Clinical Outcomes of Pedal Artery Angioplasty for Patients With Ischemic Wounds: Results From the Multicenter RENDEZVOUS Registry

Impact of High Lipoprotein(a) Levels on Delayed Wound Healing in Patients With Chronic Limb-Threatening Ischemia After Peripheral Endovascular Therapy

BACKGROUND

Elevated lipoprotein(a) [Lp(a)] levels are a causal risk factor for peripheral artery disease. However, data on their effect on delayed wound healing in patients with chronic limb-threatening ischemia (CLTI) are limited. The present study assessed the association between elevated Lp(a) levels and delayed wound healing in patients with CLTI.

METHODS AND RESULTS

This study included 280 patients who successfully received endovascular therapy for CLTI between September 2016 and August 2021. High Lp(a) levels were defined as those >30 mg/dL. The primary outcome was wound healing. During a median follow-up of 20.4 months (interquartile range 6.8-38.6 months), 146 patients achieved wound healing. The wound healing rate at 24 months was significantly lower in the high Lp(a) than low Lp(a) group (41.1% vs. 86.3%, respectively; P<0.001). The adjusted risk ratio was 0.19 (95% confidence interval 0.13-0.29, P<0.001). Lp(a) levels of 31-50 and >50 mg/dL, but not 16-30 mg/dL, were significantly associated with delayed wound healing relative to Lp(a) levels of ≤15 mg/dL.

CONCLUSIONS

Elevated Lp(a) levels were independently associated with delayed wound healing in patients with CLTI treated with endovascular therapy.

Catch Up with the Latest Trend in Vascular Intervention-Chronic Limb-threatening Ischemia Up to Date

Endovascular treatment for patients with lower extremity artery disease is conducted worldwide due to its efficacy. Many studies have shown durability for patients with intermittent claudication, and various guidelines have shifted to the use of endovascular treatment. However, clinical outcomes in patients with chronic limb-threatening ischemia who undergo endovascular treatment have not been fully investigated. Generally, chronic limb-threatening ischemia cases have complex lesions such as small vessels, severe calcification, poor runoff vessels, chronic total occlusion, and long lesions, which result in poor outcomes. Thus, endovascular treatment for chronic limb-threatening ischemia cases remains challenging, despite the many technical and device advances. In 2019, the Global Vascular Guidelines were proposed for the treatment of patients with chronic limb-threatening ischemia. Here, we review previous guidelines and reports of patients with lower extremity artery disease who underwent endovascular treatment.

Peripheral Arterial Disease in Diabetic Foot: One Disease with Multiple Patterns

Peripheral arterial disease (PAD) is a major complication in individuals with diabetes and is increasingly prevalent in those with diabetic foot ulcers (DFUs). Despite this, the characterisation of PAD in diabetic patients remains insufficiently refined, leading to suboptimal management and outcomes. This review underscores the necessity for a more nuanced understanding of PAD's anatomical and biological aspects in diabetic patients. The distribution of atherosclerotic plaques varies significantly among individuals, influencing prognosis and treatment efficacy. We describe three key patterns of PAD in diabetes: pattern 1 PAD-below-the-knee (BTK) disease (with infrageniculate disease where present); pattern 2-below-the-ankle (BTA) disease; and pattern 3-small artery disease (SAD), each presenting unique challenges and require tailored therapeutic approaches. BTK PAD, characterised by occlusions in the anterior tibial, posterior tibial, and peroneal arteries, necessitates targeted revascularisation to improve foot perfusion. BTA PAD, involving the pedal and plantar arteries, is associated with higher risks of amputation and requires advanced revascularisation techniques. SAD, affecting the small arteries of the foot, remains an enigma and is challenging to treat with the current mechanical methods, highlighting the potential of autologous cell therapy as a promising alternative. A refined characterisation of PAD in diabetes is crucial for developing effective, individualised treatment strategies, ultimately improving patient outcomes, and reducing the burden of diabetic foot complications. In light of these complexities, it is incredulous that we often use a single term, "peripheral arterial disease", to describe such a diverse array of disease patterns. This oversimplification can be perilous, as it may lead to inadequate therapeutic approaches and suboptimal patient care.

