1
|
Ghirardini F, Martini R. Current Opinion on Diagnosis of Peripheral Artery Disease in Diabetic Patients. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1179. [PMID: 39064610 PMCID: PMC11279131 DOI: 10.3390/medicina60071179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/16/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024]
Abstract
Peripheral arterial disease (PAD) prevalence and diabetes mellitus (DM) prevalence are continuously increasing worldwide. The strong relationship between DM and PAD is highlighted by recent evidence. PAD diagnosis in diabetic patients is very important, particularly in patients with diabetic foot disease (DFD); however, it is often made difficult by the characteristics of such diseases. Diagnosing PAD makes it possible to identify patients at a very high cardiovascular risk who require intensive treatment in terms of risk factor modification and medical therapy. The purpose of this review is to discuss the diagnostic methods that allow for a diagnosis of PAD in diabetic patients. Non-invasive tests that address PAD diagnosis will be discussed, such as the ankle-brachial index (ABI), toe pressure (TP), and transcutaneous oxygen pressure (TcPO2). Furthermore, imaging methods, such as duplex ultrasound (DUS), computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA), are described because they allow for diagnosing the anatomical localization and severity of artery stenosis or occlusion in PAD. Non-invasive tests will also be discussed in terms of their ability to assess foot perfusion. Foot perfusion assessment is crucial in the diagnosis of critical limb ischemia (CLI), the most advanced PAD stage, particularly in DFD patients. The impacts of PAD diagnosis and CLI identification in diabetic patients are clinically relevant to prevent amputation and mortality.
Collapse
Affiliation(s)
| | - Romeo Martini
- Department of Angiology, San Martino Hospital, 32100 Belluno, Italy;
| |
Collapse
|
2
|
Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes and a foot ulcer. Diabetes Metab Res Rev 2024; 40:e3686. [PMID: 37726988 DOI: 10.1002/dmrr.3686] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this guideline the IWGDF, the European Society for Vascular Surgery and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development, and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
Collapse
Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, New South Wales, Australia
| | | | - 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 Medical Centre, University of California, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - 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
| | - Nicolaas Schaper
- Division of Endocrinology, Department Internal Medicine, MUMC+, Maastricht, The Netherlands
| |
Collapse
|
3
|
Chuter V, Schaper N, Hinchliffe R, Mills J, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, David R, van den Berg JC, Venermo M, Fitridge R. Performance of non-invasive bedside vascular testing in the prediction of wound healing or amputation among people with foot ulcers in diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3701. [PMID: 37493206 DOI: 10.1002/dmrr.3701] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION The presence of peripheral artery disease (PAD) confers a significantly increased risk of failure to heal and major lower limb amputation for people with diabetes-related foot ulcer (DFU). Determining performance of non-invasive bedside tests for predicting likely DFU outcomes is therefore key to effective risk stratification of patients with DFU and PAD to guide management decisions. The aim of this systematic review was to determine the performance of non-invasive bedside tests for PAD to predict DFU healing, healing post-minor amputation, or need for minor or major amputation in people with diabetes and DFU or gangrene. METHODS A database search of Medline and Embase was conducted from 1980 to 30 November 2022. Prospective studies that evaluated non-invasive bedside tests in patients with diabetes, with and without PAD and foot ulceration or gangrene to predict the outcomes of DFU healing, minor amputation, and major amputation with or without revascularisation, were eligible. Included studies were required to have a minimum 6-month follow-up period and report adequate data to calculate the positive likelihood ratio (PLR) and negative likelihood ratio for the outcomes of DFU healing, and minor and major amputation. Methodological quality was assessed using the Quality in Prognosis Studies tool. RESULTS From 14,820 abstracts screened 28 prognostic studies met the inclusion criteria. The prognostic tests evaluated by the studies included: ankle-brachial index (ABI) in 9 studies; ankle pressures in 10 studies, toe-brachial index in 4 studies, toe pressure in 9 studies, transcutaneous oxygen pressure (TcPO2 ) in 7 studies, skin perfusion pressure in 5 studies, continuous wave Doppler (pedal waveforms) in 2 studies, pedal pulses in 3 studies, and ankle peak systolic velocity in 1 study. Study quality was variable. Common reasons for studies having a moderate or high risk of bias were poorly described study participation, attrition rates, and inadequate adjustment for confounders. In people with DFU, toe pressure ≥30 mmHg, TcPO2 ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg were associated with a moderate to large increase in pretest probability of healing in people with DFU. Toe pressure ≥30 mmHg was associated with a moderate increase in healing post-minor amputation. An ABI using a threshold of ≥0.9 did not increase the pretest probability of DFU healing, whereas an ABI <0.5 was associated with a moderate increase in pretest probability of non-healing. Few studies investigated amputation outcomes. An ABI <0.4 demonstrated the largest increase in pretest probability of a major amputation (PLR ≥10). CONCLUSIONS Prognostic capacity of bedside testing for DFU healing and amputation is variable. A toe pressure ≥30 mmHg, TcPO2 ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg are associated with a moderate to large increase in pretest probability of healing in people with DFU. There are little data available evaluating the prognostic capacity of bedside testing for healing after minor amputation or for major amputation in people with DFU. Current evidence suggests that an ABI <0.4 may be associated with a large increase in risk of major amputation. The findings of this systematic review need to be interpreted in the context of limitations of available evidence, including varying rates of revascularisation, lack of post-revascularisation bedside testing, and heterogenous subpopulations.
Collapse
Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Sydney, Australia
| | - Nicolaas Schaper
- Division of Endocrinology, Department of 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
| | | | - 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
| |
Collapse
|
4
|
Pitocco D, Popolla V, Rizzi A, Lancellotti S, Tartaglione L, Sacco M, Viti L, Mazzotta FA, Iezzi R, Santoliquido A, Caputo S, Flex A, Pontecorvi A, De Cristofaro R. Von Willebrand factor hyperactivity affects the outcome of lower limb revascularization in subjects with type 2 diabetes mellitus complicated by diabetic foot vasculopathy: An observational pilot study. J Diabetes Complications 2024; 38:108653. [PMID: 38039934 DOI: 10.1016/j.jdiacomp.2023.108653] [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: 01/23/2023] [Revised: 08/08/2023] [Accepted: 11/24/2023] [Indexed: 12/03/2023]
Abstract
Aim of this study is to evaluate any differences in VWF antigen, VWF activity and ADAMTS-13 activity before and after successful and non-successful Percutaneous Transluminal Angioplasty (PTA) in subjects with type 2 diabetes (T2DM) complicated by Chronic limb-threatening ischemia (CLTI) in diabetic foot vasculopathy. METHODS In this prospective observational pilot study, we enrolled 35 T2DM subjects who underwent lower limb PTA. Transcutaneous oximetry was performed in all patients before and 6 weeks after PTA. The change in oxygen partial pressure (TcpO2) before and after PTA was expressed as TcpO2-delta (ΔTcpO2). VWF antigen, VWF activity and ADAMTS-13 activity were measured before and 6 weeks after PTA; changes were expressed as delta and ratio from baseline. RESULTS Subjects with ∆TcpO2 < 15 mmHg presented higher ΔVWF activity (p = 0.050) and lower ADAMTS-13 activity ratio (p = 0.080). Subjects with ∆TcpO2 < 30 mmHg showed lower ADAMTS-13 activity Δ and ratio (p = 0.028). CONCLUSIONS VWF antigen levels and VWF activity may potentially affect PTA outcome. Higher levels of VWF could derive from VWF release as consequence of PTA-induced mechanical endothelial damage and/or oxidative stress-induced modifications of VWF structure with impairment of VWF-ADAMTS13 interactions.
Collapse
Affiliation(s)
- Dario Pitocco
- Diabetes Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore Rome, Italy.
| | - Valentina Popolla
- Diabetes Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore Rome, Italy
| | - Alessandro Rizzi
- Diabetes Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore Rome, Italy
| | - Stefano Lancellotti
- Hemorrhagic and Thrombotic Diseases Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore Rome, Italy
| | - Linda Tartaglione
- Diabetes Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore Rome, Italy
| | - Monica Sacco
- Hemorrhagic and Thrombotic Diseases Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore Rome, Italy
| | - Luca Viti
- Diabetes Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore Rome, Italy
| | - Francesco Antonio Mazzotta
- Department of Endocrinology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore Rome, Italy
| | - Roberto Iezzi
- Diagnostic Radiology and General Interventional Radiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore Rome, Italy
| | - Angelo Santoliquido
- Department of cardiovascular sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore Rome, Italy
| | - Salvatore Caputo
- Diabetes Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore Rome, Italy
| | - Andrea Flex
- Department of Internal Medicine, Medical Clinic and Vascular Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore Rome, Italy
| | - Alfredo Pontecorvi
- Department of Endocrinology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore Rome, Italy
| | - Raimondo De Cristofaro
- Hemorrhagic and Thrombotic Diseases Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore Rome, Italy
| |
Collapse
|
5
|
Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer. J Vasc Surg 2023; 78:1101-1131. [PMID: 37724985 DOI: 10.1016/j.jvs.2023.07.020] [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: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
Collapse
Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - 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
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, 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
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
| |
Collapse
|
6
|
Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot Ulcer. Eur J Vasc Endovasc Surg 2023:S1078-5884(23)00586-5. [PMID: 37724984 DOI: 10.1016/j.ejvs.2023.07.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
Collapse
Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - 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
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, 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
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
| |
Collapse
|
7
|
Kutsenko O, Sommerset J, Chandra V, Bryce Y. Techniques Providing Endpoints for Revascularization in Chronic Limb-Threatening Ischemia. Semin Intervent Radiol 2023; 40:177-182. [PMID: 37333748 PMCID: PMC10275665 DOI: 10.1055/s-0043-1768608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
It is frequently difficult to estimate the revascularization endpoint in patients with chronic limb-threatening ischemia where there may be extensive multifocal multiarterial disease. There have been attempts to identify an endpoint for revascularization procedures, but none has become the standard of care. An ideal indicator of an endpoint can objectively quantify tissue perfusion, predict wound healing, and is easily and efficiently used intraprocedurally to assist real-time decision making on whether adequate perfusion has been reached. Candidate techniques to evaluate endpoints post-revascularization are discussed here.
