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Cheun TJ, Davies MG. Influence of a Novel Morphology-Driven Classification on Limb Salvage after Isolated Tibial Intervention for Chronic Limb Threatening Ischemia. Ann Vasc Surg 2024; 106:467-478. [PMID: 38815911 DOI: 10.1016/j.avsg.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/09/2024] [Accepted: 04/10/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Infra-popliteal interventions for chronic limb-threatening ischemia (CLTI) can be impacted by the morphology of the tibial vessels. The aim of this study was to examine the impact of a novel morphology-driven classification on the outcomes of isolated tibial intervention for CLTI. METHODS A database of patients undergoing isolated tibial interventions for CLTI at a single center between 2010 and 2020 was retrospectively queried. Patients with isolated infra-popliteal disease were identified, and their anatomy was scored as present or absent for lesion calcification (1 point), target vessel diameter<3.0 mm (1 point), lesion length>300 mm (1 point), and poor pedal runoff score (1 point). Patients were then divided into 3 groups: low risk (0 or 1 points), moderate risk (2 points), and high risk (3 or 4 points). Intention to treat analysis by the patient was performed. Limb-based patency (the absence of reintervention, occlusion, critical stenosis [>70%], or hemodynamic compromise with ongoing symptoms of CLTI as it related to the patency of the preoperatively determined target artery pathway) was assessed. Patient-oriented outcomes of amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; above ankle amputation of the index limb or major reintervention: new bypass graft, jump/interposition graft revision) were evaluated. RESULTS 1,607 patients (55% male, average age 60 years, 3,846 vessels) underwent tibial intervention for CLTI. The majority of the patients were diabetic and of Hispanic origin. Morphologically, 27%, 31%, and 42% of the vessels were categorized as low risk, moderate risk, and high risk, respectively. There was a significant worsening of the infra-popliteal Global Limb Anatomic Staging System (GLASS) grading as the morphological risk increased. The 30-day major adverse cardiac events (MACE) were equivalent across the groups and were under the stated objective performance goal (OPG) of ≤10%. In contrast, both the 30-day MALE and the 30-day major amputations were significantly different across the groups, with the low-risk group remaining under the OPG of ≤9% and ≤4%, respectively, while the moderate risk and high risk exceeded the goal threshold. For the OPG, freedom from MALE was 60 ± 5%, 46 ± 5%, and 22 ± 9% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± standard error of the mean; P = 0.008). Overall AFS was 55 ± 5%, 37 ± 6%, and 18 ± 7% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± standard error of the mean; P = 0.003). CONCLUSIONS Tibial anatomic morphology impacts isolated tibial endovascular intervention with adverse morphology associated with poorer short- and long-term outcomes. Risk stratification based on anatomic predictors should be an additional consideration as one intervenes on infra-popliteal vessels for CLTI.
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Affiliation(s)
- Tracey J Cheun
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Anesthesia, Long School of Medicine, San Antonio, TX
| | - Mark G Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Vascular/Endovascular Surgery, Ascension Health, Waco, TX.
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Sundaram S, Barksdale C, Rodriguez S, Wooster MD. The Impact Of Small Artery Disease (SAD) and Medial Arterial Calcification (MAC) Scores on Chronic Wound and Amputation Healing: Can It Tell Us More? Ann Vasc Surg 2024:S0890-5096(24)00479-5. [PMID: 39059628 DOI: 10.1016/j.avsg.2024.07.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 06/19/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024]
Abstract
Plenary Session Presentation at the Vascular and Endovascular Surgical Society 28th Annual Winter Meeting; Sun Valley Resort, Sun Valley, ID January 18 - 21, 2024 OBJECTIVES: In 2021, Ferraresi et al. created a novel scoring system based on the impact of small artery disease (SAD) and medial arterial calcification (MAC) on wound healing. SAD and MAC scores functioned similar to WIfI but with minimal resource expenditure. Despite its potential, few studies have expanded on the original dataset. We aim to validate SAD and MAC's impact on wound healing outcomes and determine their utility in relation to current predictive models. METHODS Single-institution retrospective review was used to identify amputations for chronic (>1mo) podiatric wounds between 2015-2020. Foot x-ray (MAC) or angiography (SAD) <6 months of index procedure was required. Primary outcomes included major amputation, wound healing, major adverse limb events (MALE), and amputation-free survival (AFS). Statistical analysis included chi-square, one-way ANOVA, non-parametric correlation, Kaplan-Meier, Cox regression, and Akaike (AIC)/ Bayesian Inclusion Criteria (BIC) model comparison. RESULTS Of 136 limbs, 67 received SAD scores (0-2) and 128 received MAC scores (0-2). SAD cohorts exhibited similar comorbidity profiles with exception of coronary disease, heart failure, and chronic kidney disease. MAC cohorts were notably disparate in prevalence of multiple conditions. High mean SAD/MAC scores were seen in severe (3-vessel) below-ankle disease (p=.001* [SAD], p=.041* [MAC]). Both SAD and MAC correlated with lower mean toe pressure (p=.043* [SAD], p=<.001* [MAC]), while only MAC correlated with higher overall WIfI score (p=.029*). No significant procedural differences were noted. However, higher re-admission rates (73.9% [2] vs. 46.9% [0], p=.014*) and all-cause mortality (65.2% [2] vs. 26.0% [0], p=.002*) were noted with higher MAC. Survival analysis revealed higher one-year major amputation rates (p=.036*), impaired wound healing (p<.001*), and lower amputation-free survival (p=.001*) with increasing MAC severity. Additionally, MAC-2 patients underwent amputation at faster rates than MAC-0 patients (HR 5.25, 95% CI [1.82, 9.77]) with longer times to wound healing (HR 0.21, 95% CI [0.08, 0.53]). Model comparison suggested a combination of WIfI and MAC could improve accuracy of predicted time to major amputation, wound healing, and amputation-free survival. CONCLUSIONS MAC scoring showed significant promise both as individual predictor and adjunct to current predictive models of long-term wound healing outcomes. Routine use of MAC scoring in CLTI evaluation, especially when non-invasive testing is unavailable, could promote timely referral for intervention and efficient resource utilization in limited-resource or critical care settings. Further investigation is necessary to determine MAC's impact on revascularization and how scoring can be used to guide surgical decision making.
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Affiliation(s)
- Saranya Sundaram
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC.
| | | | - Stephanie Rodriguez
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Mathew D Wooster
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
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Lei FR, Shen XF, Zhang C, Li XQ, Zhuang H, Sang HF. Clinical efficacy of endovascular revascularization combined with vacuum-assisted closure for the treatment of diabetic foot. World J Diabetes 2024; 15:1499-1508. [PMID: 39099828 PMCID: PMC11292337 DOI: 10.4239/wjd.v15.i7.1499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/25/2024] [Accepted: 05/21/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND The diabetic foot is a common cause of disability and death, and comorbid foot infections usually lead to prolonged hospitalization, high healthcare costs, and a significant increase in amputation rates. And most diabetic foot trauma is complicated by lower extremity arteriopathy, which becomes an independent risk factor for major amputation in diabetic foot patients. AIM To establish the efficacy and safety of endovascular revascularization (ER) combined with vacuum-assisted closure (VAC) for the treatment of diabetic foot. METHODS Clinical data were collected from 40 patients with diabetic foot admitted to the Second Affiliated Hospital of Soochow University from April 2018 to April 2022. Diabetic foot lesions were graded according to Wagner's classification, and blood flow to the lower extremity was evaluated using the ankle-brachial index test and computerized tomography angiography of the lower extremity arteries. Continuous subcutaneous insulin infusion pumps were used to achieve glycemic control. Lower limb revascularization was facilitated by percutaneous tran-sluminal balloon angioplasty (BA) or stenting. Wounds were cleaned by nibbling debridement. Wound granulation tissue growth was induced by VAC, and wound repair was performed by skin grafting or skin flap transplantation. RESULTS Of the 35 cases treated with lower limb revascularization, 34 were successful with a revascularization success rate of 97%. Of these, 6 cases underwent stenting after BA of the superficial femoral artery, and 1 received popliteal artery stent implantation. In the 25 cases treated with infrapopliteal artery revascularization, 39 arteries were reconstructed, 7 of which were treated by drug-coated BA and the remaining 32 with plain old BA. VAC was performed in 32 wounds. Twenty-four cases of skin grafting and 2 cases of skin flap transplantation were performed. Two patients underwent major amputations, whereas 17 had minor amputations, accounting for a success limb salvage rate of 95%. CONCLUSION ER in combination with VAC is a safe and effective treatment for diabetic foot that can significantly improve limb salvage rates. The use of VAC after ER simplifies and facilitates wound repair.
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Affiliation(s)
- Feng-Rui Lei
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Xiao-Fei Shen
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Chuang Zhang
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Xin-Qing Li
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Hao Zhuang
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Hong-Fei Sang
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
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Tarricone A, Gee A, de la Mata K, Rogers L, Wiley J, Lavery LA, Krishnan P. Outcomes for Patients With Chronic Limb-Threatening Ischemia After Direct and Indirect Endovascular and Surgical Revascularization: A Meta-Analysis and Systematic Review. J Endovasc Ther 2024:15266028241248524. [PMID: 38687701 DOI: 10.1177/15266028241248524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
PURPOSE The purpose of this review and meta-analysis is to determine the clinical outcome differences between patients with chronic limb-threatening ischemia who underwent direct versus indirect angiosome revascularization using either the surgical or endovascular approach. MATERIALS AND METHODS The data sources used for article selection included PubMed, Embase/Medline, Cochrane reviews, and Web of Science (All studies were in English and included up to September 2023). All articles included were comparative in design, including retrospective, prospective, and randomized controlled trials that compared the clinical outcomes between direct and indirect angiosome-guided revascularization in chronic limb-threatening ischemia. A random-effects model was used to determine the measure of association between direct revascularization and amputation-free survival, wound healing, and overall survival. Publication bias was assessed with both Begg's and Egger's test, and heterogeneity was calculated using an I2. RESULTS Data from 9 articles were analyzed and reported in this review. Direct revascularization was associated with improved amputation-free survival (odds ratio [OR]=2.632, confidence interval [CI]: 1.625, 4.265), binary wound healing (OR=2.262, CI: 1.518, 3.372), and overall survival (OR=1.757, CI: 1.176, 2.625). Time until wound healed was not associated with either direct or indirect revascularization (Standard Mean Difference [SMD]=-2.15, p=0.11). There was a low risk of bias across all studies according to the RoB 2.0 tool. CONCLUSION Direct revascularization is associated with improved amputation-free survival, overall survival, and wound healing in chronic limb-threatening ischemic patients compared to the indirect approach. CLINICAL IMPACT Preservation of the lower extremity is critical for preventing mortality and maintaining independence. The benefit of angiosome-guided revascularization for chronic limb-threatening ischemia remains controversial. The authors of this article aim to review the current literature and compare direct and indirect angiosome-guided intervention for preserving the lower extremity. Current findings suggest direct angiosome-guided intervention reduces amputation rates and improves survival; however, many trials neglect to address the multifactorial approach needed in wound care management.
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Affiliation(s)
- Arthur Tarricone
- Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Allen Gee
- Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, FL, USA
| | - Karla de la Mata
- Department of Podiatry, Paley Orthopedic & Spine Institute, West Palm Beach, FL, USA
| | - Lee Rogers
- Department of Orthopaedics, The University of Texas Health Science Center, San Antonio, TX, USA
| | - Jose Wiley
- Section of Cardiology, Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Lawrence A Lavery
- Department of Plastic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Prakash Krishnan
- The Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Cheun TJ, Hart JP, Davies MG. Pedal medial arterial calcification influences the outcomes of isolated infra-malleolar interventions for chronic limb-threatening ischemia. J Vasc Surg 2024:S0741-5214(24)01065-6. [PMID: 38649103 DOI: 10.1016/j.jvs.2024.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/05/2024] [Accepted: 04/12/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Inframalleolar disease is present in most diabetic patients presenting with tissue loss. Inframalleolar (pedal) artery disease and pedal medial arterial calcification (pMAC) are associated with major amputation in patients with chronic limb-threatening ischemia (CLTI). This study aimed to examine the impact of pMAC on the outcomes after isolated inframalleolar (pedal artery) interventions. METHODS A database of lower extremity endovascular intervention for patients with tissue loss between 2007 and 2022 was retrospectively queried. Patients with CLTI were selected, and those undergoing isolated inframalleolar intervention on the dorsalis pedis and medial and lateral tarsal arteries and who had foot x-rays were identified. X-rays were assessed blindly for pMAC and scored on a scale of 0 to 5. Patients with concomitant superficial femoral artery and tibial interventions were excluded. Intention to treat analysis by the patient was performed. Amputation-free survival (survival without major amputation) was evaluated. RESULTS A total of 223 patients (51% female; 87% Hispanic; average age, 66 years; 323 vessels) underwent isolated infra-malleolar intervention for tissue loss. All patients had diabetes, 96% had hypertension, 79% had hyperlipidemia, and 63% had chronic renal insufficiency (55% of these were on hemodialysis). Most of the patients had Wound, Ischemia, and foot Infection (WIfI) stage 3 disease and had various stages of pMAC: severe (score = 5) in 48%, moderate (score = 2-4) in 31%, and mild (score = 0-1) in 21% of the patients. Technical success was 94%, with a median of one vessel treated per patient. All failures were in severe pMAC. Overall, major adverse cardiovascular events was 0.9% at 90 days after the procedure. Following the intervention, most patients underwent a planned forefoot amputation (single digit, multiple digits, ray amputation, or trans-metatarsal amputation). WIfI ischemic grade was improved by 51%. Wound healing at 3 months was 69%. Those not healing underwent below-knee amputations. The overall 5-year amputation-free survival rate was 35% ± 9%. The severity of pMAC was associated with decreased AFS. CONCLUSIONS Increasing severity of pMAC influences the technical and long-term outcomes of infra-malleolar intervention in diabetes. Severe pMAC is associated with amputation and should be considered as a variable in the shared decision-making of diabetic patients with CLTI.
