing direct revascularization were as follows: total occlusion of the angiosomic artery on the foot (risk ratio (95% CI) = 0.10 (0.03-0.31), p =0.0001), blind (without stump) occlusion in the site of the origin of the angiosomic artery on the crus or foot (risk ratio (95% CI)=0.41 (0.19-0.90, p=0.03), and total occlusion of the trifurcation of the popliteal artery (risk ratio (95% CI) = 028 (0.09-0.81), p=0.02).

CONCLUSION

in the presence of the above enumerated angiographic characteristics of the lesions of lower limb arteries it is appropriate to initially consider a possibility of performing indirect revascularization.

[Edemas in chronic lower extremity venous insufficiency: clinical manifestations, medical and surgical treatments]

The review presents data on the causes and pathogenesis of lower extremity (LE) edemas with special emphasis on the edemas occurring in chronic LE venous insufficiency. It discusses the possibilities of noninvasive and surgical treatments for LE edemas in venous insufficiency. Particular attention is given to the possibilities of phlebotonic therapy.

[Lower limb pain of arterial origin]

With the ageing population and increasing incidence of diabetes, arterial occlusive disease will become more common as cause of lower limb pain. In the diagnosis of limb pain of arterial origin it is essential to distinguish rest pain from intermittent claudication. Rest pain is associated with high risk of amputation and is therefore an indication for examinations within specialized care. First-line treatment of intermittent claudication instead consists of the management of risk factors and guided exercise. Specialized care consultation is required only in case of intermittent claudication which is refractory to conservative treatment and threatening the ability to work and function. Acute lower limb ischemia is always an indication for emergency assessment.

[Management strategies of arterial prosthetic graft infection in lower extremity:a report of 5 cases]

OBJECTIVE

To explore the management strategies of pyogenic vascular prosthetic graft infection.

METHODS

The clinical data of 5 cases of prosthetic vascular graft infection in lower extremity between 2003 and 2010 were retrospectively analyzed.

RESULTS

All of them were treated by antibiotics, debridement and drainage. One patient died from acute myocardial infarction and septic shock. Two patients were cured by extra-anatomic arterial bypass and removal of infected graft after a basic control of infections. And another two patients had the diseased limb amputated after the removal of infected vascular graft without blood reconstruction.

CONCLUSION

Pyogenic infection of vascular graft is hard to treat with conservative measures. Revascularization prior to removal of infected graft is recommended for a better outcome.

[Analysis of causative factors for lower limb deep vein thrombosis complicated with artery pulmonary embolism in orthopedics patients]

OBJECTIVE

To explore the causative factors of lower limb deep vein thrombosis complicated with pulmonary artery embolism in orthopedics patients.

METHODS

The clinical manifestations and causes of thrombosis defluxion of pulmonary artery embolism patients whose diagnosis were confirmed by computed tomography pulmonary angiography (CTPA) during May 2009-May 2012 were retrospectively analyzed.

RESULTS

Among 45 cases of CTPA-confirmed pulmonary artery embolism patients, 5 patients had no obvious clinical manifestation. The initial symptoms included chest stuffiness and dyspnea (n = 9) and cough (n = 8). And the major causes of thrombosis defluxion were early postoperative mobilization (n = 11), postoperative functional exercise (n = 9), rollover or defecation in bed (n = 7), sneezing (n = 2) and unknown causes (n = 14).

CONCLUSION

The patients with lower limb deep vein thrombosis have a high risk of thrombosis defluxion during unstable period. Despite adequate anticoagulation, early mobilization and functional exercise are likely to cause thrombosis defluxion and lead to pulmonary artery embolism.

[Expression of HIF-1a in acute limb ischemia of rats]

OBJECTIVE

To explore the expression of hypoxia-inducible factor 1 alpha (HIF-1a) in rat lower limb skeletal muscle with acute ischemia.

METHODS

Acute lower limb ischemia was established in 25 male or female SD rats of 200-250 g by ligating left iliac artery with microsurgical techniques. Gastrocnemius of lower limb was harvest at the time points of sham (0h), 4, 8, 12 and 24 h respectively. Immunohistochemistry, Western blot and real-time polymerase chain reaction (PCR) were used to detect the expression of HIF-1a in lower limb gastrocnemius.

RESULTS

There was a low expression of HIF-1a in normal gastrocnemius, but it was highly expressed in lower limb ischemia. With the elongation of ischemia time, its expression increased (P < 0.05), peaked at 4 h and 8 h (P < 0.05) and then declined gradually.

CONCLUSION

With a characteristic trend during acute limb ischemia, HIF-1a may play an important role in the adaptive response to acute limb ischemia.