Collapse
Affiliation(s)
- Oleksandra Kutsenko
- Department of Radiology, Miami Cardiac and Vascular Institute, Miami, Florida
| | | | - Venita Chandra
- Department of Vascular Surgery, Stanford University School of Medicine, Redwood City, California
| | - Yolanda Bryce
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| |
Collapse
|
8
|
John J, Tate S, Price A. Non-surgical treatment for arterial leg ulcers: a narrative review. J Wound Care 2022; 31:969-978. [DOI: 10.12968/jowc.2022.31.11.969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives: Arterial leg ulcers (ALUs) pose a considerable burden on patients and health services. The cornerstone of treatment is revascularisation; however, this is not always possible and does not necessarily guarantee ulcer healing. Alternative treatment options are therefore also important. This narrative review aims to summarise the evidence available for non-surgical treatment of ALUs, including topical therapy, pharmacological agents, therapeutic angiogenesis and devices. Methods: A literature search was performed in November 2020 to identify studies reporting data on the non-surgical management of ALUs. Prospective randomised controlled trials (RCTs), controlled clinical trials and meta-analyses that investigated conservative or medical interventions on patients with intractable ALUs, and which provided quantitative data on ulcer healing were included. Following screening, studies that met the inclusion criteria underwent a data extraction process and findings were synthesised and categorised narratively. Results: In total, 14 controlled trials were selected for inclusion and analysed based on experimental protocol and outcome measures. Conclusion: There is some evidence available for the use of short-term systemic prostanoids, ultrasound therapy and pneumatic compression. There are limitations to these options including side effects, patient tolerance due to pain and availability in clinical practice. Further research is needed to improve treatment options for this complex group.
Collapse
Affiliation(s)
- Jomcy John
- School of Medicine, Cardiff University, Cardiff, UK
| | - Sophia Tate
- Wound Healing Department, Cardiff and Vale University Health Board, Cardiff, UK
| | - Annie Price
- Department of Rehabilitation Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| |
Collapse
|
9
|
The Impact of Extracorporeal Shock Wave Therapy on Microcirculation in Diabetic Feet: A Pilot Study. Adv Skin Wound Care 2020; 32:563-567. [PMID: 31764146 DOI: 10.1097/01.asw.0000604180.54706.b2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Patients with diabetic foot commonly experience vascular insufficiency and compromised tissue perfusion. Extracorporeal shockwave therapy (ESWT) reportedly promotes wound healing and angiogenesis, but clinical studies on the effect of ESWT on angiogenesis are scarce and the exact mechanism remains unclear. OBJECTIVE To investigate the effect of ESWT on cutaneous microcirculation in diabetic feet. METHODS Ten patients with diabetic feet received ESWT twice weekly for a total of six sessions. Transcutaneous partial oxygen pressure (TcPO2) and cutaneous blood flow were measured before and after ESWT. MAIN RESULTS The treated feet showed statistically significant improvements in the mean TcPO2 (P < .01) and cutaneous blood flow level (P < .05) compared with control feet. In treated feet, TcPO2 increased by 19.6%, from 41.4 ± 9.9 to 49.5 ± 8.7 mm Hg (P < .05). In control feet, TcPO2 decreased by 11.6%, from 39.5 ± 14.0 to 34.9 ± 14.5 mm Hg (P = .059). The average cutaneous blood flow level of treated feet before ESWT was 36.9 ± 25.6, which increased to 48.3 ± 32.4 AU after ESWT (30.9% increase; P = .646). In control feet, the cutaneous blood flow level decreased from 80.5 ± 36.7 to 60.4 ± 38.8 AU, a decrease of 25.0% (P = .241). CONCLUSIONS These results demonstrate that ESWT may have beneficial effects on microcirculation in diabetic feet.
Collapse
|
10
|
Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S, Reekers J, Venermo M, Zierler RE, Schaper NC, Hinchliffe RJ. Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: A systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3278. [PMID: 32176442 DOI: 10.1002/dmrr.3278] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 11/10/2022]
Abstract
Clinical outcomes of patients with diabetes, foot ulceration, and peripheral artery disease (PAD) are difficult to predict. The prediction of important clinical outcomes, such as wound healing and major amputation, would be a valuable tool to help guide management and target interventions for limb salvage. Despite the existence of a number of classification tools, no consensus exists as to the most useful bedside tests with which to predict outcome. We here present an updated systematic review from the International Working Group of the Diabetic Foot, comprising 15 studies published between 1980 and 2018 describing almost 6800 patients with diabetes and foot ulceration. Clinical examination findings as well as six non-invasive bedside tests were evaluated for their ability to predict wound healing and amputation. The most useful tests to inform on the probability of healing were skin perfusion pressure ≥ 40 mmHg, toe pressure ≥ 30 mmHg, or TcPO2 ≥ 25 mmHg. With these thresholds, all of these tests increased the probability of healing by greater than 25% in at least one study. To predict major amputation, the most useful tests were ankle pressure < 50 mmHg, ABI < 0.5, toe pressure < 30 mmHg, and TcPO2 < 25 mmHg, which increased the probability of major amputation by greater than 25%. These indicative values may be used as a guide when deciding which patients are at highest risk for poor outcomes and should therefore be evaluated for revascularization at an early stage. However, this should always be considered within the wider context of important co-existing factors such as infection, wound characteristics, and other comorbidities.
Collapse
Affiliation(s)
- Rachael O Forsythe
- British Heart Foundation/University of Edinburgh Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Centre, Department of Veterans Affairs Puget Sound Health Care System and the University of Washington, Seattle, Washington
| | - Robert Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center University of Ulsan, Seoul, Korea
| | - Konstantinos Katsanos
- Department of Interventional Radiology, Patras University Hospital School of Medicine, Patras, Greece
| | - Joseph L Mills
- SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona Health Sciences Center, Tucson, Arizona
| | - Sigrid Nikol
- Department of Clinical and Interventional Angiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Jim Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
| | | |
Collapse
|
11
|
Zhang LL, Saldana-Ruiz N, Elsayed RS, Armstrong DG, Shin L, Magee GA, Woods AC, Clavijo LC, Rowe VL. Predictors of Major Adverse Limb Events after Open Forefoot Amputation in Patients with Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2020; 66:614-620. [PMID: 32027986 DOI: 10.1016/j.avsg.2020.01.099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 01/15/2020] [Accepted: 01/26/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Management of patients with chronic limb-threatening ischemia (CLTI) and extensive foot necrosis presents a challenge for limb salvage. Our study evaluates preoperative risk factors that contributed to durability and efficacy of limb salvage after open transmetatarsal amputation (TMA) in patients with critical limb-threatening ischemia. METHODS We abstracted data from patients who underwent open TMA at Los Angeles County-University of Southern California Medical Center and Keck Hospital of University of Southern California from 2009 to 2018. Multivariable logistic regression analysis, adjusting for preoperative risk factors, was used to examine predictors of major adverse limb events (MALE). The aim was to evaluate outcomes following open TMA with MALE as the primary outcome. Our hypotheses were that outcomes would be worse for patients with foot infections and renal failure. RESULTS Forty-three open TMAs were done in 39 patients during the study period. The cohort had a mean age of 63 ± 11.6 years, 89% had a history of diabetes, 95% hypertension (HTN), 54% had end-stage renal disease (ESRD), and 26% were current smokers. MALE occurred in 39% of the cohort. Sex, race, indication, HTN, smoking status, and history of prior ipsilateral revascularization or minor amputations were not associated with MALE (P > 0.05). Multivariate logistic regression found ESRD to be an independent predictor of MALE (odds ratio 7.43, 95% confidence interval 1.12-49.17, P = 0.038) after adjusting for clinically significant covariates. CONCLUSIONS Open TMA provides acceptable rates of limb salvage for complex patients with CLTI. ESRD is an independent risk factor for MALE following open TMA in these patients. Vigilant follow-up is essential for this morbid patient population given poorer outcomes after forefoot amputation.
Collapse
Affiliation(s)
- Louis L Zhang
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of USC, Los Angeles, CA.
| | - Nallely Saldana-Ruiz
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of USC, Los Angeles, CA
| | - Ramsey S Elsayed
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of USC, Los Angeles, CA
| | - David G Armstrong
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of USC, Los Angeles, CA
| | - Laura Shin
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of USC, Los Angeles, CA
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of USC, Los Angeles, CA
| | - Aria C Woods
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of USC, Los Angeles, CA
| | - Leonardo C Clavijo
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of USC, Los Angeles, CA
| | - Vincent L Rowe
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of USC, Los Angeles, CA
| |
Collapse
|
12
|
Izzo V, Meloni M, Giurato L, Uccioli L. Letter Regarding "The Prostacyclin Analogue Iloprost as an Early Predictor of Successful Revascularization in Diabetic Patients Affected by Critical Limb Ischemia and Foot Ulcers". CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:594-597. [PMID: 30197099 DOI: 10.1016/j.carrev.2018.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/26/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The aim of this study is to evaluate the role of Iloprost as an early predictor of successful revascularization in patients affected by ischemic diabetic foot ulcers (DFUs). METHODS Consecutive patients with ischemic DFUs with persistent low TcPO2 (<30mmHg) one day after a technical successful Percutaneous Transluminal Angioplasty (PTA) have been included. All patients underwent Iloprost infusion and TcPO2 has been recorded at days 3, 14 and 30. According to the TcPO2 reported at day 3, patients were divided into two groups: group A (patients with TcPO2 ≥30mmHg) and group B (patients with TcPO2 <30mmHg). Baseline TcPO2 values at days 3, 14 and 30 after Iloprost infusion and needing of re-intervention (re-PTA) have been evaluated. RESULTS Twenty-five patients have been included, 12/25 (48%) in Group A and 13/25 (52%) in Group B. There were no significant differences at the baseline and one day after PTA between the two groups while TcPO2 values recorded in Group A at days 3, 14 and 30 after Iloprost infusion were significant higher in comparison to the Group B (χ = 0.005). The rate of re-PTA were respectively 33,3% (Group A) and 53,8% (Group B) (p = 0.03). CONCLUSIONS Iloprost may be an early predictor of successful revascularization in patients affected by critical limb ischemia (CLI) and DFUs.