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Affiliation(s)
- Tracy J Cheun
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Anesthesia, Long School of Medicine, San Antonio, TX
| | - Joseph P Hart
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Division of Vascular and Endovascular Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Mark G Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Vascular and Endovascular Surgery, Ascension Health, Waco, TX.
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Chuter V, Schaper N, Mills J, Hinchliffe R, Russell D, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries MD, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, van den Berg JC, Venermo M, Fitridge R. Effectiveness of revascularisation for the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review. Diabetes Metab Res Rev 2024; 40:e3700. [PMID: 37539634 DOI: 10.1002/dmrr.3700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 07/10/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Peripheral artery disease (PAD) is associated with an increased likelihood of delayed or non-healing of a diabetes-related foot ulcer, gangrene, and amputation. The selection of the most effective surgical technique for revascularisation of the lower limb in this population is challenging and there is a lack of conclusive evidence to support the choice of intervention. This systematic review aimed to determine, in people with diabetes and tissue loss, if direct revascularisation is superior to indirect revascularisation and if endovascular revascularisation is superior to open revascularisation for the outcomes of wound healing, minor or major amputation, and adverse events including mortality. METHODS Title and abstract searches of Medline, Embase, PubMed, and EBSCO were conducted from 1980 to 30th November 2022. Cohort and case-control studies and randomised controlled trials reporting comparative outcomes of direct (angiosome) revascularisation (DR) and indirect revascularisation (IR) or the comparative outcomes of endovascular revascularisation and open or hybrid revascularisation for the outcomes of healing, minor amputation, and major amputation in people with diabetes, PAD and tissue loss (including foot ulcer and/or gangrene) were eligible. Methodological quality was assessed using the Cochrane risk-of-bias tool for randomised trials, the ROBINS-I tool for non-randomised studies, and Newcastle-Ottawa Scale for observational and cohort studies where details regarding the allocation to intervention groups were not provided. RESULTS From a total 7086 abstracts retrieved, 26 studies met the inclusion criteria for the comparison of direct angiosome revascularisation (DR) and indirect revascularisation (IR), and 11 studies met the inclusion criteria for the comparison of endovascular and open revascularisation. One study was included in both comparisons. Of the included studies, 35 were observational (31 retrospective and 4 prospective cohorts) and 1 was a randomised controlled trial. Cohort study quality was variable and generally low, with common sources of bias related to heterogeneous participant populations and interventions and lack of reporting of or adjusting for confounding factors. The randomised controlled trial had a low risk of bias. For studies of DR and IR, results were variable, and it is uncertain if one technique is superior to the other for healing, prevention of minor or major amputation, or mortality. However, the majority of studies reported that a greater proportion of participants receiving DR healed compared with IR, and that IR with collaterals may have similar outcomes to DR for wound healing. For patients with diabetes, infrainguinal PAD, and an adequate great saphenous vein available for use as a bypass conduit who were deemed suitable for either surgical procedure, an open revascularisation first approach was superior to endovascular therapy to prevent a major adverse limb event or death (Hazard Ratio: 0.72; 95% CI 0.61-0.86). For other studies of open and endovascular approaches, there was generally no difference in outcomes between the interventions. CONCLUSIONS The majority of available evidence for the effectiveness of DR and IR and open and endovascular revascularisation for wound healing and prevention of minor and major amputation and adverse events including mortality in people with diabetes, PAD and tissue loss is inconclusive, and the certainty of evidence is very low. Data from one high quality randomised controlled trial supports the use of open over endovascular revascularisation to prevent a major limb event and death in people with diabetes, infrainguinal disease and tissue loss who have an adequate great saphenous vein available and who are deemed suitable for either approach.
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Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Sydney, Australia
| | - Nicolaas Schaper
- Division of Endocrinology, Department Internal Medicine, MUMC+, Maastricht, The Netherlands
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- San Francisco (UCSF) Medical Centre, University of California, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | - Joakim Nordanstig
- Department of Molecular and Clinical Medicine at the Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Lee L, Thwaites SE, Rahmatzadeh M, Yii E, Yoong K, Yii M. Proximal Arterial Inflow Revascularization Improves Pedal Arch Quality and Its Impact on Ischemic Diabetic Foot Ulcer Healing. Ann Vasc Surg 2024; 103:23-30. [PMID: 38395348 DOI: 10.1016/j.avsg.2023.12.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/16/2023] [Accepted: 12/04/2023] [Indexed: 02/25/2024]
Abstract
BACKGROUND Arterial perfusion is a key factor in diabetic foot ulcer (DFU) healing. Although it is associated with pedal arch patency, not all patients are amenable to pedal artery angioplasty. This study aims to determine the impact of angiographic improvement of the pedal arch quality after proximal arterial inflow revascularization (PAIR) and its association with wound healing. METHODS One hundred and fifty diabetic patients with tissue loss in 163 limbs who had digital subtraction angiography were studied. Cox regression analysis was used to determine independent predictors of wound healing. Wound healing rates in association with pedal arch patency were calculated by Kaplan-Meier analysis. RESULTS End-stage renal disease, minor amputation, and complete pedal arch patency were significant independent predictors of wound healing following PAIR with hazard ratios for failure: 3.02 (P = 0.008), 0.54 (P = 0.023), and 0.40 (P = 0.039), respectively. The prevalence of complete pedal arches increased by 24.1% with successful intervention (P < 0.001). The overall rates of wound healing at 6, 12, and 24 months were 36%, 64%, and 72%, respectively. The wound healing rate at 1 year in patients with a complete pedal arch was 73% compared to 45% in those with an absent pedal arch (P = 0.017). CONCLUSIONS PAIR increases complete pedal arch patency, a significant predictor of wound healing in DFU.
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Affiliation(s)
- Limi Lee
- Vascular and Transplant Surgery Unit, Monash Health, Clayton, Australia.
| | | | - Mitra Rahmatzadeh
- Vascular and Transplant Surgery Unit, Monash Health, Clayton, Australia
| | - Erwin Yii
- Vascular and Transplant Surgery Unit, Monash Health, Clayton, Australia
| | - Kevin Yoong
- Vascular and Transplant Surgery Unit, Monash Health, Clayton, Australia
| | - Ming Yii
- Vascular and Transplant Surgery Unit, Monash Health, Clayton, Australia; School of Clinical Sciences, Monash University, Clayton, Australia
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Popitiu MI, Alexandrescu VA, Clerici G, Ionac S, Gavrila-Ardelean G, Ion MG, Ionac ME. Angiosome-Targeted Infrapopliteal Angioplasty: Impact on Clinical Outcomes-An Observational Study. J Clin Med 2024; 13:883. [PMID: 38337576 PMCID: PMC10856460 DOI: 10.3390/jcm13030883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 01/22/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Revascularization based on the angiosome concept (AC) is a controversial subject because there is currently no clear evidence of its efficacy, due to the heterogeneity of patients (multiple and diverse risk factors and comorbidities, multiple variations in the affected angiosomes). Choke vessels change the paradigm of the AC, and the presence or absence of the plantar arch directly affects the course of targeted revascularization. The aim of this study was to evaluate the effect of revascularization based on the AC in diabetic patients with chronic limb-threatening ischemia (CLTI). Methods: This retrospective analysis included 51 patients (40 men, 11 women), with a mean age of 69 years (66-72) and a total of 51 limbs, who presented with Rutherford 5-6 CLTI, before and after having undergone a drug-coated balloon angioplasty (8 patients) or plain balloon angioplasty (43). Between November 2018 and November 2019, all patients underwent below-the-knee balloon angioplasties and were followed up for an average of 12 months. The alteration of microcirculation was compared between directly and indirectly revascularized angiosomes. The study assessed clinical findings and patient outcomes, with follow-up investigations, comparing wound healing rates between the different revascularization methods. Patient records and periprocedural leg digital subtraction angiographies (DSA) were analyzed. Differences in outcomes after direct revascularization and indirect percutaneous transluminal angioplasty (PTa) were examined using Cox proportional hazards analysis, with the following endpoints: ulcer healing, limb salvage, and also amputation-free survival. Results: Direct blood flow to the angiosome supplying the ulcer area was achieved in 38 legs, in contrast to 13 legs with indirect revascularization. Among the cases, there were 39 lesions in the anterior tibial artery (ATA), 42 lesions in the posterior tibial artery (PTA), and 8 lesions in the peroneal artery (PA). According to a Cox proportional hazards analysis, having fewer than three (<3) affected angiosomes (HR 0.49, 95% CI 0.19-1.25, p = 0.136) was associated with improved wound healing. Conversely, wound healing outcomes were least favorable after indirect angioplasty (p = 0.206). When adjusting the Cox proportional hazard analysis for the number of affected angiosomes, it was found that direct drug-coated angioplasty resulted in the most favorable wound healing (p = 0.091). At the 1-year follow-up, the major amputation rate was 17.7%, and, according to a Cox proportional hazards analysis, atrial fibrillation (HR 0.85, 95% CI 0.42-1.69, p = 0.637), hemodialysis (HR 1.26, 95% CI 0.39-4.04, p = 0.699), and number of affected angiosomes > 3 (HR 0.94, 95% CI 0.63-1.39, p = 0.748) were significantly associated with poor leg salvage. Additionally, direct endovascular revascularization was associated with a lower rate of major amputation compared to indirect angioplasty (HR 1.09, 95% CI 0.34-3.50, p = 0.884). Conclusions: Observing the angiosomes concept in decision-making appears to result in improved rates of arterial ulcer healing and leg salvage, particularly in targeted drug-coated balloon angioplasty for diabetic critical limb ischemia, where multiple angiosomes are typically affected.
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Affiliation(s)
- Mircea Ionut Popitiu
- Research Center in Vascular and Endovascular Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.); (G.G.-A.); (M.G.I.); (M.E.I.)
| | - Vlad Adrian Alexandrescu
- Cardio-Vascular and Thoracic Surgery Department, CHUp Sart-Tilman Hospital, University of Liège, 4000 Liège, Belgium;
| | | | - Stefan Ionac
- Research Center in Vascular and Endovascular Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.); (G.G.-A.); (M.G.I.); (M.E.I.)
| | - Gloria Gavrila-Ardelean
- Research Center in Vascular and Endovascular Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.); (G.G.-A.); (M.G.I.); (M.E.I.)
| | - Miruna Georgiana Ion
- Research Center in Vascular and Endovascular Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.); (G.G.-A.); (M.G.I.); (M.E.I.)
| | - Mihai Edmond Ionac
- Research Center in Vascular and Endovascular Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.); (G.G.-A.); (M.G.I.); (M.E.I.)
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Kawai Y, Kodama A, Sato T, Ikeda S, Tsuruoka T, Sugimoto M, Niimi K, Banno H, Komori K. Predictors of infrapopliteal vein bypass graft revision in patients with chronic limb-threatening ischemia. Vascular 2024; 32:65-75. [PMID: 36042581 DOI: 10.1177/17085381221124706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Surgical revascularization is the standard treatment for chronic limb-threatening ischemia (CLTI). However, some patients may require reintervention. The Global Anatomic Staging System (GLASS), which evaluates the complexity of infrainguinal lesions, was proposed. This study aimed to identify predictors for graft revision and evaluate whether GLASS impacts vein graft revision. METHODS Between 2011 and 2018, CLTI patients who underwent de novo infrapopliteal bypass using autogenous veins were retrospectively analyzed. To assess anatomic complexity with GLASS, femoropopliteal, infrapopliteal, and inframalleolar/pedal (IM) disease grades were determined. The outcomes of patients with or without graft revision were compared. Cox regression analysis was performed. RESULTS Thirty-six of the 80 patients underwent reintervention for graft revision. Compared to the non-graft revision group, the graft revision group exhibited significantly higher rates of GLASS stage III (66% vs 81%, p = 0.046) and grade P2 IM disease (25% vs 58%, p = 0.009). Multivariate analysis revealed that IM grade P2 (hazard ratio [HR], 3.35; 95% confidence interval [CI], 1.66-6.75; p = 0.001) and spliced vein grafts (HR, 3.18; 95% CI, 1.43-7.06; p = 0.005) were significantly associated with graft revision. CONCLUSIONS This study demonstrated that IM grade P2 and spliced vein grafts were predictors of graft revision. The GLASS stratification of IM disease grade may be useful in optimizing treatment for CLTI.