Long-term outcomes following primary drug-eluting stenting of infrapopliteal bifurcations

PURPOSE

To investigate the outcomes following primary deployment of drug-eluting stents (DES) for the treatment of infrapopliteal bifurcation lesions in patients suffering from critical limb ischemia (CLI).

METHODS

This was a retrospective study of a registry enrolling all patients suffering from chronic infrapopliteal artery disease and undergoing treatment of tibial bifurcation lesions with DES using 3 techniques: balloon and stent (single stent), T-shape double-stent, and culotte double-stent. The analysis included 39 CLI patients (32 men; mean age 69 ± 10 years) who underwent primary stenting of 41 infrapopliteal bifurcations. Most patients (29, 70.7%) were classified as Rutherford category 4. The mean lesion length was 31.3 ± 13.1 mm. The primary endpoints were amputation-free survival, target lesion revascularization (TLR)-free survival, angiographic 2-vessel primary patency (2VPP), and 1-vessel primary patency (1VPP). Secondary endpoints included survival and angiographic binary restenosis. A Cox regression analysis was performed to identify independent predictors influencing outcomes

RESULTS

Technical success was achieved in all cases. The mean clinical and angiographic follow-up intervals were 47.5 ± 14.8 and 17.5 ± 12.5 months, respectively. According to the Kaplan-Meier analysis, overall survival, amputation-free survival, and TLR-free survival estimates were 79.5%, 84.3%, and 58.0%, respectively, at 5 years. At 12, 24, and 36 months, the 2VPP rates were 77.2%, 47.5%, and 33.9%, and the 1VPP rates were 84.0%, 65.5%, and 54.5%, respectively. Binary restenosis rates were 26.4%, 57.3%, and 82.2% at 12, 24, and 36 months; restenotic lesions were mainly detected at the origin of the bifurcations. The regression model did not identify any independent predictors influencing outcome.

CONCLUSION

DES application for below-the-knee bifurcation lesions was safe and resulted in satisfactory long-term angiographic and clinical outcomes comparable to those reported following infrapopliteal endovascular treatment.

A randomized, controlled pilot study of autologous CD34+ cell therapy for critical limb ischemia

BACKGROUND

Critical limb ischemia portends a risk of major amputation of 25% to 35% within 1 year of diagnosis. Preclinical studies provide evidence that intramuscular injection of autologous CD34+ cells improves limb perfusion and reduces amputation risk. In this randomized, double-blind, placebo-controlled pilot study, we evaluated the safety and efficacy of intramuscular injections of autologous CD34+ cells in subjects with moderate or high-risk critical limb ischemia, who were poor or noncandidates for surgical or percutaneous revascularization (ACT34-CLI).

METHODS AND RESULTS

Twenty-eight critical limb ischemia subjects were randomized and treated: 7 to 1 × 10(5) (low-dose) and 9 to 1 × 10(6) (high-dose) autologous CD34+ cells/kg; and 12 to placebo (control). Intramuscular injections were distributed into 8 sites within the ischemic lower extremity. At 6 months postinjection, 67% of control subjects experienced a major or minor amputation versus 43% of low-dose and 22% of high-dose cell-treated subjects (P=0.137). This trend continued at 12 months, with 75% of control subjects experiencing any amputation versus 43% of low-dose and 22% of high-dose cell-treated subjects (P=0.058). Amputation incidence was lower in the combined cell-treated groups compared with control group (6 months: P=0.125; 12 months: P=0.054), with the low-dose and high-dose groups individually showing trends toward improved amputation-free survival at 6 months and 12 months. No adverse safety signal was associated with cell administration.

CONCLUSIONS

This study provides evidence that intramuscular administration of autologous CD34+ cells was safe in this patient population. Favorable trends toward reduced amputation rates in cell-treated versus control subjects were observed. These findings warrant further exploration in later-phase clinical trials.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00616980.

Pregnancy-dependent changes in the vein width of the lower extremities in venous insufficiency

AIM

to analyze the changes in the width of selected veins in the lower limbs during pregnancy and puerperium, with or without venous insufficiency (VI) diagnosed at the first trimester

MATERIAL AND METHODS

the group of 100 pregnant was divided into two subgroups with or without VI. The examination was performed, namely between 11-14th, 18-22nd, 28-32nd weeks of gestation and in 6th week of the puerperium. The sonographic examination included the measurement of the transverse diameter (TD) of the common femoral vein (CFV), the superficial femoral vein (SFV) and the popliteal vein (PV). The changes in the vessel width during pregnancy and puerperium were compared in both groups. Moreover the changes of analyzed ultrasound parameters between the two groups in the 4 analyzed time periods were compared to the first trimester results.