Collapse
Affiliation(s)
- Valentina Izzo
- Department of Systems Medicine, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy.
| | - Marco Meloni
- Department of Systems Medicine, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Laura Giurato
- Department of Systems Medicine, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Luigi Uccioli
- Department of Systems Medicine, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| |
Collapse
|
13
|
Ali SR, Ozdemir BA, Hinchliffe RJ. Critical Appraisal of the Quality of Evidence Addressing the Diagnosis, Prognosis, and Management of Peripheral Artery Disease in Patients With Diabetic Foot Ulceration. Eur J Vasc Endovasc Surg 2018; 56:401-408. [DOI: 10.1016/j.ejvs.2018.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 05/10/2018] [Indexed: 02/08/2023]
|
14
|
Tan MNA, Lo ZJ, Lee SH, Teo RM, Tan WLG, Chandrasekar S. Review of Transmetatarsal Amputations in the Management of Peripheral Arterial Disease in an Asian Population. Ann Vasc Dis 2018; 11:210-216. [PMID: 30116413 PMCID: PMC6094039 DOI: 10.3400/avd.oa.17-00123] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate outcomes after transmetatarsal amputation (TMA) in peripheral arterial disease (PAD) limb salvage in an Asian population and identify risk factors associated with TMA failure. Methodology: A retrospective review of 147 patients with PAD, who had undergone TMA between 2008 and 2014, was carried out. Univariate and multivariate analysis were used to identify predictors of TMA failure. Kaplan-Meier survival analysis was used to calculate major amputation and all-cause mortality rates. Results: The mean age was 66 years. 92% were diabetic patients and 78% had preceded angioplasty. 56% of TMAs were healed via secondary intention, 8% required subsequent split-thickness skin graft closure, 24% required further debridement while 37% had wounds, which failed to heal and required below-knee amputations (BKA). Multivariate analysis showed that diabetes is the only independent predictor of TMA failure (odds ratio (OR) 7.11, p=0.064). Patients with TMA failure were at increased risk of developing nosocomial infections (p=0.025) and faced a higher risk of 30-day re-admission rate (p=0.002). Conclusion: The success rate for PAD limb salvage TMA was 63% and diabetes was an independent predictor of TMA failure. Patients with TMA failure were at increased risks of nosocomial infections, and 30-day re-admissions; hence the risks and benefits of TMA for diabetic foot limb salvage must be individualized for each patient.
Collapse
Affiliation(s)
- Ming Ngan Aloysius Tan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Zhiwen Joseph Lo
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Soon Hong Lee
- Lee Kong Chian School of Medicine, National Technological University, Singapore
| | - Rui Ming Teo
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Wei Leong Glenn Tan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Sadhana Chandrasekar
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| |
Collapse
|
15
|
Suo S, Zhang L, Tang H, Ni Q, Li S, Mao H, Liu X, He S, Qu J, Lu Q, Xu J. Evaluation of skeletal muscle microvascular perfusion of lower extremities by cardiovascular magnetic resonance arterial spin labeling, blood oxygenation level-dependent, and intravoxel incoherent motion techniques. J Cardiovasc Magn Reson 2018; 20:18. [PMID: 29551091 PMCID: PMC5858129 DOI: 10.1186/s12968-018-0441-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 03/02/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Noninvasive cardiovascular magnetic resonance (CMR) techniques including arterial spin labeling (ASL), blood oxygenation level-dependent (BOLD), and intravoxel incoherent motion (IVIM), are capable of measuring tissue perfusion-related parameters. We sought to evaluate and compare these three CMR techniques in characterizing skeletal muscle perfusion in lower extremities and to investigate their abilities to diagnose and assess the severity of peripheral arterial disease (PAD). METHODS Fifteen healthy young subjects, 14 patients with PAD, and 10 age-matched healthy old subjects underwent ASL, BOLD, and IVIM CMR perfusion imaging. Healthy young and healthy old participants were subjected to a cuff-induced ischemia experiment with pressures of 20 mmHg and 40 mmHg above systolic pressure during imaging. Perfusion-related metrics, including blood flow, T2* relaxation time, perfusion fraction f, diffusion coefficient D, and pseudodiffusion coefficient D*, were measured in the anterior, lateral, soleus, and gastrocnemius muscle groups. Friedman, Mann-Whitney, Wilcoxon signed rank, and Spearman rank correlation tests were used for statistical analysis. RESULTS In cases of significant differences determined by the Friedman test (P < 0.05), blood flow, T2*, and D values gradually decreased, while f values showed a tendency to increase in healthy subjects under cuff compression. No significant correlations were found among the ASL, BOLD, and IVIM parameters (all P > 0.05). Blood flow and T2* values showed significant positive correlations with transcutaneous oxygen pressure measurements (ρ = 0.465 and 0.522, respectively; both P ≤ 0.001), while f values showed a significant negative correlation in healthy young subjects (ρ = - 0.351; P = 0.018). T2* was independent of age in every muscle group. T2* values were significantly decreased in PAD patients compared with healthy old subjects and severe PAD patients compared with mild-to-moderate PAD patients (all P < 0.0125). Significant correlations were found between T2* and ankle-brachial index values in all muscle groups in PAD patients (ρ = 0.644-0.837; all P < 0.0125). Other imaging parameters failed to show benefits towards the diagnosis and disease severity evaluation of PAD. CONCLUSIONS ASL, BOLD, and IVIM provide complementary information regarding tissue perfusion. Compared with ASL and IVIM, BOLD may be a more reliable technique for assessing PAD in the resting state and could thus be applied together with angiography in clinical studies as a tool to comprehensively assess microvascular and macrovascular properties in PAD patients.
Collapse
Affiliation(s)
- Shiteng Suo
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160, Pujian Rd, Shanghai, 200127 China
| | - Lan Zhang
- Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hui Tang
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160, Pujian Rd, Shanghai, 200127 China
| | - Qihong Ni
- Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Suqin Li
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160, Pujian Rd, Shanghai, 200127 China
| | - Haimin Mao
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160, Pujian Rd, Shanghai, 200127 China
| | - Xiangyu Liu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160, Pujian Rd, Shanghai, 200127 China
| | - Shengyun He
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160, Pujian Rd, Shanghai, 200127 China
| | | | - Qing Lu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160, Pujian Rd, Shanghai, 200127 China
| | - Jianrong Xu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160, Pujian Rd, Shanghai, 200127 China
| |
Collapse
|
16
|
Abstract
OBJECTIVE Negative-pressure wound therapy (NPWT) has become a common wound care treatment modality for a variety of wounds. Several previous studies have reported that NPWT increases blood flow in the wound bed. However, NPWT might decrease tissue oxygenation in the wound bed because the foam sponge of NPWT compresses the wound bed under the influence of the applied negative pressure. Adequate tissue oxygenation is an essential consideration during diabetic foot management, and the foot is more sensitive to ischemia than any other region. Furthermore, the issue as to whether NPWT reduces or increases tissue oxygenation in diabetic feet has never been correctly addressed. The aim of this study was to evaluate the influence of NPWT on tissue oxygenation in diabetic feet. PARTICIPANTS Transcutaneous partial oxygen pressures (TcPO2) were measured to determine tissue oxygenation levels beneath NPWT dressings on 21 feet of 21 diabetic foot ulcer patients. DESIGN A TcPO2 sensor was fixed at the tarsometatarsal area of contralateral unwounded feet. A suction pressure of -125 mm Hg was applied until TcPO2 reached a steady state. The TcPO2 values for diabetic feet were measured before, during, and after NPWT. MAIN RESULTS The TcPO2 levels decreased significantly after applying NPWT in all patients. Mean TcPO2 values before, during, and after therapy were 44.6 (SD, 15.2), 6.0 (SD, 7.1), and 40.3 (SD, 16.4) mm Hg (P < .01), respectively. CONCLUSION These results show that NPWT significantly reduces tissue oxygenation levels in diabetic feet.
Collapse
|
17
|
Chung J. Endovascular Devices and Revascularization Techniques for Limb-Threatening Ischemia in Individuals With Diabetes. J Diabetes Sci Technol 2017; 11:904-913. [PMID: 28349710 PMCID: PMC5950991 DOI: 10.1177/1932296817702169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Diabetes mellitus (DM) is a rapidly worsening global epidemic over the last thirty-five years. The increased prevalence of DM has changed the phenotypic expression of atherosclerotic limb threatening ischemia (LTI), resulting in an increase in lesions in the tibial vessels. These patients are also afflicted with peripheral neuropathy, foot deformities, and medial calcification of the vasculature. In response to the evolving phenotype of atherosclerosis, newer minimally invasive tools and techniques have been developed to improve the blood supply in LTI. Arterial access, traditionally obtained from the contralateral common femoral artery (CFA) in a retrograde fashion, is now also frequently being obtained in the ipsilateral limb in an antegrade fashion. Retrograde access of the tibial, pedal, tarsal, or calf collateral vessels is also being utilized to provide a route through which wires, catheters, balloons and stents may be placed. Wires have evolved to have a variety of diameters, materials and coatings providing interventionalists with a wide variety of choices when attempting to traverse blockages in the arteries. When catheters and wires fail to traverse the lesion, newer chronic total occlusion (CTO) devices have been developed to aid in the placement of a wire across the offending lesions. Due to medial calcification associated with DM, atherectomy devices have been developed to debulk the atherosclerotic plaque within the vessel. High pressure balloon angioplasty with or without stents remain the mainstay of intervention, with drug-coated balloons (DCBs) and drug-eluting stents (DESs) now being frequently used to prevent reocclusions of atherosclerotic lesions.