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Affiliation(s)
- Yohei Kawai
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akio Kodama
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomohiro Sato
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shuta Ikeda
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Tsuruoka
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masayuki Sugimoto
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kiyoaki Niimi
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Banno
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Komori
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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10
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Vacirca A, Faggioli G, Pini A, Pini R, Abualhin M, Sonetto A, Spath P, Gargiulo M. Revascularisation of Chronic Limb Threatening Ischaemia in Patients with no Pedal Arteries Leads to Lower Midterm Limb Salvage. Eur J Vasc Endovasc Surg 2023; 65:878-886. [PMID: 37028588 DOI: 10.1016/j.ejvs.2023.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 02/16/2023] [Accepted: 03/30/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE Chronic limb threatening ischaemia (CLTI) involving the infragenicular arteries is treated by distal angioplasty or pedal bypass; however, this is not always possible, due to chronically occluded pedal arteries (no patent pedal artery, N-PPA). This pattern represents a hurdle to successful revascularisation, which must be limited to the proximal arteries. The aim of the study was to analyse the outcome of patients with CLTI and N-PPA after a proximal revascularisation. METHODS All patients with CLTI submitted to revascularisation in a single centre (2019 - 2020) were analysed. All angiograms were reviewed to identify N-PPA, defined as total obstruction of all pedal arteries. Revascularisation was performed with proximal surgical, endovascular, and hybrid procedures. Early and midterm survival, wound healing, limb salvage, and patency rates were compared between N-PPA and patients with one or more patent pedal artery (PPA). RESULTS Two hundred and eighteen procedures were performed. One hundred and forty of 218 (64.2%) patients were male, mean age 73.2 ± 10.6 years. The procedure was surgical in 64/218 (29.4%) cases, endovascular in 138/218 (63.3%), and hybrid in 16/218 (7.3%). N-PPA was present in 60/218 (27.5%) cases. Eleven of 60 (18.3%) cases were treated surgically, 43/60 (71.7%) by endovascular and 6/60 (10%) by hybrid procedures. Technical success was similar in the two groups (N-PPA 85% vs. PPA 82.3%, p = .42). At a mean follow up of 24.5 ± 10.2 months, survival (N-PPA 93.7 ± 3.5% vs. PPA 95.3 ± 2.1%, p = .22) and primary patency (N-PPA 53.1 ± 8.1% vs. PPA 55.2 ± 5%, p = .56) were similar. Limb salvage was significantly lower in N-PPA patients (N-PPA 71.4 ± 6.6% vs. PPA 81.5 ± 3.4%, p = .042); N-PPA was an independent predictor of major amputation (hazard ratio [HR] 2.02, 1.07 - 3.82, p = .038) together with age > 73 years (HR 2.32, 1.17 - 4.57, p = .012) and haemodialysis (2.84, 1.48 - 5.43, p = .002). CONCLUSION N-PPA is not uncommon in patients with CLTI. This condition does not hamper technical success, primary patency, and midterm survival; however, midterm limb salvage is significantly lower than in patients with PPA. This should be considered in the decision making process.
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Affiliation(s)
- Andrea Vacirca
- Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy.
| | | | - Alessia Pini
- Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria, Bologna, Italy
| | - Mohammad Abualhin
- Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria, Bologna, Italy
| | - Alessia Sonetto
- Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria, Bologna, Italy
| | - Paolo Spath
- Vascular Surgery Unit, AUSL Romagna, Rimini, Italy
| | - Mauro Gargiulo
- Vascular Surgery, University of Bologna, DIMEC, Bologna, Italy
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11
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Troisi N, Adami D, Piaggesi A, Canovaro F, Pieruzzi L, Torri L, Ferrari M, Berchiolli R. Non-reversed bifurcated vein graft improves time to healing in ischemic patients undergoing lower limb distal bypass. INT ANGIOL 2023; 42:1-8. [PMID: 36416199 DOI: 10.23736/s0392-9590.22.04952-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Bifurcated vein grafts have been described in reconstructive microsurgery. No comparative studies have been published in lower limb arterial revascularization. The aim of this study was to compare non-reversed bifurcated vs. single vein graft in patients with critical limb-threatening ischemia (CLTI) undergoing lower limb distal bypass. METHODS Between January 2015 and December 2021 193 CLTI patients have been treated at our center with vein bypass, and distal anastomosis on infrapopliteal vessels; 137 patients (71%) received a single graft (Group SIN), and 56 patients (29%) had a bifurcated bypass (Group BIF). Primary outcomes measures were time to healing, primary patency, primary assisted patency, secondary patency, and limb salvage. Two-year outcomes according to Kaplan-Meier curves were evaluated and compared. RESULTS Both groups were homogeneous in terms of demographic data, preoperative risk factors, and clinical presentation except for an elderly age in Group BIF (77.5 vs. 71.5 years; P<0.001). Intraoperative technical success was achieved in all patients. Overall median duration of follow-up was 19 months (interquartile range 9-36). Wound healing did not differ between the two groups (77.4% Group SIN vs. 73.2% Group BIF; P=0.33). Mean time to healing was faster in Group BIF (2.4 vs. 6.8 months; P<0.001). At 2-year follow-up there were no differences between the two groups in terms of primary patency (71.4% Group SIN vs. 54% Group BIF; P=0.10), primary assisted patency (81.7% Group SIN vs. 76.4% Group BIF; P=0.53), secondary patency (85.1% Group SIN vs. 80.9% Group BIF; P=0.79), and limb salvage (92.3% Group SIN vs. 87.2% Group BIF; P=0.64). CONCLUSIONS Bifurcated graft improved time to healing in CLTI patients undergoing infrapopliteal non-reversed vein bypass. Two-year overall patencies and limb salvage did not differ accordingly to vein graft configuration (single vs. bifurcated).
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Affiliation(s)
- Nicola Troisi
- Unit of Vascular Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy -
| | - Daniele Adami
- Unit of Vascular Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Alberto Piaggesi
- Section of Diabetic Foot, Department of Medicine, University of Pisa, Pisa, Italy
| | - Francesco Canovaro
- Unit of Vascular Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Letizia Pieruzzi
- Section of Diabetic Foot, Department of Medicine, University of Pisa, Pisa, Italy
| | - Lorenzo Torri
- Unit of Vascular Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Mauro Ferrari
- Unit of Vascular Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Raffaella Berchiolli
- Unit of Vascular Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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Choi JCB, Miranda J, Greenleaf E, Conte MS, Gerhard-Herman MD, Mills JL, Barshes NR. Lower-extremity pressure, staging, and grading thresholds to identify chronic limb-threatening ischemia. Vasc Med 2023; 28:45-53. [PMID: 36759932 DOI: 10.1177/1358863x221147945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
INTRODUCTION The Society for Vascular Surgery Threatened Limb Classification System ('WIfI') is used to predict risk of limb loss and identify peripheral artery disease in patients with foot ulcers or gangrene. We estimated the diagnostic sensitivity of multiple clinical and noninvasive arterial parameters to identify chronic limb-threatening ischemia (CLTI). METHODS We performed a single-center review of 100 consecutive patients who underwent angiography for foot gangrene or ulcers. WIfI stages and grades were determined for each patient. Toe, ankle, and brachial pressure measurements were performed by registered vascular technologists. CLTI severity was characterized using Global Limb Anatomic Staging System (GLASS stages) and angiosomes. Medial artery calcification in the foot was quantified on foot radiographs. RESULTS GLASS NA (not applicable), I, II, and III angiographic findings were seen in 21, 21, 23, and 35 patients, respectively. A toe-brachial index < 0.7 and minimum ipsilateral ankle-brachial index < 0.9 performed well in identifying GLASS II and III angiographic findings, with sensitivity rates 97.8% and 91.5%, respectively. The diagnostic accuracy rates of noninvasive measures peaked at 74.7% and 89.3% for identifying GLASS II/III and GLASS I+ angiographic findings, respectively. The presence of medial artery calcification significantly diminished the sensitivity of most noninvasive parameters. CONCLUSIONS The use of alternative noninvasive arterial testing parameters improves sensitivity for detecting PAD. Abnormal noninvasive results should suggest the need for diagnostic angiography to further characterize arterial anatomy of the affected limb. Testing strategies with better accuracy are needed.
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Affiliation(s)
- Justin Chin-Bong Choi
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Jorge Miranda
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Erin Greenleaf
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Michael S Conte
- Division of Vascular & Endovascular Surgery, University of California at San Francisco, San Francisco, CA, USA
| | | | - Joseph L Mills
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA.,Baylor-St Luke's Medical Center, Houston, TX, USA
| | - Neal R Barshes
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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13
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Glousman BN, Cragon R, Steinberg JS, Evans KK, Attinger CE, Kiguchi MM, Tefera E, Akbari CM. Presence of a patent pedal arch is the primary predictor of transmetatarsal amputation healing and limb salvage. J Vasc Surg 2023; 77:1487-1494. [PMID: 36717038 DOI: 10.1016/j.jvs.2023.01.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/17/2023] [Accepted: 01/22/2023] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Transmetatarsal amputation (TMA) is a durable and important functional limb salvage option. We have presented our results in identifying the angiographic predictors of TMA healing using single-institution retrospective data. METHODS Consecutive patients within our institution who had undergone TMA and lower extremity arteriography from 2012 to 2020 were included. Patients whose TMA had healed were compared with those whose TMA had not healed. Using pre- and perioperative patient factors, in addition to the Global Limb Anatomic Staging System (GLASS) and evaluation of the tibial runoff vessels, multivariate analysis was used to define the predictors of TMA healing at 30 days and 1 year. For those patients who had undergone an intervention after TMA, including repeat interventions, the postintervention GLASS stage was calculated. All patients were followed up by the vascular surgeon using standard ultrasound surveillance and clinical examinations. Once the predictors had been identified, an analysis was performed to correlate the 30-day and 1-year limb salvage rates. RESULTS A total of 89 patients had met the inclusion criteria for the study period. No difference was found in the GLASS femoropopliteal or infrapopliteal stages for those with a healed TMA and those without. After multivariate regression analysis, the presence of a patent pedal arch vs a nonintact arch had a 5.5 greater odds of TMA healing at 30 days but not at 1 year. Additionally, the presence of a patent arch was strongly associated with limb salvage at both 30 days (86% vs 49%; P < .01) and 1 year (79% vs 49%; P < .01). CONCLUSIONS In the present series of patients who had undergone TMA and arteriography, with appropriate GLASS staging, we found patency of the pedal arch was a significant predictor of healing and limb salvage. The GLASS femoropopliteal and infrapopliteal stages did not predict for TMA healing.
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Affiliation(s)
- Brandon N Glousman
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC.
| | - Robert Cragon
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - John S Steinberg
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Karen K Evans
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | | | - Misaki M Kiguchi
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Eshetu Tefera
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Cameron M Akbari
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
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14
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Toyoshima T, Iida O, Hata Y, Okamoto S, Ishihara T, Nanto K, Tsujimura T, Higashino N, Takahara M, Mano T. Effects of Infra-malleolar Status According to Global Limb Anatomic Staging System on Clinical Outcomes in Patients With Chronic Limb-Threatening Ischemia. Angiology 2023; 74:79-87. [PMID: 35465705 DOI: 10.1177/00033197221091642] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
The global vascular guideline proposed a novel anatomical classification of infra-malleolar (IM) arterial lesions. We aimed to investigate the association of IM classification with clinical outcomes in patients with chronic limb-threatening ischemia (CLTI) due to isolated infrapopliteal (IP) lesions. We retrospectively analyzed 509 limbs with tissue loss in 357 patients due to isolated IP lesions who underwent endovascular therapy (EVT) between April 2010 and December 2018. The primary outcome was 1-year wound healing rate. The association of patient and anatomic characteristics with non-healing was evaluated using Cox proportional hazards regression analysis. The 1-year cumulative wound healing rate was 59.7%. Multivariable analysis demonstrated that IM grade 2 (hazard ratio [HR], 1.41; P = .044), non-ambulatory status (HR, 1.49; P = .008), hemodialysis (HR, 1.37; P = .020), left ventricular ejection fraction < 50% (HR, 1.72; P = .030), and wound, ischemia, and foot infection (WIfI) classification 4 (HR, 1.33; P = .032) were significantly associated with non-healing, whereas no below-the-ankle (BTA), below-the-knee (BTK) runoff, and Global Limb Anatomic Staging System (GLASS) IP grade had no statistically significant association with non-healing. Global Limb Anatomic Staging System IM grade 2 was an independent risk factor for wound healing in patients who underwent EVT with CLTI due to isolated IP disease.
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Affiliation(s)
- Taku Toyoshima
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Yosuke Hata
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Shin Okamoto
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | | | - Kiyonori Nanto
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | | | - Naoko Higashino
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine and Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Toshiaki Mano
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
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15
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Ji S, Hou X, Zhang X, Wu Z, Lin J, Lin Y, Wu J, Guo P, Cai F, Dai Y, Zhang J. The Relationship Between the Global Limb Anatomic Staging System Inframalleolar Modifier and the Outcomes of Diabetic Foot Ulcer with Peripheral Artery Disease. Ann Vasc Surg 2022; 92:256-263. [PMID: 36549472 DOI: 10.1016/j.avsg.2022.12.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/04/2022] [Accepted: 12/04/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND We aimed to investigate the relationship between the condition of the inframalleolar (IM) arteries, as assessed by the Global Limb Anatomic Staging System Inframalleolar (GLASS IM) modifier, and the outcomes of patients with diabetic foot ulcers. METHODS The data of 215 patients, who underwent endovascular therapy from January 2016 to May 2020 at our center, were retrospectively reviewed. Patients were divided into the P0, P1, and P2 groups according to the angiography results. The rates of ulcer healing, limb salvage, survival, and amputation-free survival were compared during the 2-year period after discharge. RESULTS Of the 216 affected limbs, 35 (16%) were classed as P0, 122 (57%) as P1, and 59 (27%) as P2. Compared with the P2 group, the P0 + P1 group had a higher ulcer healing rate (P = 0.001), a shorter ulcer healing time (P = 0.004), and a higher survival rate (P = 0.044). GLASS IM Modifier classification P2 was an independent predictor of nonhealing ulcers. No significant difference was observed between the P0 versus P1 groups. CONCLUSIONS GLASS IM modifier classification P2 is an independent risk factor for a poor outcome. GLASS IM modifier classification P0 versus P1 demonstrates similar outcomes to each other.