RESULTS

there was a statistically significant increase in the TD of CFV with the highest values in the third trimester and significantly higher in the puerperium compared to the first visit. TD in all analyzed stages of pregnancy in the group with VI was significantly higher SFV and PV were not statistically different between the groups in any of the analyzed periods. Average TD of these vessels was higher in the third trimester decreasing gradually during the postpartum period.

CONCLUSIONS

The average TD was highest in the third trimester decreasing during the postpartum period. In VI group a full return of TD to the values observed in the first trimester was not observed in the puerperium.

Role of anti-HSP 60/65 antibodies in atherogenesis in patients with type 2 diabetes and lower limb ischemia

The role of heat shock proteins and anti-HSP 60/65 antibodies in atherogenesis has been widely described in the literature, but the participation of these molecules in the pathogenesis of diabetic macroangiopathy has not been extensively investigated. 30 patients with type 2 diabetes complicated with macroangiopathy of the lower extremities in the intermittent claudication stage. The control group (n=18) consisted of healthy volunteers of corresponding age. Levels of anti-HSP 60/65 antibodies, von Willebrand factor (vWF) and hsCRP in blood serum were measured. We also assessed static effort based on isometric contraction lasting until full fatigue. In patients with lower limb ischemia in diabetic macroangiopathy, a positive correlation between anti-HSP 60/65 antibodies and von Willebrand factor levels in blood serum was found (R=0.543, p<0.05). Concentrations of anti-HSP 60/65 antibodies were higher than in the control group, but not statistically significant (44.77±55.00 vs. 26.09±13.85; NS). The ongoing disease process contributed statistically significantly to the strength of the quadriceps muscle of the thigh (21.47 vs. 27.82 for the right limb, and 20.27 vs. 28.33 for the left limb; p<0.05). Increased concentrations of anti-HSP 60/65 antibodies in blood serum suggests their involvement in the pathogenesis of diabetic macroangiopathy and correlates with the parameters of endothelial cell damage. In patients with type 2 diabetes complicated with atherosclerotic changes, a statistically significant reduction in lower limb muscle strength was found compared with the control group.

Percutaneous transluminal angioplasty improves glucose control and quality of life in patients with critical limb ischemia

AIM

To evaluate the benefit of endovascular peripheral revascularization on glucose control in patients with chronic limb ischemia.

METHODS AND RESULTS

Over a 12 month period, 61 patients (41 male, range 49-88 years of age) presenting with critical limb ischemia (CLI) were treated according to the Trans Atlantic Inter Society Consensus (TASC II) guidelines. After discharge, all patients were asked to measure their glucose level three times daily, and glycated hemoglobin was checked monthly up to 12 months, as well as to fill a questionnaire to assess their Quality of Life (QoL). The revascularization procedure was successful in 90% of cases. Glycemic control and glycated hemoglobin in 22 diabetic patients subgroup were significantly improved after the treatment and remained stable over the follow-up period. There was a significant improvement in QoL that increased steadily from the operation and to reach a plateau after six months.

CONCLUSIONS

Peripheral percutaneous angioplasty in subjects with CLI significantly improves glycemic control and ameliorates QoL. Revascularization positively effects also long-term diabetes control as well as QoL.

Soluble ST2 is regulated by p75 neurotrophin receptor and predicts mortality in diabetic patients with critical limb ischemia

OBJECTIVE

The p75 neurotrophin receptor (p75(NTR)) contributes to diabetes mellitus-induced defective postischemic neovascularization. The interleukin-33 receptor ST2 is expressed as transmembrane (ST2L) and soluble (sST2) isoforms. Here, we studied the following: (1) the impact of p75(NTR) in the healing of ischemic and diabetic calf wounds; (2) the link between p75(NTR) and ST2; and (3) circulating sST2 levels in critical limb ischemia (CLI) patients.

METHODS AND RESULTS

Diabetes mellitus was induced in p75(NTR) knockout (p75KO) mice and wild-type (WT) littermates by streptozotocin. Diabetic and nondiabetic p75KO and WT mice received left limb ischemia induction and a full-thickness wound on the ipsilateral calf. Diabetes mellitus impaired wound closure and angiogenesis and increased ST2 expression in WT, but not in p75KO wounds. In cultured endothelial cells, p75(NTR) promoted ST2 (both isoforms) expression through p38(MAPK)/activating transcription factor 2 pathway activation. Next, sST2 was measured in the serum of patients with CLI undergoing either revascularization or limb amputation and in the 2 nondiabetic groups (with CLI or nonischemic individuals). Serum sST2 increased in diabetic patients with CLI and was directly associated with higher mortality at 1 year from revascularization.

CONCLUSIONS

p75(NTR) inhibits the healing of ischemic lower limb wounds in diabetes mellitus and promotes ST2 expression. Circulating sST2 predicts mortality in diabetic CLI patients.