Collapse
Affiliation(s)
- Jayer Chung
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston TX, USA
| |
Collapse
|
18
|
Abstract
PURPOSE Transcutaneous partial oxygen tension (TcpO2) is considered the gold standard for assessment of tissue oxygenation, which is an essential factor for wound healing. The purpose of this study was to evaluate the association between macrocirculation and TcpO2 in persons with diabetes mellitus. SUBJECTS AND SETTING Ninety-eight patients with diabetic foot ulcers participated in the study (61 men and 37 women). The subjects had a mean age of 66.6 years (range, 30-83 years) and were treated at the Diabetic Wound Center of Korea University Guro Hospital, Seoul, Republic of Korea. METHODS Macrocirculation was evaluated using 2 techniques: computed tomographic angiography and Doppler ultrasound. Macrocirculation scores were based on the patency of the two tibial arteries in 98 patients. Computed tomographic angiography and Doppler ultrasound scores (0-4 points) were given according to intraluminal filling defects and arterial pulse waveform of each vessel, respectively. Tissue oxygenation was measured by TcpO2. Macrocirculation scores were statistically analyzed as a function of the TcpO2. RESULTS Statistical analysis revealed no significant linear trend between the macrocirculation status and TcpO2. Biavariate analysis using the Fisher exact test, Mantel-Haenszel tests, and McNemar-Bowker tests also found no significant relationship between macrocirculation and TcpO2. CONCLUSIONS Computed tomographic angiography and Doppler ultrasound are not sufficiently reliable substitutes for TcpO2 measurements in regard to determining the optimal treatment for diabetic patients.
Collapse
|
19
|
Brownrigg JRW, Hinchliffe RJ, Apelqvist J, Boyko EJ, Fitridge R, Mills JL, Reekers J, Shearman CP, Zierler RE, Schaper NC. Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: a systematic review. Diabetes Metab Res Rev 2016; 32 Suppl 1:128-35. [PMID: 26342129 DOI: 10.1002/dmrr.2704] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Prediction of wound healing and major amputation in patients with diabetic foot ulceration is clinically important to stratify risk and target interventions for limb salvage. No consensus exists as to which measure of peripheral artery disease (PAD) can best predict outcomes. To evaluate the prognostic utility of index PAD measures for the prediction of healing and/or major amputation among patients with active diabetic foot ulceration, two reviewers independently screened potential studies for inclusion. Two further reviewers independently extracted study data and performed an assessment of methodological quality using the Quality in Prognostic Studies instrument. Of 9476 citations reviewed, 11 studies reporting on 9 markers of PAD met the inclusion criteria. Annualized healing rates varied from 18% to 61%; corresponding major amputation rates varied from 3% to 19%. Among 10 studies, skin perfusion pressure ≥ 40 mmHg, toe pressure ≥ 30 mmHg (and ≥ 45 mmHg) and transcutaneous pressure of oxygen (TcPO2 ) ≥ 25 mmHg were associated with at least a 25% higher chance of healing. Four studies evaluated PAD measures for predicting major amputation. Ankle pressure < 70 mmHg and fluorescein toe slope < 18 units each increased the likelihood of major amputation by around 25%. The combined test of ankle pressure < 50 mmHg or an ankle brachial index (ABI) < 0.5 increased the likelihood of major amputation by approximately 40%. Among patients with diabetic foot ulceration, the measurement of skin perfusion pressures, toe pressures and TcPO2 appear to be more useful in predicting ulcer healing than ankle pressures or the ABI. Conversely, an ankle pressure of < 50 mmHg or an ABI < 0.5 is associated with a significant increase in the incidence of major amputation.
Collapse
Affiliation(s)
- J R W Brownrigg
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - R J Hinchliffe
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - J Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - E J Boyko
- Seattle Epidemiologic Research and Information Centre-Department of Veterans Affairs Puget Sound Health Care System and the University of Washington, Seattle, WA, USA
| | - R Fitridge
- Department of Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - J L Mills
- Michael E. Debakey Department of Surgery, Baylor College of Medicine, Houston, USA
| | - J Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - C P Shearman
- Department of Vascular Surgery, Southampton University Hospitals NHS Trust, Hampshire, UK
| | - R E Zierler
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - N C Schaper
- Division of Endocrinology, MUMC+, CARIM Institute, Maastricht, The Netherlands
| |
Collapse
|
20
|
Possagnoli I, Bianchi C, Chiriano J, Teruya T, Bishop V, Abou-Zamzam A, Smith K, Valenzuela A. Clinical outcomes of patients with peripheral artery disease and lower extremity wounds based on a predetermined intention-to-treat strategy. Semin Vasc Surg 2015; 28:184-9. [DOI: 10.1053/j.semvascsurg.2016.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
21
|
Abstract
Multiple nonmorphologic magnetic resonance sequences are available in musculoskeletal imaging that can provide additional information to better characterize and diagnose musculoskeletal disorders and diseases. These sequences include blood-oxygen-level-dependent (BOLD), arterial spin labeling (ASL), diffusion-weighted imaging (DWI), and diffusion-tensor imaging (DTI). BOLD and ASL provide different methods to evaluate skeletal muscle microperfusion. The BOLD signal reflects the ratio between oxyhemoglobin and deoxyhemoglobin. ASL uses selective tagging of inflowing blood spins in a specific region for calculating local perfusion. DWI and DTI provide information about the structural integrity of soft tissue including muscles and fibers as well as pathologies.
Collapse
|
22
|
Brownrigg JRW, Schaper NC, Hinchliffe RJ. Diagnosis and assessment of peripheral arterial disease in the diabetic foot. Diabet Med 2015; 32:738-47. [PMID: 25764390 DOI: 10.1111/dme.12749] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2015] [Indexed: 01/20/2023]
Abstract
Approximately half of all patients with a diabetic foot ulcer have co-existing peripheral arterial disease. Identifying peripheral arterial disease among patients with foot ulceration is important, given its association with failure to heal, amputation, cardiovascular events and increased risk of premature mortality. Infection, oedema and neuropathy, often present with ulceration, may adversely affect the performance of diagnostic tests that are reliable in patients without diabetes. Early recognition and expert assessment of peripheral arterial disease allows measures to be taken to reduce the risk of amputation and cardiovascular events, while determining the need for revascularization to promote ulcer healing. When peripheral arterial disease is diagnosed, the extent of perfusion deficit should be measured. Patients with a severe perfusion deficit, likely to affect ulcer healing, will require further imaging to define the anatomy of disease and indicate whether a revascularization procedure is appropriate.
Collapse
Affiliation(s)
| | - N C Schaper
- Division of Endocrinology, Department of Medicine, Maastricht University Medical Centre, The Netherlands
| | | |
Collapse
|
23
|
Kumagai M, Marui A, Tabata Y, Takeda T, Yamamoto M, Yonezawa A, Tanaka S, Yanagi S, Ito-Ihara T, Ikeda T, Murayama T, Teramukai S, Katsura T, Matsubara K, Kawakami K, Yokode M, Shimizu A, Sakata R. Safety and efficacy of sustained release of basic fibroblast growth factor using gelatin hydrogel in patients with critical limb ischemia. Heart Vessels 2015; 31:713-21. [PMID: 25861983 DOI: 10.1007/s00380-015-0677-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 04/01/2015] [Indexed: 12/22/2022]
Abstract
As a form of therapeutic angiogenesis, we sought to investigate the safety and efficacy of a sustained-release system of basic fibroblast growth factor (bFGF) using biodegradable gelatin hydrogel in patients with critical limb ischemia (CLI). We conducted a phase I-IIa study that analyzed 10 CLI patients following a 200-μg intramuscular injection of bFGF-incorporated gelatin hydrogel microspheres into the ischemic limb. Primary endpoints were safety and transcutaneous oxygen pressure (TcO2) at 4 and 24 weeks after treatment. During the follow-up, there was no death or serious procedure-related adverse event. After 24 weeks, TcO2 (28.4 ± 8.4 vs. 46.2 ± 13.0 mmHg for pretreatment vs after 24 weeks, p < 0.01) showed significant improvement. Regarding secondary endpoints, the distance walked in 6 min (255 ± 105 vs. 318 ± 127 m, p = 0.02), the Rutherford classification (4.4 ± 0.5 vs. 3.1 ± 1.4, p = 0.02), the rest pain scale (1.7 ± 1.0 vs. 1.2 ± 1.3, p = 0.03), and the cyanotic scale (2.0 ± 1.1 vs. 0.9 ± 0.9, p < 0.01) also showed improvement. The blood levels of bFGF were within the normal range in all patients. A subanalysis of patients with arteriosclerosis obliterans (n = 7) or thromboangiitis obliterans (Buerger's disease) (n = 3) revealed that TcO2 had significantly improved in both subgroups. TcO2 did not differ between patients with or without chronic kidney disease. The sustained release of bFGF from biodegradable gelatin hydrogel may offer a safe and effective form of angiogenesis for patients with CLI.