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Affiliation(s)
- Shiping Ji
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xinhuang Hou
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xunliang Zhang
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zhiye Wu
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jie Lin
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yichen Lin
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jie Wu
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Pingfan Guo
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Fanggang Cai
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yiquan Dai
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jinchi Zhang
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China.
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Wang C, Chen J, Lei J, Shao J, Lai Z, Li K, Cao W, Liu X, Yuan J, Liu B. Angiosome-directed endovascular intervention and infrapopliteal disease: Intraoperative evaluation of distal hemodynamic changes and foot blood volume of lower extremity. Front Surg 2022; 9:988639. [PMID: 36189392 PMCID: PMC9520246 DOI: 10.3389/fsurg.2022.988639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesTo evaluate foot blood volume and hemodynamics and explore whether quantitative techniques can guide revascularization.Materials and methodsA prospective single-center cohort study included thirty-three patients with infrapopliteal artery occlusion who underwent percutaneous transluminal angioplasty (PTA) between November 2016 and May 2020. The time-to-peak (TTP) from color-coded quantitative digital subtraction angiography (CCQ-DSA) and parenchymal blood volume (PBV) were used to evaluate the blood volume and hemodynamic changes in different regions of the foot before and after the operation.ResultsAfter the intervention procedure, the overall blood volume significantly increased from 25.15 ± 21.1 ml/1,000 ml to 72.33 ± 29.3 ml/1,000 ml (p < 0.001, with an average increase of 47.18 ml/1,000 ml. The overall TTP decrease rate, postoperative blood flow time significantly faster than those preoperatively, from 22.93 ± 7.83 to 14.85 ± 5.9 s (p < 0.001, with an average decrease of 8.08 s). Direct revascularization (DR) resulted in significant blood volume improvement than compared with indirect revascularization (IR) [188% (28, 320) vs.51% (10, 110), p = 0.029]. Patients with DR had a significantly faster blood flow time than those with IR [80% (12, 180) vs. 26% (5, 80), p = 0.032]. The ankle-brachial index (ABI) of the affected extremity also showed an significant change from 0.49 ± 0.3 to 0.63 ± 0.24 (p < 0.001) after the intervention. The relative values of ΔTTP and ΔABI showed a weak correlation (r = −0.330).ConclusionsThe quantitative measurement results based on PBV and CCQ-DSA techniques showed that the overall blood volume increased significantly and that the foot distal hemodynamics were significantly improved after endovascular treatment. DR in the ischemic area could r improve foot perfusion.
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Affiliation(s)
- Chaonan Wang
- Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Junye Chen
- Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jinsong Lei
- Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiang Shao
- Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhichao Lai
- Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Kang Li
- Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Wenteng Cao
- Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaolong Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jinghui Yuan
- Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Bao Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Eight-year Program of Clinical Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Correspondence: Bao Liu
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17
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Whelan JH, Kiser CR, Lazoritz JP, Vardaxis V. Avoiding the Deep Plantar Arterial Arch in Transmetatarsal Amputations: A Cadaver Study. J Am Podiatr Med Assoc 2022; 112:20-298. [PMID: 36115032 DOI: 10.7547/20-298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The deep plantar arterial arch (DPAA) is formed by an anastomosis between the deep plantar artery and the lateral plantar artery. The potential risk of injury to the DPAA is concerning when performing transmetatarsal amputations, and care must be taken to preserve the anatomy. We sought to determine the positional anatomy of the DPAA based on anatomical landmarks that could be easily identified and palpated during transmetatarsal amputation. METHODS In an effort to improve our understanding of the positional relationship of the DPAA to the distal metatarsal parabola, dissections were performed on 45 cadaveric feet to measure the location of the DPAA with respect to the distal metatarsal epiphyses. Images of the dissected specimens were digitally acquired and saved for measurement using in-house-written software. The mean, SD, SEM, and 95% confidence interval were calculated for all of the measurement parameters and are reported on pooled data and by sex. An independent-samples t test was used to assess for sex differences. Interrater reliability of the measurements was estimated using the intraclass correlation coefficient. RESULTS The origin of the DPAA was located a mean ± SD of 35.6 ± 3.9 mm (95% confidence interval, 34.5-36.8 mm) proximal to the perpendicular line connecting the first and fifth metatarsal heads. The average interrater reliability across all of the measurements was 0.921. CONCLUSIONS This study provides the positional relationship of the DPAA with respect to the distal metatarsal parabola. This method is easily reproducible and may assist the foot and ankle surgeon with surgical planning and approach when performing partial pedal amputation.
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18
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Croo A, Versyck T, Duinslaeger A, Harth C, Vermassen F, Randon C. The impact of an angiosome-targeted revascularization on healing rate, limb salvage and survival in critical limb threatening ischemia. Acta Chir Belg 2022; 122:107-115. [PMID: 34076565 DOI: 10.1080/00015458.2021.1881337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE According to the angiosome concept ulcer healing and limb salvage should be superior if direct arterial flow to the source vessel of an affected angiosome is established compared to indirect flow where the angiosome is perfused by means of collaterals. The objective of this study was to evaluate the impact of direct versus indirect revascularization (DR/IR) in endovascular versus bypass surgery on ulcer healing, limb salvage and mortality. MATERIALS AND METHODS A retrospective analysis of both endovascular and bypass distal (below the knee) lower limb revascularizations for chronic limb-threatening ischemia (CLTI) between 1993 and 2014 was performed. RESULTS The study population consisted of 126 endovascular and 198 bypass procedures. DR and IR were achieved in 57.4% and 42.6% limbs respectively. DR was not superior to IR regarding all three major endpoints when endovascular and bypass procedures were analyzed separately. Endovascular and bypass procedures resulted in comparable healing rates. All patients who did not achieve wound healing (HR 7.49; 95% CI 4.25-13.20, p = .0001) or needed to be treated with a bypass (HR 1.79; 95% CI 1.05-3.05, p = .034) were at an increased risk for major amputation. Increased mortality rate was noted after endovascular procedures (HR 1.45; 95% CI 1.04-2.00, p = .026). CONCLUSION This retrospective study with comparable results for DR and IR did not support the angiosome concept. Achieving wound healing remains critical in patients with CLTI to reduce major amputation rates. Overall the implications of the angiosome concept seem to be limited due to its feasibility in patients with CLTI.
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Affiliation(s)
- Alexander Croo
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Timothy Versyck
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Alec Duinslaeger
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Charlotte Harth
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Frank Vermassen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Caren Randon
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
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Comparison of clinical outcomes, including the wound healing rate, between inframalleolar bypass to the pedal artery and that to the pedal branch artery in the modern endovascular era. J Vasc Surg 2022; 75:2019-2029.e2. [PMID: 35182663 DOI: 10.1016/j.jvs.2022.01.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/30/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Inframalleolar (IM) bypass has been reported to demonstrate acceptable patency and limb salvage in chronic limb-threatening ischemia (CLTI) patients. However, wound healing after IM bypass and comparisons between pedal artery (PA) bypass and pedal branch artery (PBA) bypass are lacking. METHODS We reviewed prospectively collected data from 208 consecutive patients after IM bypass performed over a period of six years. Patients were divided into two groups based on the distal anastomotic artery: the PA group (dorsal pedis artery or common plantar artery) and the PBA group (medial tarsal, lateral tarsal, medial plantar, and lateral plantar artery). The primary outcome was wound healing, and secondary outcomes included loss of patency and limb and life prognosis. RESULTS Of the 208 patients, 174 (74%) had PA bypass, whereas 34 (16%) had PBA bypass. Patients in the PBA group were significantly younger than those in the PA group (69 ± 7 vs. 73 ± 9, P = .03). Although early (30-day) graft failure was more common in the PBA group, late clinical outcomes, including the wound healing rate (79% in the PA group and 84% in the PBA group, P=.74), were similar between the two groups. The Global Limb Anatomic Staging System (GLASS) IM grade (HR, 0.73; 95% confidence interval [CI], 0.58-0.93: P=.006); wound, ischemia, and foot infection (WIfI) wound grade (HR, 0.67; 95% CI, 0.51-0.89: P<.01); and WIfI foot infection grade (HR, 0.79; 95% CI, 0.65-0.96: P=.02) were independent predictors of wound healing. CONCLUSIONS The current study revealed that wound healing in patients following PBA bypass was acceptable and comparable to that following PA bypass. In the modern era, including high prevalence of infrapopliteal angioplasty, our results could provide useful information to clinicians in actual clinical settings. Moreover, PBA bypass may be an alternative revascularization procedure to avoid major amputation when the pedal artery is occluded, such as in the GVG IM P2 grade. Prospective multicenter larger studies are warranted to confirm the findings of this study and to compare PBA bypass and IM EVT in anatomical "no-option" CLTI.
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Bockeria LA, Arakelyan VS, Papitashvili VG, Tsurtsumiya SS. Long-term results of proximal and distal reconstructions in patients with lower limb arteries diffuse lesions and diabetes mellitus. RUDN JOURNAL OF MEDICINE 2021. [DOI: 10.22363/2313-0245-2021-25-4-271-281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Relevance . Treatment of diffuse lesions of the arteries of the lower extremities is often reduced to primary amputation at the hip level, since the healing of trophic ulcers is not guaranteed during arterial reconstruction. Profundoplasty without distal bypass surgery can be considered an alternative method. The aim of this study is to compare the long-term results of distal shunting and isolated profundoplasty in patients with diffuse lesions of the lower limb arteries and trophic ischemic ulcers. Materials and Methods . The study included 86 patients with diffuse lesions of the lower limb arteries. There were 52 (60.4%) men and 34 (39.6%) women. The average age was 67.3 16.8 years. All patients had diffuse lesions of the arteries below the pupar ligament, the state of the lower leg arteries was 5-8.5 points on the Rutherford scale, in all cases there were trophic ulcers. Group 1 included 48 patients who underwent reconstruction of the leg arteries. Group 2 consisted of 38 individuals who had limited intervention with endarcteriotomy from common femoral and deep femoral arteries. Results and Discussion . Amputations at the hip level were performed within a year in 11 (23.4%) patients of group 1 and in 3 (6.3%) patients within 30 days after surgery. Thus, 14 (29.7%) patients lost their limbs. A comparative analysis revealed that the group of patients with amputations had a more severe form of diabetes (p = 0.003), an outflow score on the Rutherford scale (p 0.001), and lower transcutaneous oxygen tension values before and after surgery. Within 12 months after the bypass surgery, the primary patency of the shunts was 65.9% (thrombosis occurred in 16 patients). Conclusion . The preservation of the limb in patients in our study by the end of 1 year after reconstruction is similar regardless of the reconstruction method. Given the minimal invasion during profundoplasty, this operation may be the method of choice for diffuse lesions of the arteries of the lower extremities.
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Meyer A, Yagshyyev S, Lang W, Rother U. The predictive value of microperfusion assessments for the follow-up of tibial bypass grafts. J Vasc Surg 2021; 75:1008-1013. [PMID: 34600032 DOI: 10.1016/j.jvs.2021.08.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/29/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We conducted a prospective evaluation of microperfusion parameters after tibial bypass surgery was performed. Differences between grafts with occlusions during follow-up and patent grafts were analyzed in relation to the pedal arch quality. METHODS Patients receiving tibial bypass grafts for chronic limb-threatening ischemia from 2019 to 2020 were included. Assessment of microcirculation (parameters: hemoglobin oxygen saturation [sO2] and flow) was done by laser Doppler flowmetry and white light spectrometry (oxygen-to-see), supine and in elevation, whereas the macrocirculation was evaluated by the ankle-brachial index and duplex ultrasound examination. The quality of run-off was graded for each patient. Measurements were performed preoperatively, 1 day postoperatively, and after 6 months. Patients with graft occlusions during follow-up (OCCLUDED) and patients without occlusions (OPEN) were compared. RESULTS We included 42 patients (13 women, 29 men; mean age, 76.1 years; range, 60-89 years) were included. The patency of all grafts 1 day after the operation was confirmed by ultrasound examination. The overall analysis of the microcirculation showed significant changes in both the supine and elevated leg position between measurements taken preoperatively, 1 day after the operation, and after 6 months for the parameters sO2 and FLOW (sO2 supine, P = .001; sO2 elevated, P < .001; FLOW supine, P < .001; FLOW elevated, P < .001). The comparison of the values 1 day after the operation yielded significantly decreased microperfusion parameters (both O2 and FLOW) in the group that developed bypass occlusion in the later follow-up period (sO2 supine: OCCLUDED, 35.7% [7.3-65.0] and OPEN, 48.7% [25.0-72.3] P = .011; FLOW supine: OCCLUDED, 27.7 A.U. [12.7-52.7] and OPEN, 57.3 A.U. [16.0-106.7], P = .008). No significant differences in the severity of the arch impairment was found between the OPEN and OCCLUDED groups (P = .651). Absolute values of the parameters sO2 and flow showed no correlation with the pedal arch classification. CONCLUSIONS Significantly poorer microperfusion was detected postoperatively in patients with later occurrence of graft occlusions despite patent grafts on the first postoperative day. Microperfusion measurements might be a possible tool for the prediction of graft failure.
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Affiliation(s)
- Alexander Meyer
- Department of Vascular Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany.
| | - Shatlyk Yagshyyev
- Department of Vascular Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Werner Lang
- Department of Vascular Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
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Kurianov P, Lipin A, Antropov A, Atmadzas K, Gruzdev N, Tankaeva Z, Atmadzas A, Orlov A, Borisov A, Sobolev R, Eminov Y. Propensity-matched analysis does not support angiosome-guided revascularization of multilevel peripheral artery disease (PAD). Vasc Med 2021; 27:47-54. [PMID: 34569374 DOI: 10.1177/1358863x211038627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND This retrospective comparative cohort study evaluated the clinical outcome of angiosome-guided endovascular arterial reconstructions in chronic limb-threatening ischemia (CLTI) due to multilevel peripheral artery disease (PAD). METHODS Patients treated in an endovascular fashion for CLTI with tissue loss due to multilevel PAD were analyzed. Limbs were classified as having undergone either angiosome-guided (direct) revascularization (DR) or nonangiosomic (indirect) revascularization (IR). DR was defined as uninterrupted in-line flow to the affected angiosome, revascularization through the pedal arch was also considered direct. Groups were adjusted with propensity score (PS) matching and compared for amputation-free survival (AFS), freedom from major adverse limb events (MALE), and healing rate at 12 months. RESULTS A total of 174 patients (81 men, mean age 70.0 ± 10.4 y) were included. PS matching produced two groups of 55 patients each: DR (24 men, mean age 71.7 ± 10.7 y) and IR (26 men, mean age 72.0 ± 9.4 y). The matched groups had no significant differences in baseline variables. At 12 months there were no significant differences in AFS (73.2% vs 71.6%; p = 0.841), freedom from MALE (71.7% vs 66.1%; p = 0.617), and healing rate (72.7% vs 72.0%; p = 1.000) between DR and IR, respectively. CONCLUSION This study failed to support the use of angiosome concept in CLTI due to multilevel disease.
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Affiliation(s)
- Pavel Kurianov
- Center on Diabetic Foot and Surgical Infection, St George's Hospital, Saint Petersburg, Russia
| | - Alexandr Lipin
- Limb Salvage Center, Hospital #14, Saint Petersburg, Russia
| | | | | | - Nikita Gruzdev
- Limb Salvage Center, Hospital #14, Saint Petersburg, Russia
| | - Zaynab Tankaeva
- Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - Alisa Atmadzas
- Limb Salvage Center, Hospital #14, Saint Petersburg, Russia
| | - Anton Orlov
- Limb Salvage Center, Hospital #14, Saint Petersburg, Russia
| | - Alexey Borisov
- Limb Salvage Center, Hospital #14, Saint Petersburg, Russia
| | - Roman Sobolev
- Limb Salvage Center, Hospital #14, Saint Petersburg, Russia
| | - Yanis Eminov
- Limb Salvage Center, Hospital #14, Saint Petersburg, Russia
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Liu IH, Wu B, Krepkiy V, Ferraresi R, Reyzelman AM, Hiramoto JS, Schneider PA, Conte MS, Vartanian SM. Pedal arterial calcification score is associated with the risk of major amputation in chronic limb-threatening ischemia. J Vasc Surg 2021; 75:270-278.e3. [PMID: 34481900 DOI: 10.1016/j.jvs.2021.07.235] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The medial arterial calcification (MAC) score is a simple metric that describes the burden of inframalleolar calcification using a plain foot radiograph. We hypothesized that a higher MAC score would be independently associated with the risk of major amputation in patients with chronic limb-threatening ischemia (CLTI). METHODS We performed a single-institution, retrospective study of 250 patients who had undergone infrainguinal revascularization for CLTI from January 2011 to July 2019 and had foot radiographs available for MAC score calculation. A single blinded reviewer assigned MAC scores of 0 to 5 using two-view minimum plain foot radiographs, with 1 point each for calcification of >2 cm in the dorsalis pedis, plantar, and metatarsal arteries and >1 cm in the hallux and non-hallux digital arteries. RESULTS The MAC score was 0 in 36%, 1 in 5.2%, 2 in 8.4%, 3 in 14%, 4 in 14%, and 5 in 21%. The MAC score was trichotomized to facilitate analysis and clinical utility (mild, MAC score 0-1; moderate, MAC score 2-4; and severe, MAC score 5). The variables independently associated with a higher MAC score were male sex, diabetes, end-stage renal disease, and the global limb anatomic staging system pedal score. The MAC score was not associated with the Society for Vascular Surgery WIfI (wound, ischemia, foot infection) grade or overall WIfI stage (P = .58). The median follow-up was 759 days (interquartile range, 264-1541 days). A higher MAC score was significantly associated with the risk of major amputation (P < .0001). In a Cox proportional hazards multiple regression model for major amputation that included the trichotomized MAC score, diabetes, end-stage renal disease, and WIfI stage (1-3 vs 4). The MAC score (MAC score 5: hazard ratio [HR], 4.9; 95% confidence interval [CI], 1.9-13.1; P = .001; MAC score 2-4: HR, 3.4; 95% CI, 1.3-8.8; P = .01) and WIfI stage (WIfI stage 4: HR, 2.1; 95% CI, 1.1-3.9; P = .03) were significantly associated with the risk of major amputation. In the subsets of patients with the most advanced WIfI stage of 3 to 4 (191 of 250; 76%) and patients with diabetes (185 of 250; 74%), the MAC score further stratified the risk of major amputation on univariate and multivariate analyses. CONCLUSIONS The MAC score is a simple, practical tool and a strong independent predictor of major amputation in patients with CLTI. It provides novel clinical data that are currently unmeasured using any validated CLTI staging system. The MAC score is a promising standardized measure of inframalleolar disease burden that can be used in conjunction with the WIfI staging system to help improve outcomes stratification and determine the optimal treatment strategies for patients with CLTI.
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Affiliation(s)
- Iris H Liu
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Bian Wu
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Viktoriya Krepkiy
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | | | - Alexander M Reyzelman
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Jade S Hiramoto
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Shant M Vartanian
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif.
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Kobayashi T, Hamamoto M, Okazaki T, Hasegawa M, Takahashi S. Does the Global Limb Anatomic Staging System Inframalleolar Modifier Influence Long Term Outcomes of Chronic Limb Threatening Ischaemia after Distal Bypass? Eur J Vasc Endovasc Surg 2021; 62:590-596. [PMID: 34465536 DOI: 10.1016/j.ejvs.2021.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 07/01/2021] [Accepted: 07/11/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the influence of inframalleolar disease (Global Limb Anatomic Staging System Inframalleolar [GLASS IM] modifier) on long term outcomes of patients with chronic limb threatening ischaemia (CLTI) after distal bypass. METHODS Patients who underwent distal bypass for CLTI from January 2012 to December 2019 at a single centre were reviewed retrospectively. Comparisons including baseline characteristics, procedural details, and long term outcomes were made between patients with an intact pedal arch (GLASS IM modifier P0), an absent or severely diseased pedal arch (P1), and no target artery crossing the ankle into the foot (P2), diagnosed by pre- and intra-operative high quality angiography. The primary endpoint was limb salvage. The secondary endpoints were graft patency and wound healing. RESULTS A total of 254 distal bypasses were performed in 206 patients (139 males; median age, 76 years). The GLASS IM modifier was P0 in 80 (32%) limbs, P1 in 127 (50%), and P2 in 47 (18%). During the follow up period, 22 limbs (9%) required major amputation. The limb salvage rates at three years in P0, P1, and P2 cases were 94%, 89%, and 93%, respectively, with no significant differences among the modifiers. The primary patencies at three years in P0, P1, and P2 cases were 49%, 38% and 24%, respectively. The primary patency in P2 cases was significantly lower than that in P0 cases (p < .050). The respective wound healing rates at 12 months were 97%, 93%, and 79%, and again the wound healing rate in P2 cases was significantly lower than those in other cases (p < .050). CONCLUSION Long term outcomes including patency, limb salvage, and wound healing after distal bypass for CLTI patients with an infrapopliteal lesion were acceptable in cases in each GLASS IM modifier.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Japan.
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Japan
| | - Misa Hasegawa
- Department of Reconstructive and Plastic Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University, Minami-ku, Japan
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Troisi N, Guidotti A, Turini F, Lombardi R, Falciani F, Baggiore C, Michelagnoli S, Chisci E. Influence of pedal arch quality on 5-year survival and limb salvage in patients with diabetic foot ulcers undergoing peripheral angiography. Vascular 2021; 30:848-855. [PMID: 34256628 DOI: 10.1177/17085381211032050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The aim of this study was to evaluate the influence of pedal arch quality on 5-year survival and limb salvage in diabetic patients with foot wounds undergoing peripheral angiography. METHODS Between January 2014 and December 2014, 153 diabetic patients with foot wounds underwent peripheral angiography. Final foot angiograms were used to allocate patients according to pedal arch: complete pedal arch (CPA), incomplete pedal arch (IPA), and absent pedal arch (APA). Five-year survival and limb salvage rates were analyzed with Kaplan-Meier curves and compared by means of Gehan-Breslow-Wilcoxon test. Associations of patient and procedure variables with overall survival and limb salvage outcomes were sought with univariate and multivariate analyses. RESULTS A below-the-knee (BTK) artery was the target vessel in 80 cases (52.3%). Five-year Kaplan-Meier rates of survival were similar in all groups (p = 0.1): CPA 30%, IPA 27.5%, and APA 26.4%. Five-year limb salvage rates were significantly better in patients with CPA/IPA (p < 0.001): CPA 95.1%, IPA 94.3%, and APA 67.3%. In the whole population study, multivariate analysis showed significant association of smoking (p = 0.01), chronic renal failure (p = 0.02), and severity of foot wounds (p < 0.001) with survival. Coronary artery disease (p = 0.03), severity of foot wounds (p = 0.001), and pedal arch status (p = 0.05) showed strong association with limb salvage. CONCLUSIONS Pedal arch quality significantly affected limb salvage but not survival at 5 years in patients with diabetic foot ulcers. Smoking, chronic renal failure, and severity of foot wounds affected overall survival, whilst coronary artery disease, and severity of foot wounds limb salvage.
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Affiliation(s)
- Nicola Troisi
- Department of Surgery, Vascular and Endovascular Surgery Unit, 26187San Giovanni di Dio Hospital, Florence, Italy
| | - Azzurra Guidotti
- Department of Surgery, Vascular and Endovascular Surgery Unit, 26187San Giovanni di Dio Hospital, Florence, Italy
| | - Filippo Turini
- Department of Surgery, Vascular and Endovascular Surgery Unit, 26187San Giovanni di Dio Hospital, Florence, Italy
| | - Renzo Lombardi
- Department of Surgery, Vascular and Endovascular Surgery Unit, 26187San Giovanni di Dio Hospital, Florence, Italy
| | | | | | - Stefano Michelagnoli
- Department of Surgery, Vascular and Endovascular Surgery Unit, 26187San Giovanni di Dio Hospital, Florence, Italy
| | - Emiliano Chisci
- Department of Surgery, Vascular and Endovascular Surgery Unit, 26187San Giovanni di Dio Hospital, Florence, Italy
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BENEDETTO D, FERRARESI R, SANGIORGI G. Attempting mini-invasiveness in the critically ill patient. The endovascular first act: the below-the-knee challenges. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.23736/s1824-4777.21.01503-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Langhoff R, Arjumand J, Waliszewski M, Reimer P, Härtel D, Hohl C, Raut W, Romani S, Alós J, Martínez E, Schmidt A, Yahya SA, Riazi H, Korosoglou G. The Real-World CONSEQUENT ALL COMERS Study: Predictors for Target Lesion Revascularization and Mortality in an Unselected Patient Population. Angiology 2021; 72:724-732. [PMID: 33779291 DOI: 10.1177/0003319721997314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
We evaluated the safety and efficacy of a resveratrol-paclitaxel-coated peripheral balloon catheter in an all-comer patient cohort undergoing endovascular treatment of above-the-knee and below-the-knee peripheral artery disease. CONSEQUENT ALL COMERS (Clinical Post-Market Clinical Follow-up [PMCF] on Peripheral Arteries treated with SeQuent Please OTW [Over-the Wire]) is a prospective, single-arm, multicenter observational study (ClinicalTrials Identifier: NCT02460042). The primary end point was the 12-month target lesion revascularization (TLR) rate. Secondary end points included vessel patency, target vessel revascularization, and all-cause mortality. A total of 879 lesions in 784 consecutive patients (71.3 ± 10.4 years old, 57.7% male) were analyzed; 53.3% had claudication, whereas the remaining 46.7% exhibited critical limb ischemia (CLI). Substantial comorbidities were present, including diabetes mellitus (41.2%), smoking (66.1%), and coronary artery disease (33.9%). Lesion length (879 lesions) was 12.0 ± 9.3 cm and 31.8% were Transatlantic Inter-Society Consensus II C/D lesions. The overall technical success rate of the 1269 drug-coated balloon (DCB)'s used was 99.6% (1.60 ± 0.79 DCB's/patient). At 12 months, the TLR rates were 6.3% in patients with CLI and 9.6% in claudicants, with a primary patency rate of 89.9% and 87.1%, respectively. All-cause mortality was 4.3% (28/658). The most important predictors for TLR were female gender, in-stent restenosis at baseline and lesion length.