Collapse
Affiliation(s)
- Motoyuki Kumagai
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Akira Marui
- Division of Cardiovascular Surgery, Tenri Hospital, Nara, Japan.,Department of Experimental Therapeutics, Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | - Yasuhiko Tabata
- Department of Biomaterials, Institute for Frontier Medical Sciences, Kyoto University, Kyoto, Japan
| | - Takahide Takeda
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.,Department of Experimental Therapeutics, Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | - Masaya Yamamoto
- Department of Biomaterials, Institute for Frontier Medical Sciences, Kyoto University, Kyoto, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Shiro Tanaka
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan.,Department of Data Science, Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | - Shigeki Yanagi
- Department of Cardiovascular Surgery, Kumamoto Central Hospital, Kumamoto, Japan
| | - Toshiko Ito-Ihara
- Department of Clinical Innovative Medicine, Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | - Takafumi Ikeda
- Department of Experimental Therapeutics, Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | - Toshinori Murayama
- Department of Clinical Innovative Medicine, Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshiya Katsura
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Kazuo Matsubara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan.,Department of Data Science, Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | - Masayuki Yokode
- Department of Clinical Innovative Medicine, Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | - Akira Shimizu
- Department of Experimental Therapeutics, Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | - Ryuzo Sakata
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| |
Collapse
|
24
|
Moon KC, Han SK, Lee YN, Jeong SH, Dhong ES, Kim WK. Effect of normobaric hyperoxic therapy on tissue oxygenation in diabetic feet: A pilot study. J Plast Reconstr Aesthet Surg 2014; 67:1580-6. [DOI: 10.1016/j.bjps.2014.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 05/20/2014] [Accepted: 07/06/2014] [Indexed: 11/16/2022]
|
25
|
Resnick KA, Gordon IL. Effects of Cilostazol on Arterial Wound Healing: A Retrospective Analysis. Ann Vasc Surg 2014; 28:1513-21. [DOI: 10.1016/j.avsg.2014.02.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 02/06/2014] [Accepted: 02/09/2014] [Indexed: 10/25/2022]
|
26
|
Darmanin G, Jaggard M, Hettiaratchy S, Nanchahal J, Jain A. Evaluating optimal superficial limb perfusion at different angles using non-invasive micro-lightguide spectrophotometry. J Plast Reconstr Aesthet Surg 2013; 66:821-6. [DOI: 10.1016/j.bjps.2013.02.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 02/05/2013] [Accepted: 02/18/2013] [Indexed: 11/16/2022]
|
27
|
Wound dehiscence and stump infection after lower limb amputation: risk factors and association with antibiotic use. J Orthop Sci 2012; 17:588-94. [PMID: 22669444 DOI: 10.1007/s00776-012-0245-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Accepted: 05/14/2012] [Indexed: 02/09/2023]
Abstract
BACKGROUND Optimal duration of antibiotic prophylaxis following major lower limb amputation in preventing adverse stump outcomes is controversial. OBJECTIVE We assess the epidemiology and risk factors of wound dehiscence and stump infection after mid-thigh to transmetatarsal amputations with regard to antibiotic administration. METHODS Our retrospective observational study at the Geneva University Hospital (January 1995-June 2010) includes a total of 289 amputations in 270 adult patients (199 males; median age 70 years). RESULTS Wound dehiscence and/or stump infection occurred in 47 (16.3%) and 63 (21.8%) patients with a median delay of 24 and 14 days, respectively. No clinical variable was significantly associated with stump infection. Diabetes and older age (>80 years) were associated with dehiscence. Importantly, transcutaneous tissue oxygen tension (TcPO2) and duration of antibiotic administration showed no association with either outcome. CONCLUSION The duration of antibiotic administration before or after surgery does not change the epidemiology of stump complications.
Collapse
|
28
|
The Use of Transcutaneous Oximetry to Predict Healing Complications of Lower Limb Amputations: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2012; 43:329-36. [DOI: 10.1016/j.ejvs.2011.12.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 12/05/2011] [Indexed: 11/18/2022]
|
29
|
|
30
|
Arsenault KA, McDonald J, Devereaux PJ, Thorlund K, Tittley JG, Whitlock RP. The use of transcutaneous oximetry to predict complications of chronic wound healing: A systematic review and meta-analysis. Wound Repair Regen 2011; 19:657-63. [DOI: 10.1111/j.1524-475x.2011.00731.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 07/07/2011] [Indexed: 11/28/2022]
Affiliation(s)
- Kyle A. Arsenault
- Department of Surgery; McMaster University; Hamilton; Ontario; Canada
| | - Joey McDonald
- Department of Surgery; McMaster University; Hamilton; Ontario; Canada
| | | | - Kristian Thorlund
- Department of Clinical Epidemiology and Biostatistics; McMaster University; Hamilton; Ontario; Canada
| | | | | |
Collapse
|
31
|
A Framework for the Evaluation of “Value” and Cost-Effectiveness in the Management of Critical Limb Ischemia. J Am Coll Surg 2011; 213:552-66.e5. [DOI: 10.1016/j.jamcollsurg.2011.07.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 07/11/2011] [Accepted: 07/14/2011] [Indexed: 11/20/2022]
|
32
|
Autologous bone marrow mononuclear cell therapy is safe and promotes amputation-free survival in patients with critical limb ischemia. J Vasc Surg 2011; 53:1565-74.e1. [PMID: 21514773 DOI: 10.1016/j.jvs.2011.01.074] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 01/27/2011] [Accepted: 01/28/2011] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The purpose of this Phase I open label nonrandomized trial was to assess the safety and efficacy of autologous bone marrow mononuclear cell (ABMNC) therapy in promoting amputation-free survival (AFS) in patients with critical limb ischemia (CLI). METHODS Between September 2005 and March 2009, 29 patients (30 limbs), with a median age of 66 years (range, 23-84 years; 14 male, 15 female) with CLI were enrolled. Twenty-one limbs presented with rest pain (RP), six with RP and ulceration, and three with ulcer only. All patients were not candidates for surgical bypass due to absence of a patent artery below the knee and/or endovascular approaches to improving perfusion was not possible as determined by an independent vascular surgeon. Patients were treated with an average dose of 1.7 ± 0.7 × 10(9) ABMNC injected intramuscularly in the index limb distal to the anterior tibial tuberosity. The primary safety end point was accumulation of serious adverse events, and the primary efficacy end point was AFS at 1 year. Secondary end points at 12 weeks posttreatment were changes in first toe pressure (FTP), toe-brachial index (TBI), ankle-brachial index (ABI), and transcutaneous oxygen measurements (TcPO(2)). Perfusion of the index limb was measured with positron emission tomography-computed tomography (PET-CT) with intra-arterial infusion of H(2)O(15). RP, using a 10-cm visual analogue scale, quality of life using the VascuQuol questionnaire, and ulcer healing were assessed at each follow-up interval. Subpopulations of endothelial progenitor cells were quantified prior to ABMNC administration using immunocytochemistry and fluorescent-activated cell sorting. RESULTS There were two serious adverse events; however, there were no procedure-related deaths. Amputation-free survival at 1 year was 86.3%. There was a significant increase in FTP (10.2 ± 6.2 mm Hg; P = .02) and TBI (0.10 ± 0.05;P = .02) and a trend in improvement in ABI (0.08 ± 0.04; P = .73). Perfusion index by PET-CT H(2)O(15) increased by 19.3 ± 3.1, and RP decreased significantly by 2.2 ± 0.6 cm (P = .02). The VascuQol questionnaire demonstrated significant improvement in quality of life, and three of nine ulcers (33%) healed completely. KDR(+) but not CD34(+) or CD133(+) subpopulations of ABMNC were associated with improvement in limb perfusion. CONCLUSION This Phase I study has demonstrated safety, and the AFS rates suggest efficacy of ABMNC in promoting limb salvage in "no option" CLI. Based on these results, we plan to test the concept that ABMNCs improve AFS at 1 year in a Phase III randomized, double-blinded, multicenter trial.
Collapse
|
33
|
Henry TD, Hirsch AT, Goldman J, Wang YL, Lips DL, McMillan WD, Duval S, Biggs TA, Keo HH. Safety of a non-viral plasmid-encoding dual isoforms of hepatocyte growth factor in critical limb ischemia patients: a phase I study. Gene Ther 2011; 18:788-94. [PMID: 21430785 DOI: 10.1038/gt.2011.21] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We aimed to evaluate in a phase I dose-escalation study, the safety of intramuscular injections of a novel non-viral plasmid DNA expressing two isoforms of human hepatocyte growth factor (HGF) (VM202) in patients with critical limb ischemia (CLI). In total, 12 patients with CLI and unsuitable for revascularization were consecutively assigned to increasing doses (2 to 16 mg) of VM202 administered into the ischemic calf muscle at days 1 and 15. Patients were evaluated for safety and tolerability, changes in ankle- and toe brachial index (ABI and TBI), and pain severity score using a visual analog scale (VAS) throughout a 12-month follow-up period. Median age was 72 years and 53% of the patients were male. VM202 was safe and well tolerated with no death during the 12-month follow-up. Median ABI and TBI significantly increased from 0.35 to 0.52 (P=0.005) and from 0.15 to 0.24 (P=0.01) at 12 months follow-up. Median VAS decreased from 57.5 to 16.0 mm at 6 months follow-up (P=0.03). In this first human clinical trial, VM202, which expresses two isoforms of human HGF, appear to be safe and well tolerated with encouraging clinical results and thus supports the performance of a phase II randomized controlled trial.
Collapse
Affiliation(s)
- T D Henry
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Kim HR, Han SK, Rha SW, Kim HS, Kim WK. Effect of percutaneous transluminal angioplasty on tissue oxygenation in ischemic diabetic feet. Wound Repair Regen 2010; 19:19-24. [PMID: 21134031 DOI: 10.1111/j.1524-475x.2010.00641.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Percutaneous transluminal angioplasty (PTA) has been performed as an alternative to bypass surgery for improving tissue oxygenation in ischemic diabetic feet because the former is less invasive than the latter. The purpose of this study was to evaluate the effect of PTA on tissue oxygenation in ischemic diabetic feet. This study included 29 ischemic diabetic feet, as determined by a transcutaneous oxygen pressure (TcPO(2) )<30 mmHg. The PTA was carried out in 29 limbs. The PTA procedure was considered successful, acceptable, and failed when residual stenosis was<30%, between 30 and 50%, and>50%, respectively. For evaluation of tissue oxygenation, the foot TcPO(2) was measured before PTA and weekly for 6 weeks after PTA. Immediately after PTA, 26 feet were evaluated as being successful and the remaining three as acceptable. Before PTA, the average foot TcPO(2) was 12.7 ± 8.9 mmHg. The TcPO(2) values were increased to 43.6 ± 24.1, 51.0 ± 22.6, 58.3 ± 23.0, 61.3 ± 24.2, 59.0 ± 22.2, and 53.8 ± 21.0 mmHg 1, 2, 3, 4, 5, and 6 weeks after PTA, respectively (p<0.01). The PTA procedure significantly increases tissue oxygenation in ischemic diabetic feet. The maximal level of tissue oxygenation was measured on the fourth week following PTA.