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Affiliation(s)
- Ralf Langhoff
- Department of Angiology, 155840Sankt-Gertrauden-Krankenhaus, Berlin, Germany.,Brandenburg Medical School Theodor Fontane, Campus Clinic Brandenburg, Deutsche Angiologie Zentrum Brandenburg-Berlin, Department for Angiology, Center for Internal Medicine I, Brandenburg an der Havel, Germany
| | | | - Matthias Waliszewski
- Medical Scientific Affairs, B. Braun Melsungen AG, Berlin, Germany.,Department of Internal Medicine and Cardiology, 14903Charité-Universitätsmedizin Berlin, Campus Virchow, Berlin, Germany
| | | | | | | | | | | | - Jesús Alós
- 16380Hospital de Mataró, Barcelona, Spain
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Steiner S, Schmidt A. Repeat BTK revascularization: when, how and what are the results? THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:118-123. [PMID: 33635043 DOI: 10.23736/s0021-9509.21.11679-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Owing to the ageing of the population and rising rates of diabetes, more patients suffering from chronic limb threatening ischemia (CLTI) need revascularization for often complex, multilevel peripheral arterial occlusive disease. Below the knee (BTK) lesions are common in CLTI and short-term outcomes of BTK endovascular revascularizations have improved substantially over the last decade as a consequence of improved techniques and dedicated low profile devices. EVIDENCE ACQUISITION The manuscript summarized the information identified through a limited literature review conducted on key resources including MEDLINE and EMBASE databases as well as conference proceedings. The keywords were "angioplasty," "endovascular intervention," "infrapopliteal," "tibial arteries" and "below the knee." The search was limited to contemporary English-language documents published between 2000 and 2020. EVIDENCE SYNTHESIS Rates of re-stenosis and re-occlusion are high after infrapopliteal interventions limiting long-term success and necessitating frequent repeat procedures. CONCLUSIONS In this article we aimed to summarize current knowledge regarding the need, options and outcome of repeat BTK interventions through a limited literature review and presentation of own data.
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Affiliation(s)
- Sabine Steiner
- Division of Angiology, Department of Internal Medicine, Neurology and Dermatology, University Hospital Leipzig, Leipzig, Germany -
| | - Andrej Schmidt
- Division of Angiology, Department of Internal Medicine, Neurology and Dermatology, University Hospital Leipzig, Leipzig, Germany
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Thai DQ, Lee DH, Lee WB, Hahn HM, Lee IJ. What is the impact of infrapopliteal endovascular intervention on free flap survival in diabetic foot reconstruction? J Orthop Surg Res 2021; 16:42. [PMID: 33430921 PMCID: PMC7802144 DOI: 10.1186/s13018-020-02173-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/25/2020] [Indexed: 11/29/2022] Open
Abstract
Background The combination of endovascular intervention and microvascular free flap transfer has been effectively used for chronic ischemic wounds of lower limb. The aim of this study was to determine the influence of angioplasty on free flap survival in diabetic foot ulcer reconstruction. Methods A retrospective research was conducted for 46 diabetic patients with chronic ulcer of the foot. All patients underwent free flap reconstruction because of their non-healing wound with tendon or bone exposure. Patient’s demography, clinical data related to vascular status, vascular intervention, and free flap transfer procedure were collected. Flap survival rate was compared between the group with severe arterial stenosis group and non-severe stenosis group. It was also compared among groups with different revascularization results. Results The average age of patients was 56.2 ± 10.8 years. There were 14 (30.4%) men and 32 (69.6%) women. Of 46 patients, 23 (50%) had severe infrapopliteal arterial stenosis. All 23 patients underwent endovascular intervention. Their final results of the pedal arch were type 1 in 13 patients, type 2A in 7 patients, type 2B in 2 patients, and type 3 in 1 patient. Total flap necrosis was found in 5 (10.9%) cases, marginal necrosis in 4 (8.7%) cases, and wound dehiscence in 4 (8.7%) cases. There was no significant difference in flap loss between severe arterial stenosis patients and non-severe arterial stenosis patients. In the severe arterial stenosis group, after endovascular intervention, patients with type 1 of pedal arch had a significantly lower rate of total flap necrosis than others. There was no association between the use of revascularized recipient artery and flap survival. Conclusions Our study revealed that the quality of pedal arch was crucial for free flap survival. Thus, PTA should aim to re-establish a complete pedal arch to increase wound healing rate and flap success.
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Affiliation(s)
- Duy Quang Thai
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Dong Hwan Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Woo Beom Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Hyung Min Hahn
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Il Jae Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea.
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Marco M, Valentina I, Daniele M, Valerio DR, Andrea P, Roberto G, Laura G, Luigi U. Peripheral Arterial Disease in Persons with Diabetic Foot Ulceration: a Current Comprehensive Overview. Curr Diabetes Rev 2021; 17:474-485. [PMID: 33023453 DOI: 10.2174/1573399816999201001203111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 11/22/2022]
Abstract
In developed countries, the prevalence of persons with diabetes and peripheral arterial disease (PAD) is approximately 50%. The presence of PAD is associated with non-healing ulcers, major amputation, cardiovascular morbidity, and mortality. It is estimated that persons with diabetes, foot ulceration and PAD have 50% of 5-years mortality rate. Therefore, subjects with ischemic diabetic foot ulcers (DFUs) should be considered a special group of patients with specific clinical characteristics, general health status and prognosis. In persons with ischemic DFUs, an early diagnosis and treatment are mandatory to reduce the risk of worse outcomes such as major amputation. Revascularization of occluded lower extremity arteries is the main treatment to restore blood flow in the foot and promote wound healing. Nonetheless, there are several unmet needs in the management of diabetic subjects with PAD and foot ulceration as medical therapy, diagnostic criteria and indications for revascularization, revascularization strategy and technical approach as well as the management of no-option critical limb ischemia patients. It is a common opinion that there is an evolution of PAD features in diabetic persons, which seems to present a more aggressive pattern. This may be related to the frequent presence of concomitant comorbidities such as renal failure which could influence the characteristics of atherosclerotic plaques and their distribution. The aim of this review is to commence a complete overview and state of the art in the treatment of patients with diabetes, PAD, and foot ulceration and to describe the current challenges and future perspectives.
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Affiliation(s)
- Meloni Marco
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Izzo Valentina
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Morosetti Daniele
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Da Ros Valerio
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Panunzi Andrea
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Gandini Roberto
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Giurato Laura
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Uccioli Luigi
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
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Hahn HM, Lee DH, Lee IJ. Influence of time interval between endovascular intervention and free flap transfer on flap outcomes in critical limb-threatening ischemia: A retrospective analysis of 64 consecutive cases. J Plast Reconstr Aesthet Surg 2020; 74:1544-1552. [PMID: 33454224 DOI: 10.1016/j.bjps.2020.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/18/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Arterial revascularization and free flap reconstruction is safe and effective for limb salvage in patients with critical limb-threatening ischemia (CLTI). This study aimed to determine whether reconstruction outcomes were affected by the time interval between endovascular treatment and free flap transfer in lower extremity reconstruction for critical limb ischemia. METHODS Patients who underwent endovascular intervention and subsequent free flap reconstruction with >6 months of follow-up were reviewed. Those with wounds with oncological and traumatic etiologies were excluded. Patients' demographics, risk factors, details of microsurgical procedures, details of endovascular intervention, and flap outcomes were collected. RESULTS Overall, 64 consecutive patients (M:F = 50:14 and mean age, 57.3 [range, 29-82] years) were evaluated between November 2011 and October 2019. Angioplasty failed in three patients. For soft-tissue reconstruction, anterolateral free flaps were used most frequently (n = 54 and 84.4%). Flap-related complications developed in 12 cases, of which five cases included total flap necrosis. The interval between endovascular intervention and free flap transfer was not associated with flap loss in multivariate regression analysis. Patients with kidney transplants and higher serum creatinine were associated with total flap necrosis. Advanced age, failed angioplasty, and perfusion status of the pedal arch were associated with major flap complications. CONCLUSION The time interval between endovascular treatment and free flap reconstruction was not associated with flap complications. Free flap reconstruction of chronic wounds caused by CLTI can be safely planned regardless of the time duration from preoperative angioplasty.
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Affiliation(s)
- Hyung Min Hahn
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do 16499, Republic of Korea
| | - Dong Hwan Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do 16499, Republic of Korea
| | - Il Jae Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do 16499, Republic of Korea.
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Slim H, Pran L, Zyada RWA, Valenti D, Rashid H. Novel Technique for Latero-anterior Approach to the Terminal Peroneal Artery for Bypass Surgery without Fibular Resection. Ann Vasc Surg 2020; 72:637-642. [PMID: 33373772 DOI: 10.1016/j.avsg.2020.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/22/2020] [Accepted: 11/25/2020] [Indexed: 12/24/2022]
Abstract
The peroneal artery (PeA) is often a vital target vessel for lower limb revascularization. Exploring the distal PeA can be challenging via the conventional approaches. We present a new, minimally invasive technique for a latero-anterior approach to the terminal PeA without fibular resection as either a target outflow vessel for open bypass revascularization surgery or, as in this report, the inflow for a crural-pedal bypass in a challenging case of critical limb-threatening ischemia.
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Affiliation(s)
- Hani Slim
- Department of Vascular Surgery, King's College Hospital, London, UK
| | - Lemuel Pran
- Department of Vascular Surgery, King's College Hospital, London, UK.
| | | | - Domenico Valenti
- Department of Vascular Surgery, King's College Hospital, London, UK
| | - Hisham Rashid
- Department of Vascular Surgery, King's College Hospital, London, UK
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Bekeny JC, Alfawaz A, Day J, Naz I, Attinger CE, Fan KL, Evans KK, Akbari CM. Indirect Endovascular Revascularization via Collaterals: A New Classification to Predict Wound Healing and Limb Salvage. Ann Vasc Surg 2020; 73:264-272. [PMID: 33373768 DOI: 10.1016/j.avsg.2020.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/01/2020] [Accepted: 11/09/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND In the setting of chronic limb ischemia, lower extremity (LE) wounds require revascularization of source arteries for wound healing and limb salvage. Direct revascularization of the source artery is preferred but cannot always be performed. Our objective was to analyze the influence of arterial-arterial connections on clinical outcomes after angiosome-directed endovascular revascularization. METHODS Consecutive LE wounds in patients with isolated infra-popliteal disease revascularized endovascularly from 2012 to 2016 within a single center were retrospectively reviewed. Treatment was classified as direct revascularization (DR) if the source artery supplying the wound angiosome was treated, indirect revascularization via collaterals (IR-C) if the source artery angiosome was revascularized by another major artery via arterial connections, or indirect revascularization (IR) if direct revascularization of the source artery angiosome was not possible. Demographics, comorbidities, and patient outcomes were collected. RESULTS Of 105 patients with 106 LE wounds, there were 35, 38, and 33 patients in the DR, IR-C, and IR groups, respectively. The mean age was 65.8 years old (standard deviation (SD) 11.9) with 81 males (77.1%) and 24 females (22.9%). Average follow-up was 21.0 months (SD 14.0). Overall wound healing rates were 80.0%, 92.1%, and 63.6% for DR, IR-C, and IR, respectively (P = 0.009). Significant differences were found between all 3 group comparisons, DR versus IR-C (P = 0.010), DR versus IR (P = 0.013), IR-C versus IR (P = 0.008). Overall major amputation-free survival was 85.7%, 89.5%, and 69.7% in DR, IR-C, and IR groups, respectively, with statistically significant differences between the IR-C and IR groups (P = 0.036). CONCLUSIONS Treating diseased infra-popliteal arteries and improving blood flow via arterial-arterial connections as per the angiosome model improved wound healing and amputation-free survival in this cohort. Although DR is still the gold standard, revascularization using IR-C may give superior healing results even in highly comorbid patients. This offers an additional avenue for treatment, especially when DR is not possible.
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Affiliation(s)
- Jenna C Bekeny
- Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Abdullah Alfawaz
- Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Jonathan Day
- Georgetown University School of Medicine; Washington, DC
| | - Iram Naz
- Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Christopher E Attinger
- Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Kenneth L Fan
- Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Karen K Evans
- Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Cameron M Akbari
- Center for Wound Healing and Hyperbaric Medicine, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC.
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Ferraresi R, Ucci A, Casini A, Caminiti M, Minnella D, Clerici G, Montero-Baker M. GLASS (Global Limb Anatomic Staging System): a critical appraisal. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 62:98-103. [PMID: 33307645 DOI: 10.23736/s0021-9509.20.11696-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND THE Global Vascular Guidelines (GVGs) propose a new Global Anatomic Staging System (GLASS) resulting in three stages of complexity for intervention. The aim of this study was to retrospectively classify a large cohort of CLTI patients according to the GLASS, evaluating its distribution in a real-world setting. METHODS Retrospective, single center, observational study enrolling all consecutive CLTI patients submitted to infra-inguinal endovascular revascularization in our institution, between June 2014 and September 2019. Patients were categorized according to the GLASS for femoro-popliteal (FP), infra-popliteal (IP) and infra-malleolar grading. FP and IP grades were merged to get the final GLASS stage for each limb. RESULTS The study included 1995 CLTI patients who underwent 2850 endovascular procedures in which 6009 arterial lesions were successfully treated. The FP segment was classified as: 1292 (45.3%) grade 0, 475 (16.6%) grade 1, 159 (5.6%) grade 2, 209 (7.4%) grade 3, and 715 (25.1%) grade 4. The IP segment was classified as: 1529 (53.6%) grade 0, 183 (6.4%) grade 1, 80 (2.8%) grade 2, 207 (7.3%) grade 3, and 851 (29.9%) grade 4. The combination of FP and IP grading led to GLASS stages: 922 (32.3%) stage 1, 375 (13.2%) stage 2, 1472 (51.6%) stage 3. CONCLUSIONS The distribution of the FP, IP and final GLASS grading was mainly grouped at the two extremes, letting the intermediate grades rather scarce. The majority of patients present with an absent or severely diseased pedal arch, stressing the need to incorporate infra-malleolar disease into the GLASS.