Collapse
Affiliation(s)
- Hong-Ryul Kim
- Department of Plastic Surgery, Diabetic Wound Center, Korea University Guro Hospital, Seoul, South Korea
| | | | | | | | | |
Collapse
|
35
|
Ruangsetakit C, Chinsakchai K, Mahawongkajit P, Wongwanit C, Mutirangura P. Transcutaneous oxygen tension: a useful predictor of ulcer healing in critical limb ischaemia. J Wound Care 2010; 19:202-6. [DOI: 10.12968/jowc.2010.19.5.48048] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- C. Ruangsetakit
- Vascular Surgery Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - K. Chinsakchai
- Vascular Surgery Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - P. Mahawongkajit
- Vascular Surgery Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - C. Wongwanit
- Vascular Surgery Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - P. Mutirangura
- Vascular Surgery Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
36
|
Abstract
Multiple clinical pathways lead to lower extremity amputation, including trauma, dysvascular disease, congenital defects, and malignancy. However, the principles of successful amputation-careful preoperative planning, coordination of a multidisciplinary team, and good surgical technique-remain the same. Organized rehabilitation and properly selected prostheses are integral components of amputee care. In the civilian setting, amputation is usually performed as a planned therapy for an unsalvageable extremity, not as an emergency procedure. The partial loss of a lower limb often represents a major change in a person's life, but patients should be encouraged to approach amputation as the beginning of a new phase of life and not as the culmination of previous treatment failures.
Collapse
|
37
|
Svalestad J, Hellem S, Vaagbø G, Irgens Å, Thorsen E. Reproducibility of transcutaneous oximetry and laser Doppler flowmetry in facial skin and gingival tissue. Microvasc Res 2010; 79:29-33. [DOI: 10.1016/j.mvr.2009.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Revised: 09/22/2009] [Accepted: 10/09/2009] [Indexed: 11/25/2022]
|
38
|
Capobianco CM, Stapleton JJ. Diabetic foot infections: a team-oriented review of medical and surgical management. Diabet Foot Ankle 2010; 1:DFA-1-5438. [PMID: 22396806 PMCID: PMC3284273 DOI: 10.3402/dfa.v1i0.5438] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Revised: 08/10/2010] [Accepted: 08/16/2010] [Indexed: 11/25/2022]
Abstract
As the domestic and international incidence of diabetes and metabolic syndrome continues to rise, health care providers need to continue improving management of the long-term complications of the disease. Emergency department visits and hospital admissions for diabetic foot infections are increasingly commonplace, and a like-minded multidisciplinary team approach is needed to optimize patient care. Early recognition of severe infections, medical stabilization, appropriate antibiotic selection, early surgical intervention, and strategic plans for delayed reconstruction are crucial components of managing diabetic foot infections. The authors review initial medical and surgical management and staged surgical reconstruction of diabetic foot infections in the inpatient setting.
Collapse
Affiliation(s)
- Claire M Capobianco
- Division of Podiatric Medicine and Surgery, Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | | |
Collapse
|
39
|
Zgonis T, Stapleton JJ, Roukis TS. A stepwise approach to the surgical management of severe diabetic foot infections. Foot Ankle Spec 2009. [PMID: 19825691 DOI: 10.1177/1938640007312316.] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Foot infections are common among diabetic patients with ulceration and are a major cause of hospitalization and lower extremity amputation. Aggressive and emergent surgical intervention is essential in the face of life- or limb-threatening infection to achieve limb salvage and survival. Critical limb ischemia, neuropathy, and an impaired host complicate the treatment of a severe diabetic foot infection. A severe diabetic foot infection carries a 25% risk of major amputation. For this reason, surgery should be coordinated with a well-functioning multidisciplinary team that specializes in diabetic limb preservation. Timing of surgery and strategies employed should be understood and agreed on by both the surgical and medical disciplines managing the diabetic patient with a limb-threatening infection. The overall strategy for surgically managing a severe diabetic foot infection is as follows: the first step is infection control through aggressive and extensive surgical debridement, the second step is a comprehensive vascular assessment with possible vascular surgery and/or endovascular intervention, and the final step is soft tissue and skeletal reconstruction after infection is eradicated to obtain wound closure and limb salvage. A consistent stepwise surgical approach combined with sound surgical principles is paramount for successful management of the severe diabetic foot infection. The authors discuss their stepwise surgical approach to reduce the mortality, morbidity, psychological distress, and length of hospitalization associated with life- or limb-threatening diabetic foot infections.
Collapse
Affiliation(s)
- Thomas Zgonis
- Department of Orthopedics/Podiatry Division and the Reconstructive Foot & Ankle Fellowship, University of Texas HealthScience Center, San Antonio, Texas 78229, USA.
| | | | | |
Collapse
|
40
|
Marfella R, Luongo C, Coppola A, Luongo M, Capodanno P, Ruggiero R, Mascolo L, Ambrosino I, Sardu C, Boccardi V, Lettieri B, Paolisso G. Use of a non-specific immunomodulation therapy as a therapeutic vasculogenesis strategy in no-option critical limb ischemia patients. Atherosclerosis 2009; 208:473-9. [PMID: 19709658 DOI: 10.1016/j.atherosclerosis.2009.08.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 07/28/2009] [Accepted: 08/01/2009] [Indexed: 11/25/2022]
Abstract
BACKGROUND/AIMS Inflammatory mediators contribute to the impairment of vasculogenesis by reducing endothelial progenitor cells (EPCs) mobilization in atherosclerotic vasculopathy. We tested the hypothesis that administration of an oxygen/ozone mixture (IMT) might counteract this pathophysiological mechanism and enhance limb tissue perfusion in patients with critical limb ischemia (CLI). METHODS Randomized patients with rest pain or ischemic ulcers and transcutaneous oxygen tension (TcPO(2)) <40 mmHg and/or toe pressure <50 mmHg received placebo (n=74) or a non-specific immunomodulation therapy (IMT) (n=77), autologous blood exposed to oxygen/ozone gas mixture by intragluteal injection, on day 1, 2, 7, and once a week thereafter for at least 22 weeks. Patients were evaluated for changes in TcPO(2), levels of circulating EPCs (CD34/KDR-positive cells) and inflammation (tumor necrosis factor-alpha-TNF-alpha). RESULTS TcPO(2) and CD34/CD133-positive cells increased at 22 weeks in IMT group (P<0.01) whereas no changes were observed in placebo group. TNF-alpha levels decreased at 6 months in IMT group (P<0.001) whereas no changes were observed in placebo group. There was a strong positive correlation between CD34/KDR-positive cells and TcPO(2) (r=0.56, P<0.01). Moreover, there was an inverse correlation between CD34/KDR-positive cells and TNF-alpha (r=-0.51, P<0.01). CONCLUSIONS Intramuscular injection of IMT may improve wound healing and limb salvage in patients with CLI.
Collapse
Affiliation(s)
- Raffaele Marfella
- Department of Geriatrics and Metabolic Diseases, Second University of Naples, Piazza Miraglia, 2. 80138 Napoli, Italy.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
O'Donnell ME, Badger SA, Sharif MA, Young IS, Lee B, Soong CV. The vascular and biochemical effects of cilostazol in patients with peripheral arterial disease. J Vasc Surg 2009; 49:1226-34. [PMID: 19217745 DOI: 10.1016/j.jvs.2008.11.098] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Revised: 11/24/2008] [Accepted: 11/26/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Cilostazol improves walking distance and quality of life in patients with peripheral arterial disease (PAD). This study assessed the vascular and biochemical effects of cilostazol therapy in PAD patients. METHODS PAD patients were prospectively recruited to a randomized, double-blinded, placebo-controlled trial. Baseline clinical data were recorded. Clinical assessment included measurement of arterial compliance, transcutaneous oxygenation, ankle-brachial index (ABI), and treadmill walking distance. Blood analyses included a full blood panel, coagulation screen, urea and electrolytes, liver function tests, estimated glomerular filtration rate, and lipid profiles. Quality of life indices were recorded using validated generic and walking-specific questionnaires. All tests were performed at baseline, 6, and 24 weeks. RESULTS Eighty patients (53 men) were recruited from December 2004 to January 2006. The cilostazol group had a significant reduction in the augmentation index compared with the placebo group at 6 weeks (19.7% vs 26.7%, P = .001) and at 24 weeks (19.7% vs 27.7%, P = .005). A paradoxic reduction in transcutaneous oxygenation levels was identified in the cilostazol group for the left foot at 6 weeks and for the right foot at both 6 and 24 weeks. The ABIs were not significantly different between treatment groups at baseline, 6 weeks, or 24 weeks for the left and right lower limbs. The mean percentage change in walking distance from baseline improved more markedly in the cilostazol compared with the placebo group for absolute claudication distance at 6 (78.6% vs 26.4%, P = .20) and 24 weeks (173.1% vs 92.1%, P = .27); however, these failed to reach significance. Significant improvements in lipid profiles were demonstrated with cilostazol therapy at 6 weeks (triglycerides, high-density lipoprotein [HDL]) and at 24 weeks (cholesterol, triglycerides, HDL, and low-density lipoprotein). The cilostazol treatment group demonstrated significant improvements in the Short Form-36 (physical functioning, physical component score), Walking Impairment (distance and speed), and Vascular Quality of Life (pain) indices at 6 and 24 weeks. Although cilostazol was associated with side effects in approximately one-third of patients, most settled within 6 weeks, facilitating the continuation of therapy in >89%. CONCLUSION Cilostazol is a well-tolerated, safe, and efficacious treatment for PAD patients. It not only improves patients' symptomatology and quality of life but also appears to have beneficial effects on arterial compliance, possibly through its lipid-lowering property.