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Affiliation(s)
- Roberto Ferraresi
- Clinic of Diabetic Foot, San Carlo Clinic, Paderno Dugnano, Milan, Italy -
| | | | - Andrea Casini
- Clinic of Diabetic Foot, San Carlo Clinic, Paderno Dugnano, Milan, Italy
| | - Maurizio Caminiti
- Clinic of Diabetic Foot, San Carlo Clinic, Paderno Dugnano, Milan, Italy
| | - Daniela Minnella
- Clinic of Diabetic Foot, San Carlo Clinic, Paderno Dugnano, Milan, Italy
| | - Giacomo Clerici
- Clinic of Diabetic Foot, San Carlo Clinic, Paderno Dugnano, Milan, Italy
| | - Miguel Montero-Baker
- Division of Vascular and Endovascular Surgery, Baylor College of Medicine, Houston, TX, USA
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Takahashi LA, França GJ, Valle CED, Ferreira LRC. Assessment of the pedal arteries with Duplex Scanning. J Vasc Bras 2020; 19:e20200068. [PMID: 34211519 PMCID: PMC8218015 DOI: 10.1590/1677-5449.200068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Vascular Doppler ultrasound is a noninvasive method that can help in diagnostic and therapeutic planning in case of pedal arterial obstructive disease. The dorsalis pedis artery is the direct continuation of the anterior tibial artery and follows a straight course along the dorsum of the foot, leading medially to the first intermetatarsal space, where it gives off its terminal branches. The posterior tibial artery forks distal to the medial malleolus and gives rise to the lateral plantar and medial plantar arteries. The medial plantar artery has a smaller caliber and runs medially in the sole of the foot, while the lateral plantar artery is of larger caliber, following a lateral course in the plantar region and forming the deep plantar arch, which anastomoses with the dorsalis pedis artery via the deep plantar artery. The arteries of the foot can be assessed noninvasively with Doppler, providing an adequate level of anatomical detail.
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Affiliation(s)
- Luciana Akemi Takahashi
- Universidade Federal do Paraná - UFPR, Hospital de Clínicas - HC, Unidade Cardiopulmonar, Curitiba, PR, Brasil
| | - Graciliano José França
- Universidade Federal do Paraná - UFPR, Hospital de Clínicas - HC, Unidade Cardiopulmonar, Curitiba, PR, Brasil
| | - Carlos Eduardo Del Valle
- Universidade Federal do Paraná - UFPR, Hospital de Clínicas - HC, Unidade Cardiopulmonar, Curitiba, PR, Brasil
| | - Luis Ricardo Coelho Ferreira
- Universidade Federal do Paraná - UFPR, Hospital de Clínicas - HC, Unidade de Diagnóstico por Imagem, Curitiba, PR, Brasil
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Ni WW, Leong S, Irani F, Patel A, Damodharan K, Venkataranasimha N, Chandramohan S, Kumar P, Chua J, Gogna A, Da Zhuang K, Chong TT, Tang TY, Chng SP, Tay KH. "Angioplasty-First" Approach for Limb Salvage in Asian Patients with Critical Limb Ischemia: Outcomes from 3,303 Angioplasties on 2,402 Limbs in a Single Tertiary Hospital. J Vasc Interv Radiol 2020; 31:1969-1977.e1. [PMID: 33139186 DOI: 10.1016/j.jvir.2020.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 01/16/2023] Open
Abstract
PURPOSE To review outcomes of patients with critical limb ischemia (CLI) who underwent conventional percutaneous transluminal angioplasty (PTA) as first-line treatment for revascularization. MATERIALS AND METHODS Retrospective review of 3,303 angioplasty procedures on 2,402 limbs in 1,968 patients with CLI was conducted. Mean patient age was 68 years ± 11, and 1,057 patients (54%) were male. Diabetes mellitus (DM) was present in 1,736 patients (88%), and end-stage renal disease (ESRD) in 579 (29%). A majority of patients (90%) had tissue loss. Limb salvage rates were generated by Kaplan-Meier plot. Univariate and multivariate Cox regression analysis was conducted to investigate associations between clinical predictors and time-to-event outcome. RESULTS Limb salvage rates at 1, 3, 5, and 10 years were 75%, 73%, 72%, and 62%, respectively, and overall survival rates were 79%, 64%, 56%, and 34%, respectively. In multivariable Cox regression analysis with the outcome of major amputation, significant predictors included age < 69 years (P = .032), Malay race (P = .029), DM (P < .001), history of cerebral vascular disease (P = .003), ESRD (P < .001), Rutherford classification (P = .042), repeat intervention (P = .034), and number of straight-line flows (P < .001) and plantar arch integrity (P < .001) on completion angiography. Significant associations with mortality were age < 69 years (P < .001), male sex (P = .030), Malay race (P = .027), history of ischemic heart disease (P < .001), ESRD (P < .001), and repeat intervention (P < .001). CONCLUSIONS PTA as first-line revascularization for patients with CLI is safe and effective. Further studies are suggested to validate the outcome predictive model.
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Affiliation(s)
- Wen Wen Ni
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Sum Leong
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Farah Irani
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Ankur Patel
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Karthikeyan Damodharan
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Nanda Venkataranasimha
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Sivanathan Chandramohan
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Pradesh Kumar
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Jasmine Chua
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Apoorva Gogna
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Kun Da Zhuang
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Outram Road, Singapore
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Outram Road, Singapore
| | - Siew Ping Chng
- Department of Vascular Surgery, Singapore General Hospital, Outram Road, Singapore
| | - Kiang Hiong Tay
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore.
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Ferraresi R, Ucci A, Pizzuto A, Losurdo F, Caminiti M, Minnella D, Casini A, Clerici G, Montero-Baker M, Mills J. A Novel Scoring System for Small Artery Disease and Medial Arterial Calcification Is Strongly Associated With Major Adverse Limb Events in Patients With Chronic Limb-Threatening Ischemia. J Endovasc Ther 2020; 28:194-207. [DOI: 10.1177/1526602820966309] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose: To evaluate the roles of small artery disease (SAD) and medial arterial calcification (MAC) in patients with chronic limb-threatening ischemia (CLTI) and to identify any correlation between these factors and peripheral artery disease (PAD) or outcomes after treatment. Materials and Methods: A retrospective review was conducted of 259 limbs with tissue loss among 223 CLTI patients (mean age 72.2±11.4 years; 194 men) having an angiographic foot vessel study, foot radiography, and at least 6 months of follow-up after intervention. SAD and MAC were quantified using a 3-level score (0=absent, 1=moderate, 2=severe) based on angiography for SAD and foot radiographs for MAC. The MAC score was validated and compared with the SAD score, evaluating their associations with PAD distribution and clinical outcomes. Results: Based on the MAC score, the 259 limbs were classified as 55 group 0 (21.2%), 89 group 1 (34.4%), and 115 group 2 (44.4%). The SAD score stratified the 259 limbs as 67 group 0 (25.9%), 76 group 1 (29.3%), and 116 group 2 (44.8%). Interobserver reproducibility of the MAC score was high (correlation coefficient 0.96). Sensitivity and specificity of the MAC score in detecting SAD was 100% and 98.1%, respectively, in SAD groups 0 and 2 vs 99.1% and 92.7%, respectively, for SAD group 1. PAD was more proximal in MAC and SAD groups 0 and more distal in groups 1 and 2. Both MAC and SAD scores were able to predict clinical endpoints. Multivariable analysis demonstrated that the MAC score represents an independent risk factor for adverse limb events. Conclusion: SAD and MAC must be considered expressions of the same obstructing disease, able to adversely impact the fate of CLTI patients. SAD and MAC scores are powerful prognostic indicators of major adverse limb events in CLTI patients.
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Affiliation(s)
- Roberto Ferraresi
- Peripheral Interventional Unit, San Carlo Clinic, Paderno Dugnano, Milan, Italy
| | | | | | - Fabrizio Losurdo
- Diabetic Foot Clinic, San Carlo Clinic, Paderno Dugnano, Milan, Italy
| | - Maurizio Caminiti
- Diabetic Foot Clinic, San Carlo Clinic, Paderno Dugnano, Milan, Italy
| | - Daniela Minnella
- Diabetic Foot Clinic, San Carlo Clinic, Paderno Dugnano, Milan, Italy
| | - Andrea Casini
- Vascular Surgery Unit, San Carlo Clinic, Paderno Dugnano, Milan, Italy
| | - Giacomo Clerici
- Diabetic Foot Clinic, San Carlo Clinic, Paderno Dugnano, Milan, Italy
| | - Miguel Montero-Baker
- Division of Vascular and Endovascular Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Joseph Mills
- Division of Vascular and Endovascular Surgery, Baylor College of Medicine, Houston, TX, USA
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Kim TI, Vartanian SS, Schneider PA. A Review and Proposed Classification System for the No-Option Patient With Chronic Limb-Threatening Ischemia. J Endovasc Ther 2020; 28:183-193. [PMID: 33032494 DOI: 10.1177/1526602820963911] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A growing, but poorly defined subset of patients with chronic limb-threatening ischemia (CLTI) have "no option" for revascularization. One notable subgroup includes patients with severe ischemia and advanced pedal artery occlusive disease, termed "desert foot," who are at high risk for major amputation due to a lack of conventional revascularization options. Although new therapies are being developed for no-option patients with desert foot anatomy, this subgroup and the broader group of no-option patients are not well defined, limiting the ability to evaluate outcomes. Based on a systematic review, a classification of the no-option CLTI patient was constructed for use in clinical practice and studies. Several no-option conditions were identified, including type I-severe and pedal occlusive disease (desert foot anatomy) for which there is no accepted method of repair; type II-lack of suitable venous conduit for bypass in the setting of an acceptable target for bypass; type III-extensive tissue loss with exposure of vital structures that renders salvage impossible; type IV-advanced medical comorbidities for which available revascularization options would pose a prohibitive risk; and type V-presence of a nonfunctional limb. While type I and type II patients may have no option for revascularization, type III and type V patients have wounds, infection, comorbidities, or functional status that may leave them with few options for revascularization. As treatment strategies continue to evolve and novel methods of revascularization are developed, the ability to identify no-option patients in a standardized fashion will aid in treatment selection and assessment of outcomes.
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Affiliation(s)
- Tanner I Kim
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Shant S Vartanian
- Division of Vascular and Endovascular Surgery, University of California at San Francisco School of Medicine, San Francisco, CA, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California at San Francisco School of Medicine, San Francisco, CA, USA
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Settembre N, Biancari F, Spillerova K, Albäck A, Söderström M, Venermo M. Competing Risk Analysis of the Impact of Pedal Arch Status and Angiosome-Targeted Revascularization in Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2020; 68:384-390. [DOI: 10.1016/j.avsg.2020.03.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/21/2020] [Accepted: 03/27/2020] [Indexed: 11/30/2022]
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Ferraresi R, Clerici G, Casini A, Ucci A, Caminiti MS, Minnella D, Frykberg RG. Foot Angiosomes: Instructions for Use. INT J LOW EXTR WOUND 2020; 19:293-304. [DOI: 10.1177/1534734620954745] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the last 15 years an abundance of literature has demonstrated that angiosome-targeted revascularization, either endovascular or open, can lead to better clinical results in patients with chronic limb-threatening ischemia. According to this literature, the angiosome concept should guide our treatment strategy in every chronic limb-threatening ischemia patient. However, in our daily practice, its application is often difficult or impossible. Most foot wounds spread over multiple angiosomes and, moreover, the value of an angiosome-guided revascularization approach can vary according to vascular anatomy, collateral vessel network, type of revascularization, and wound. The aim of this article is to explore values and limits of the angiosome concept, and to propose some “instructions for use” regarding its application in our daily practice.
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Kagadis GC, Tsantis S, Gatos I, Spiliopoulos S, Katsanos K, Karnabatidis D. 2D perfusion DSA with an open-source, semi-automated, color-coded software for the quantification of foot perfusion following infrapopliteal angioplasty: a feasibility study. Eur Radiol Exp 2020; 4:47. [PMID: 32875390 PMCID: PMC7462946 DOI: 10.1186/s41747-020-00176-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/03/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Foot perfusion has been recently implemented as a new tool for optimizing outcomes of peripheral endovascular procedures. A custom-made, two-dimensional perfusion digital subtraction angiography (PDSA) algorithm has been implemented to quantify outcomes of endovascular treatment of critical limb ischemia (CLI), assist intra-procedural decision-making, and enhance clinical outcomes. METHODS The study was approved by the Hospital's Ethics Committee. This prospective, single-center study included seven consecutive patients scheduled to undergo infrapopliteal endovascular treatment of CLI. Perfusion blood volume (PBV), mean transit time (MTT), and perfusion blood flow (PBF) maps were extracted by analyzing time-intensity curves and signal intensity on the perfused vessel mask. Mean values calculated from user-specified regions of interest (ROIs) on perfusion maps were employed to evaluate pre- and post-endovascular treatment condition. Measurements were performed immediately after final PDSA. RESULTS In total, five patients (aged 54 ± 16 years, mean ± standard deviation) were analyzed, as two patients were excluded due to significant motion artifacts. Post-procedural MTT presented a mean decrease of 19.1% for all patients and increased only in 1 of 5 patients, demonstrating in 4/5 patients an increase in tissue perfusion after revascularization. Overall mean PBF and PBV values were also analogously increased following revascularization (446% and 69.5% mean, respectively) and in the majority of selected ROIs (13/15 and 12/15 ROIs, respectively). CONCLUSIONS Quantification of infrapopliteal angioplasty outcomes using this newly proposed, custom-made, intra-procedural PDSA algorithm was performed using PBV, MTT, and PBF maps. Further studies are required to determine its role in peripheral endovascular procedures ( ClinicalTrials.gov Identifier: NCT04356092).
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Affiliation(s)
- George C Kagadis
- Department of Medical Physics, School of Medicine, University of Patras, GR 26504, Rion, Greece
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Stavros Tsantis
- Department of Medical Physics, School of Medicine, University of Patras, GR 26504, Rion, Greece
| | - Ilias Gatos
- Department of Medical Physics, School of Medicine, University of Patras, GR 26504, Rion, Greece
| | - Stavros Spiliopoulos
- 2nd Department of Radiology, School of Medicine, "ATTIKON" University Hospital, National and Kapodistrian University of Athens, GR 12461, Athens, Greece.
| | - Konstantinos Katsanos
- Department of Radiology, School of Medicine, University of Patras, GR 26504, Rion, Greece
| | - Dimitris Karnabatidis
- Department of Radiology, School of Medicine, University of Patras, GR 26504, Rion, Greece
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Harth C, Randon C, Vermassen F. Impact of Angiosome Targeted Femorodistal Bypass Surgery on Healing Rate and Outcome in Chronic Limb Threatening Ischaemia. Eur J Vasc Endovasc Surg 2020; 60:68-75. [DOI: 10.1016/j.ejvs.2020.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 02/08/2020] [Accepted: 03/08/2020] [Indexed: 12/12/2022]
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Abstract
Although several studies showed that angiosome-guided endovascular treatment improved wound healing and major amputation rates in patients with chronic limb-threatening ischemia (CLTI), effectiveness of the angiosome concept to the treatment of ischemic foot remains to be elucidated, especially in bypass surgery. Arterial anatomy of the foot and ankle shows that there are multiple supplementary circulation including arterial–arterial connections and choke nexus, which indicates angiosome concept may carry limited importance in bypass surgery for CLTI. On the other hand, patients with diabetes or renal dysfunction have partial occlusion of arterial–arterial connections and, therefore, quite a few patients with CLTI in Japan may present with limited but impaired supplementary circulation around the ankle. This article reviews the arterial anatomy and circulation of the foot and ankle and discusses availability and limitations of angiosome-guided bypass surgery.
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Affiliation(s)
- Juno Deguchi
- Department of Vascular Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
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Hata Y, Iida O, Takahara M, Asai M, Masuda M, Okamoto S, Ishihara T, Nanto K, Kanda T, Tsujimura T, Okuno S, Matsuda Y, Mano T. Infrapopliteal Anatomic Severity and Delayed Wound Healing in Patients With Chronic Limb-Threatening Ischemia in the Era of the Global Limb Anatomic Staging System. J Endovasc Ther 2020; 27:641-646. [PMID: 32571134 DOI: 10.1177/1526602820933880] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To investigate the prognostic impact of infrapopliteal (IP) artery anatomic severity according to the Global Limb Anatomic Staging System (GLASS) on delayed wound healing in patients with chronic limb-threatening ischemia (CLTI). Materials and Methods: This study retrospectively analyzed 639 limbs with tissue loss in 484 CLTI patients (mean age 74±10 years; 300 men) presenting IP lesions treated with endovascular therapy between April 2010 and December 2015. Two-thirds of patients had diabetes (323, 67%) and over half were on hemodialysis (255, 53%). More than a third of the limbs (251, 39%) were classified as clinical stage 4 according to the Wound, Ischemia, and foot Infection (WIfI) system. IP anatomic severity was classified based on preprocedural angiography according to the GLASS. Severity of arterial calcification was assessed using high-intensity fluoroscopy and classified into 3 groups: none (grade 0), unilateral (grade 1), and bilateral (grade 2). Poor below-the-ankle (BTA) runoff was defined as the lack of a pedal arch with 0 to 1-vessel runoff within the dorsal pedis artery and the lateral and medial plantar arteries. The outcome measure was 1-year wound healing. The association of anatomic characteristics with delayed wound healing was evaluated using Cox proportional hazards regression analysis. Outcomes are presented as the adjusted hazard ratio (HR) with 95% confidence interval (CI). Results: During a mean follow-up of 22±19 months, the 1-year cumulative wound healing rate was estimated to be 59.0% (95% CI 54.5% to 63.5%). Multivariable analysis demonstrated independent associations between delayed wound healing and IP calcification grade (HR 1.24, 95% CI 1.02 to 1.50, p=0.027) and poor BTA runoff (HR 1.39, 95% CI 1.04 to 1.85, p=0.025) but not the GLASS IP grade (HR 0.92, 95% CI 0.82 to 1.14, p=0.21). Conclusion: The current study revealed that IP arterial calcification and poor BTA runoff were significantly associated with delayed wound healing, whereas the GLASS was not predictive of wound healing.
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Affiliation(s)
- Yosuke Hata
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Osamu Iida
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Mitsutoshi Asai
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Masaharu Masuda
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Shin Okamoto
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Takayuki Ishihara
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Kiyonori Nanto
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Takashi Kanda
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Takuya Tsujimura
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Shota Okuno
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Yasuhiro Matsuda
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Toshiaki Mano
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
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Kim TI, Schneider PA. New Innovations and Devices in the Management of Chronic Limb-Threatening Ischemia. J Endovasc Ther 2020; 27:524-539. [PMID: 32419596 DOI: 10.1177/1526602820921555] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
As the number of patients afflicted by chronic limb-threatening ischemia (CLTI) continues to grow, new solutions are necessary to provide effective, durable treatment options that will lead to improved outcomes. The diagnosis of CLTI remains mostly clinical, and endovascular revascularization remains mostly balloon-based. Multiple innovative techniques and technologies are in development or in early usage that may provide new solutions. This review categorizes areas of advancement, highlights recent developments in the management of CLTI and looks forward to novel devices that are currently under investigation.
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Affiliation(s)
- Tanner I Kim
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California at San Francisco School of Medicine, San Francisco, CA, USA
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Cheun TJ, Jayakumar L, Sideman MJ, Pounds LC, Davies MG. Outcomes of isolated inframalleolar interventions for chronic limb-threatening ischemia in diabetic patients. J Vasc Surg 2020; 71:1644-1652.e2. [PMID: 32081478 DOI: 10.1016/j.jvs.2019.07.094] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/11/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Inframalleolar disease is present in many diabetic patients presenting with tissue loss. The aim of this study was to examine the patient-centered outcomes after isolated inframalleolar interventions. METHODS A database of patients undergoing lower extremity endovascular interventions for tissue loss (critical limb-threatening ischemia, Wound, Ischemia, and foot Infection [WIfI] stage 1-3) and a de novo intervention on the index limb between 2007 and 2017 was retrospectively queried. Those patients with isolated inframalleolar interventions on the dorsalis pedis and medial and lateral tarsal arteries were identified. Patients with concomitant superficial femoral artery and tibial interventions were excluded. Intention-to-treat analysis by patient was performed. Patient-oriented outcomes of clinical efficacy (absence of recurrent symptoms, maintenance of ambulation, and absence of major amputation), amputation-free survival (AFS; survival without major amputation), and freedom from major adverse limb events (above-ankle amputation of the index limb or major reintervention [new bypass graft, jump or interposition graft revision]) were evaluated. RESULTS There were 109 patients (48% male; average age, 65 years; 153 vessels) who underwent isolated inframalleolar interventions for tissue loss. All patients had diabetes, and 53% had chronic renal insufficiency (47% of these were on hemodialysis). The majority of the patients had WIfI stage 3 disease. Technical success was 81%, with a median of one vessel treated per patient. Thirty-four percent of interventions were a direct revascularization of the intended angiosome in the foot. The 30-day major adverse cardiovascular event rate was 0%. The majority of patients underwent some form of planned forefoot surgery (single digit, multiple digits, ray or transmetatarsal amputation). Wound healing at 3 months in those not requiring amputation was 76%. Predictors for wound healing were improved pedal runoff score (<7), absence of infection, direct angiosome revascularization, and absence of end-stage renal disease. Those in whom the primary wounds or the initial amputation site failed to heal ultimately underwent below-knee amputations. The clinical efficacy was 25% ± 7% (mean ± standard error of the mean) at 5 years. The 5-year AFS rate was 33% ± 8%, and the 5-year freedom from major adverse limb events was 27% ± 9%. On Cox proportional multivariate analysis, predictors for AFS were absence of significant coronary disease, postprocedure pedal runoff score <7 (good runoff), WIfI stage <3, and absence of end-stage renal disease. CONCLUSIONS Inframalleolar intervention can be successfully performed in high-risk limbs with acceptable short-term results. However, long-term AFS remains poor because of the underlying disease process.
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Affiliation(s)
- Tracy J Cheun
- Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex
| | - Lalithapriya Jayakumar
- Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex
| | - Matthew J Sideman
- Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex
| | - Lori C Pounds
- Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex
| | - Mark G Davies
- Division of Vascular and Endovascular Surgery, Department of Surgery, Long School of Medicine, University of Texas Health at San Antonio, San Antonio, Tex; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Tex.
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Awari P, Vatsalaswamy P. Unusual anatomical variations in plantar metatarsal arteries and plantar arterial arch with surgical significance. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.4103/ijves.ijves_101_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Nishan B, Krishna KS, Hudgi VV, Ahsan VP, Anand V. Limb salvage following below-the-ankle angioplasty in critical limb ischemia. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.4103/ijves.ijves_59_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Chaudhari H, Sumanthraj KB, Anand V, Motukuru V, Rodney SR, Sravan CPS, Sivakrishna K, Suresh KR. Comparative study of outcomes between single-vessel versus multiple-vessel infrapopliteal angioplasties in patients with chronic limb-threatening ischemia. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.4103/ijves.ijves_64_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Alexandrescu VA, Brochier S, Limgba A, Balthazar S, Khelifa H, De Vreese P, Azdad K, Nodit M, Pottier M, Van Espen D, Sinatra T. Healing of Diabetic Neuroischemic Foot Wounds With vs Without Wound-Targeted Revascularization: Preliminary Observations From an 8-Year Prospective Dual-Center Registry. J Endovasc Ther 2019; 27:20-30. [PMID: 31709886 DOI: 10.1177/1526602819885131] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Purpose: To assess the clinical efficacy of endovascular angiosome-oriented wound-targeted revascularization (WTR) vs indirect (wound-indifferent) revascularization (IR) in diabetic patients with neuroischemic foot ulcers. Materials and Methods: Between April 2009 and July 2017, 167 diabetic patients (mean age 72.8 years; 137 men) with chronic limb-threatening ischemia (Rutherford category 5) and foot wounds (Wagner 2-4) in 194 limbs were prospectively registered and scheduled for primary infragenicular endovascular treatment. Specific angiosome source artery reperfusion sustained by patent foot arches or arterial-arterial connections was attempted initially. If this approach failed, topographic revascularization via available collaterals (WTRc) and IR were sequentially attempted. Results: Reperfusion was successful in 176 (91%) of 194 limbs (113 with WTR, 28 with WTRc, and 35 with IR); the global angiosome-oriented technical success (WTR and WTRc) was 73% (141/194). The mean follow-up was 10.9±0.7 months (range 3-12.5). Over 1 year, 102 (58%) of the 176 successfully treated limbs experienced wound healing [79/113 (70%) in the WTR group, 15/28 (54%) in the WTRc group, and 7/35 (20%) in the IR group; p=0.011]. The mean time to healing was 6.8±0.4 months in the WTR group, 7.9±0.6 months in the WTRc group, and 9.8±0.7 months in the IR group (p=0.001). Relapses were noted in 18 (16%) WTR limbs, 5 (18%) WTRc limbs, and 6 (17%) IR limbs. Comparison between WTR and IR and WTRc vs IR showed improved cicatrization in the angiosome-oriented groups (p<0.05). Major adverse limb events (MALE) and limb salvage were different between WTR and WTRc and between WTR and IR groups (p<0.05), while WTRc vs IR was not. Amputation-free survival was not influenced by the revascularization strategy (p=0.093). Conclusion: Wound healing in diabetic patients with chronic limb-threatening ischemia appeared to be improved by intentional wound-targeted revascularization, but no uniform benefit concerning MALE or limb preservation was observed. IR still represents an alternative for limb salvage in cases in which angiosome-guided revascularization fails.
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Affiliation(s)
| | - Sophie Brochier
- Department of Diabetology, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Augustin Limgba
- Department of Surgery, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Severine Balthazar
- Department of Anesthesiology, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Hafid Khelifa
- Department of Intensive Care, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Pierrick De Vreese
- Department of Anesthesiology, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Khalid Azdad
- Department of Radiology, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Mihaela Nodit
- Department of Geriatric Care, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Morgane Pottier
- Department of Surgery, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Didier Van Espen
- Department of Orthopedic Surgery, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Tommy Sinatra
- Department of Surgery, Princess Paola Hospital, Marche-en-Famenne, Belgium
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