Collapse
Affiliation(s)
- Mark E O'Donnell
- Department of Vascular and Endovascular Surgery, Belfast City Hospital, Belfast, Northern Ireland, United Kingdom.
| | | | | | | | | | | |
Collapse
|
42
|
Park DJ, Han SK, Kim WK. Is the foot elevation the optimal position for wound healing of a diabetic foot? J Plast Reconstr Aesthet Surg 2008; 63:561-4. [PMID: 19117825 DOI: 10.1016/j.bjps.2008.11.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Revised: 10/15/2008] [Accepted: 11/07/2008] [Indexed: 10/21/2022]
Abstract
In managing diabetic foot ulcers, foot elevation has generally been recommended to reduce oedema and prevent other sequential problems. However, foot elevation may decrease tissue oxygenation of the foot more than the dependent position since the dependent position is known to increase blood flow within the arterial system. In addition, diabetic foot ulcers, which have peripheral vascular insufficiency, generally have less oedema than other wounds. Therefore, we argue that foot elevation may not be helpful for healing of vascularly compromised diabetic foot ulcers since adequate tissue oxygenation is an essential factor in diabetic wound healing. The purpose of this study was to evaluate the influence of foot height on tissue oxygenation and to determine the optimal foot position to accelerate wound healing of diabetic foot ulcers. This study included 122 cases (73 males and 47 females; two males had bilateral disease) of diabetic foot ulcer patients aged 40-93 years. Trans-cutaneous partial oxygen tension (TcpO(2)) values of diabetic feet were measured before and after foot elevation (n=21). Elevation was achieved by placing a foot over four cushions. We also measured foot TcpO(2) values before and after lowering the feet (n=122). Feet were lowered to the patient's tibial height, approximately 30-35 cm, beside a bed handrail. Due to the large number of lowering measurements, we divided them into five sub-groups according to initial TcpO(2.) Tissue oxygenation values were compared. Foot-elevation-lowered TcpO(2) values before and after elevation were 32.5+/-22.2 and 23.8+/-23.1 mmHg (p<0.01), respectively. Foot-lowering-augmented TcpO(2) values before and after lowering were 44.6+/-23.8 and 58.0+/-25.9 mmHg (p<0.01), respectively. The lower the initial TcpO(2) level, the more the TcpO(2) level increased. The foot lowering, rather than elevation, significantly augments TcpO(2) and may stimulate healing of diabetic foot ulcers.
Collapse
Affiliation(s)
- D J Park
- Department of Plastic Surgery, Korea University Guro Hospital, 97 Guro-Dong, Guro-Gu, Seoul (Zip) 152-703, Republic of Korea
| | | | | |
Collapse
|
43
|
Powell RJ, Simons M, Mendelsohn FO, Daniel G, Henry TD, Koga M, Morishita R, Annex BH. Results of a Double-Blind, Placebo-Controlled Study to Assess the Safety of Intramuscular Injection of Hepatocyte Growth Factor Plasmid to Improve Limb Perfusion in Patients With Critical Limb Ischemia. Circulation 2008; 118:58-65. [DOI: 10.1161/circulationaha.107.727347] [Citation(s) in RCA: 231] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The Study to Assess the Safety of Intramuscular Injection of Hepatocyte Growth Factor Plasmid to Improve Limb Perfusion in Patients With Critical Limb Ischemia (HGF-STAT trial) determined the effect of hepatocyte growth factor (HGF) plasmid on safety and limb tissue perfusion as measured by transcutaneous oxygen tension (TcP
o
2
) in patients with critical limb ischemia (CLI).
Methods and Results—
Randomized patients with rest pain or ischemic ulcers and TcP
o
2
<40 mm Hg and/or toe pressure <50 mm Hg received placebo or HGF-plasmid intramuscular injection as follows: 0.4 mg at days 0, 14, and 28 (low dose); 4.0 mg at days 0 and 28 (middle dose); or 4.0 mg at days 0, 14, and 28 (high dose). Patients were evaluated for safety, changes in TcP
o
2
and ankle and toe pressure, amputation, and wound healing. Ninety-three of 104 treated patients were evaluated for safety (mean age 70 years, 63% male, 53% diabetic, 64% with tissue loss, mean ankle-brachial index 0.41, and mean toe pressure 26 mm Hg). Adverse events occurred in 86% of the patients, most of which were related to CLI or comorbid conditions and were not different between groups. TcP
o
2
(mean±SE) increased at 6 months in the high-dose group (24.0±4.2 mm Hg, 95% CI 15.5 to 32.4 mm Hg) compared with the placebo (9.4±4.2 mm Hg, 95% CI 0.9 to 17.8), low-dose (11.1±3.7 mm Hg, CI 3.7 to 18.7 mm Hg), and middle-dose (7.3±4.8 mm Hg, CI −2.2 to 17.0 mm Hg) groups (ANCOVA
P
=0.0015). There was no difference between groups in secondary end points, including ankle-brachial index, toe-brachial index, pain relief, wound healing, or major amputation.
Conclusions—
Intramuscular injection of HGF plasmid was safe and well tolerated. Larger studies to determine whether HGF plasmid can improve wound healing and limb salvage in patients with CLI are warranted.
Collapse
Affiliation(s)
- Richard J. Powell
- From Department of Surgery, Section of Vascular Surgery (R.J.P.) and Department of Medicine, Section of Cardiology (M.S.), Dartmouth-Hitchcock Medical Center, Lebanon, NH; Princeton Heart and Vascular Center (F.O.M.), Birmingham, Ala; John F. Kennedy Medical Center (G.D.), Atlantis, Fla; Minneapolis Heart Institute Foundation (T.D.H.), Minneapolis, Minn; AnGes Inc (M.K.), Gaithersburg, Md; Osaka University (R.M.), Osaka, Japan; and Duke University Medical Center (B.H.A.), Durham, NC
| | - Michael Simons
- From Department of Surgery, Section of Vascular Surgery (R.J.P.) and Department of Medicine, Section of Cardiology (M.S.), Dartmouth-Hitchcock Medical Center, Lebanon, NH; Princeton Heart and Vascular Center (F.O.M.), Birmingham, Ala; John F. Kennedy Medical Center (G.D.), Atlantis, Fla; Minneapolis Heart Institute Foundation (T.D.H.), Minneapolis, Minn; AnGes Inc (M.K.), Gaithersburg, Md; Osaka University (R.M.), Osaka, Japan; and Duke University Medical Center (B.H.A.), Durham, NC
| | - Farrel O. Mendelsohn
- From Department of Surgery, Section of Vascular Surgery (R.J.P.) and Department of Medicine, Section of Cardiology (M.S.), Dartmouth-Hitchcock Medical Center, Lebanon, NH; Princeton Heart and Vascular Center (F.O.M.), Birmingham, Ala; John F. Kennedy Medical Center (G.D.), Atlantis, Fla; Minneapolis Heart Institute Foundation (T.D.H.), Minneapolis, Minn; AnGes Inc (M.K.), Gaithersburg, Md; Osaka University (R.M.), Osaka, Japan; and Duke University Medical Center (B.H.A.), Durham, NC
| | - George Daniel
- From Department of Surgery, Section of Vascular Surgery (R.J.P.) and Department of Medicine, Section of Cardiology (M.S.), Dartmouth-Hitchcock Medical Center, Lebanon, NH; Princeton Heart and Vascular Center (F.O.M.), Birmingham, Ala; John F. Kennedy Medical Center (G.D.), Atlantis, Fla; Minneapolis Heart Institute Foundation (T.D.H.), Minneapolis, Minn; AnGes Inc (M.K.), Gaithersburg, Md; Osaka University (R.M.), Osaka, Japan; and Duke University Medical Center (B.H.A.), Durham, NC
| | - Timothy D. Henry
- From Department of Surgery, Section of Vascular Surgery (R.J.P.) and Department of Medicine, Section of Cardiology (M.S.), Dartmouth-Hitchcock Medical Center, Lebanon, NH; Princeton Heart and Vascular Center (F.O.M.), Birmingham, Ala; John F. Kennedy Medical Center (G.D.), Atlantis, Fla; Minneapolis Heart Institute Foundation (T.D.H.), Minneapolis, Minn; AnGes Inc (M.K.), Gaithersburg, Md; Osaka University (R.M.), Osaka, Japan; and Duke University Medical Center (B.H.A.), Durham, NC
| | - Minako Koga
- From Department of Surgery, Section of Vascular Surgery (R.J.P.) and Department of Medicine, Section of Cardiology (M.S.), Dartmouth-Hitchcock Medical Center, Lebanon, NH; Princeton Heart and Vascular Center (F.O.M.), Birmingham, Ala; John F. Kennedy Medical Center (G.D.), Atlantis, Fla; Minneapolis Heart Institute Foundation (T.D.H.), Minneapolis, Minn; AnGes Inc (M.K.), Gaithersburg, Md; Osaka University (R.M.), Osaka, Japan; and Duke University Medical Center (B.H.A.), Durham, NC
| | - Ryuichi Morishita
- From Department of Surgery, Section of Vascular Surgery (R.J.P.) and Department of Medicine, Section of Cardiology (M.S.), Dartmouth-Hitchcock Medical Center, Lebanon, NH; Princeton Heart and Vascular Center (F.O.M.), Birmingham, Ala; John F. Kennedy Medical Center (G.D.), Atlantis, Fla; Minneapolis Heart Institute Foundation (T.D.H.), Minneapolis, Minn; AnGes Inc (M.K.), Gaithersburg, Md; Osaka University (R.M.), Osaka, Japan; and Duke University Medical Center (B.H.A.), Durham, NC
| | - Brian H. Annex
- From Department of Surgery, Section of Vascular Surgery (R.J.P.) and Department of Medicine, Section of Cardiology (M.S.), Dartmouth-Hitchcock Medical Center, Lebanon, NH; Princeton Heart and Vascular Center (F.O.M.), Birmingham, Ala; John F. Kennedy Medical Center (G.D.), Atlantis, Fla; Minneapolis Heart Institute Foundation (T.D.H.), Minneapolis, Minn; AnGes Inc (M.K.), Gaithersburg, Md; Osaka University (R.M.), Osaka, Japan; and Duke University Medical Center (B.H.A.), Durham, NC
| |
Collapse
|
44
|
Zgonis T, Stapleton JJ, Roukis TS. A stepwise approach to the surgical management of severe diabetic foot infections. Foot Ankle Spec 2008; 1:46-53. [PMID: 19825691 DOI: 10.1177/1938640007312316] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Foot infections are common among diabetic patients with ulceration and are a major cause of hospitalization and lower extremity amputation. Aggressive and emergent surgical intervention is essential in the face of life- or limb-threatening infection to achieve limb salvage and survival. Critical limb ischemia, neuropathy, and an impaired host complicate the treatment of a severe diabetic foot infection. A severe diabetic foot infection carries a 25% risk of major amputation. For this reason, surgery should be coordinated with a well-functioning multidisciplinary team that specializes in diabetic limb preservation. Timing of surgery and strategies employed should be understood and agreed on by both the surgical and medical disciplines managing the diabetic patient with a limb-threatening infection. The overall strategy for surgically managing a severe diabetic foot infection is as follows: the first step is infection control through aggressive and extensive surgical debridement, the second step is a comprehensive vascular assessment with possible vascular surgery and/or endovascular intervention, and the final step is soft tissue and skeletal reconstruction after infection is eradicated to obtain wound closure and limb salvage. A consistent stepwise surgical approach combined with sound surgical principles is paramount for successful management of the severe diabetic foot infection. The authors discuss their stepwise surgical approach to reduce the mortality, morbidity, psychological distress, and length of hospitalization associated with life- or limb-threatening diabetic foot infections.
Collapse
Affiliation(s)
- Thomas Zgonis
- Department of Orthopedics/Podiatry Division and the Reconstructive Foot & Ankle Fellowship, University of Texas HealthScience Center, San Antonio, Texas 78229, USA.
| | | | | |
Collapse
|
45
|
Mathieu D, Mani R. A review of the clinical significance of tissue hypoxia measurements in lower extremity wound management. INT J LOW EXTR WOUND 2008; 6:273-83. [PMID: 18048873 DOI: 10.1177/1534734607310299] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this paper is to review techniques that are currently available to measure tissue hypoxia in order to benefit the management of wounds. Direct measurement of tissue partial oxygen pressure (PO(2)) is invasive and therefore unappealing in clinical practice. Several techniques (PET scans, MRI derived techniques) are primarily applicable to research rather than clinical applications. Imaging techniques (duplex ultrasonography, arteriography, MRI techniques) are recommended only as part of the workup for revascularisation. Techniques that assess local perfusion include clearance methods, transcutaneous O(2) and CO( 2) pressure measurement, and laser Doppler flowmetry and imaging. These techniques permit interpretation of altered perfusion states. Each technique offers subtly different information concerning microvascular function. All these techniques require strict protocols to derive reliable data. The potential of the promising near infrared reflectance spectroscopy (NIRS) technique is yet to be determined.
Collapse
Affiliation(s)
- Daniel Mathieu
- Service d'Urgence Respiratoire, de Réanimation Médicale et de Médecine Hyperbare, Hôpital Calmette, Lille, France.
| | | |
Collapse
|
46
|
Tartari S, Zattoni L, Rizzati R, Aliberti C, Capello K, Sacco A, Mollo F, Benea G. Subintimal Angioplasty as the First-Choice Revascularization Technique for Infrainguinal Arterial Occlusions in Patients with Critical Limb Ischemia. Ann Vasc Surg 2007; 21:819-28. [DOI: 10.1016/j.avsg.2007.07.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2006] [Revised: 05/29/2007] [Accepted: 07/16/2007] [Indexed: 10/21/2022]
|
47
|
|
48
|
Faglia E, Clerici G, Clerissi J, Mantero M, Caminiti M, Quarantiello A, Curci V, Lupattelli T, Morabito A. When is a technically successful peripheral angioplasty effective in preventing above-the-ankle amputation in diabetic patients with critical limb ischaemia? Diabet Med 2007; 24:823-9. [PMID: 17559430 DOI: 10.1111/j.1464-5491.2007.02167.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To determine parameters predictive of avoidance of major (above-the-ankle) amputation after a technically successful peripheral angioplasty (PTA) in patients with diabetes with critical limb ischaemia. METHODS From January 1999 to December 2003, 420 consecutive patients with diabetes admitted to hospital because of critical limb ischaemia underwent peripheral angiography and concomitant technically successful PTA. Transcutaneous oxygen tension (TcPO(2)) was measured before and after PTA. Major amputation at 30 days was recorded. RESULTS After PTA, the iliac-femoral-popliteal axis was patent in all patients. In 67 patients, all three crural arteries were patent, in 143 patients 2 crural arteries were patent, and in 186 patients one crural artery was patent (104 peroneal, 62 anterior tibial, 20 posterior tibial). In 24 patients, all three crural arteries were occluded. Twenty-two major amputations were performed. Of these, 15 were performed in the 24 patients with occlusion of all the infrapopliteal arteries. Seven of the 186 patients in whom only the peroneal artery was patent required amputation. In patients not requiring amputation, TcPO(2) increased from 15.5 +/- 11.9 to 45.0 +/- 12.0 mmHg (P = 0.000), while in those requiring amputation, TcPO(2) increased from 9.6 +/- 7.7 to 18.6 +/- 8.1 mmHg (P < 0.082). Multivariate analysis indicated an independent role of occlusion of infrapopliteal arteries after PTA (OR 8.20 for every crural obstructed artery, P = 0.022, CI 1.35-49.6) and TcPO(2) after PTA (OR 0.80 for increase of 1 mmHg, P < 0.001, CI 0.74-0.88). CONCLUSIONS In patients with diabetes, PTA is effective in avoiding major amputation, provided recanalization occurs in at least one tibial artery down to the foot. In a few patients, re-canalization of the peroneal artery alone is not sufficient to avoid major amputation.
Collapse
Affiliation(s)
- E Faglia
- Diabetology Centre-Diabetic Foot Centre- IRCCS Multimedica, Sesto San Giovanni, Milan, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Faglia E, Clerici G, Caminiti M, Quarantiello A, Curci V, Morabito A. Predictive Values of Transcutaneous Oxygen Tension for Above-the-ankle Amputation in Diabetic Patients with Critical Limb Ischemia. Eur J Vasc Endovasc Surg 2007; 33:731-6. [PMID: 17296318 DOI: 10.1016/j.ejvs.2006.12.027] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Accepted: 12/20/2006] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To assess the values of transcutaneous oxygen tension (TcPO2) capable of predicting above-the-ankle amputation in diabetic patients diagnosed for critical limb ischemia (CLI) according to the criteria of the TransAtlantic Inter-Society Consensus. DESIGN Retrospective study. METHODS From January 1999 to December 2003, 564 diabetic patients were consecutively hospitalized for CLI in one limb. Revascularization with angioplasty or bypass graft was performed when possible and, if not possible, prostanoid therapy was used. In patients in whom therapies did not relieve the rest pain or the gangrene was extended above the Chopart joint, an above-the-ankle-amputation was performed. After treatment TcPO2 values were evaluated in all patients at the dorsum of the foot. RESULTS Fifty-five (9.8%) patients underwent an above-the-ankle amputation: 22 of 420 patients who underwent angioplasty, 17 of 117 patients who underwent bypass (14.5%) and 16 of 27 patients in whom revascularization was not possible. Post-treatment TcPO2, measured by a receiver operating characteristic (ROC) curve, showed a value 34 mmHg as the best threshold for determining the need for revascularization, with an area under the curve of 0.89 (95%CI 0.85-0.94). Using logistic regression analysis the probability of above-the-ankle amputation for this threshold is 9.7% and reduces to 3% for TcPO2 > 40 mmHg. CONCLUSION TcPO2 levels<34 mmHg indicate the need for revascularization, while for values >or= 34 < 40 mmHg this need appears less pressing, although there remains a considerable probability of amputation. TcPO2 levels greater than 40 mmHg suggest that revascularization is dependent on the severity of tissue loss and possible morbidity caused by the procedure.
Collapse
Affiliation(s)
- E Faglia
- Diabetology Center-Diabetic Foot Center, IRCCS Multimedica, Sesto San Giovanni, Milano, Italy.
| | | | | | | | | | | |
Collapse
|
50
|
De Vries J, De Jongste MJL, Spincemaille G, Staal MJ. Spinal cord stimulation for ischemic heart disease and peripheral vascular disease. Adv Tech Stand Neurosurg 2007; 32:63-89. [PMID: 17907475 DOI: 10.1007/978-3-211-47423-5_4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Ischemic disease (ID) is now an important indication for electrical neuromodulation (NM), particularly in chronic pain conditions. NM is defined as a therapeutic modality that aims to restore functions of the nervous system or modulate neural structures involved in the dysfunction of organ systems. One of the NM methods used is chronic electrical stimulation of the spinal cord (spinal cord stimulation: SCS). SCS in ID, as applied to ischemic heart disease (IHD) and peripheral vascular disease (PVD), started in Europe in the 1970s and 1980s, respectively. Patients with ID are eligible for SCS when they experience disabling pain, resulting from ischaemia. This pain should be considered therapeutically refractory to standard treatment intended to decrease metabolic demand or following revascularization procedures. Several studies have demonstrated the beneficial effect of SCS on IHD and PVD by improving the quality of life of this group of severely disabled patients, without adversely influencing mortality and morbidity. SCS used as additional treatment for IHD reduces angina pectoris (AP) in its frequency and intensity, increases exercise capacity, and does not seem to mask the warning signs of a myocardial infarction. Besides the analgesic effect, different studies have demonstrated an anti-ischemic effect, as expressed by different cardiac indices such as exercise duration, ambulatory ECG recording, coronary flow measurements, and PET scans. SCS can be considered as an alternative to open heart bypass grafting (CABG) for patients at high risk from surgical procedures. Moreover, SCS appears to be more efficacious than transcutaneous electrical nerve stimulation (TENS). The SCS implantation technique is relatively simple: implanting an epidural electrode under local anesthesia (supervised by the anesthesist) with the tip at T1, covering the painful area with paraesthesia by external stimulation (pulse width 210, rate 85 Hz), and connecting this electrode to a subcutaneously implanted pulse generator. In PVD the pain may manifest itself at rest or during walking (claudication), disabling the patient severely. Most of the patients suffer from atherosclerotic critical limb ischemia. All patients should be therapeutically refractory (medication and revascularization) to become eligible for SCS. Ulcers on the extremities should be minimal. In PVD the same implantation technique is used as in IHD except that the tip of the electrode is positioned at T10-11. In PVD the majority of the patients show significant reduction in pain and more than half of the patients show improvement of circulatory indices, as shown by Doppler, thermography, and oximetry studies. Limb salvage studies show variable results depending on the stage of the trophic changes. The underlying mechanisms of action of SCS in PVD require further elucidation.
Collapse
Affiliation(s)
- J De Vries
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, The Netherlands
| | | | | | | |
Collapse
|