Concomitant Pedal Interventions Improve Outcomes for Tibial Interventions in Chronic Limb-Threatening Ischemia

BACKGROUND

Tibial interventions for chronic limb-threatening ischemia (CLTI) are now commonplace, and poor pedal runoff is associated with worse outcomes. This study aimed to examine the impact of pedal interventions to improve poor pedal runoff on the outcomes following tibial interventions.

METHODS

A database of patients undergoing tibial interventions for CLTI at a single center between 2010 and 2022 was retrospectively queried. Patients with critical ischemia (Rutherford 5 and 6) were identified. Preintervention and postintervention angiograms were reviewed in all cases to assess pedal runoff (total = 10), resulting in 2 run-off score groups as follows: good versus poor, <7 and ≥ 7, respectively. The presence or absence of a pedal intervention then segmented the poor runoff group. Outcomes of wound healing at 3 months, amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; above ankle amputation of the index limb or major reintervention (new bypass graft and jump or interposition graft revision) were evaluated.

RESULTS

1,768 patients (63% male, age 67 ± 12 years, mean ± SD) with CLTI underwent isolated tibial intervention on a median of 2 tibial vessels. All patients had Wound, Ischemia, and foot Infection (WIfI) grade 3 and 4 disease. Preoperatively, 40% of cases had good runoff (4.4 ± 1.1, mean ± SD), 38% had poor runoff and no pedal intervention (8.6 ± 0.8; P = 0.01 compared to good runoff), and 22% had poor runoff with a concomitant pedal intervention (8.7 ± 0.6; P = 0.01 compared to good runoff). Pedal intervention was performed on a median of 2 tarsal vessels with a technical success of 91% and overall improved pedal runoff (6.5 ± 2.1; P = 0.01 vs. preoperative). Patients with a successful concomitant pedal intervention had improved 30-day MALE rate (7% vs. 12%; P = 0.001) and 30-day amputation rate (5% vs. 11%; P = 0.001) compared to the poor runoff and no pedal intervention group and were comparable to the good runoff and no pedal intervention group (7% and 5%, respectively). Ulcer healing at 3 months was improved in the poor runoff group with intervention (55%) compared to the poor runoff and no pedal intervention group (25%; P = 0.001) but remained significantly below the good runoff group (73%). At 5 years in patients with poor runoff, pedal intervention improved freedom from MALE (41 ± 8% vs. 17 ± 8% mean ± standard error of the mean (SEM); P = 0.008) and AFS (38 ± 6% vs. 11 ± 6%, mean ± SEM; P = 0.003) and these were equivalent to the good runoff group (46 ± 4% and 51 ± 5%, mean ± SEM; freedom from MALE and AFS, respectively).

CONCLUSION

Concomitant pedal intervention to improve pedal runoff in patients with poor pedal runoff during a tibial intervention for CLTI results in improved short-term and long-term outcomes and should be considered for effective limb salvage.

Free Flap Limb Salvage and Ulcer Recurrence in Chronic Limb-threatening Ischemia

Free flap transfer is a well-established treatment for foot reconstruction in patients with chronic limb-threatening ischemia (CLTI) and can achieve prolonged amputation-free survival. However, reports on ulcer recurrence after free flap transfer are scarce, with most focusing on trauma patients. Therefore, we retrospectively reviewed patients with CLTI who underwent free flap reconstruction at our institution over a 17-year period. Patient characteristics, ulcer recurrence rates, activity level, and variables associated with ulcer recurrence were investigated in patients who met the following criteria: successful reconstructive surgery, complete wound healing, and at least 1 year of follow-up. Free flap foot reconstruction was performed in 42 patients (92.9% male, 7.1% female; mean age 57.1 years, range 37-81 years). Among them, 39 patients (92.9%) had diabetes mellitus, 15 (35.7%) had critical limb ischemia, and 15 (35.7%) had end-stage renal disease/hemodialysis. Mean postoperative follow-up was 60.5 (range 12.0-208.0) months. The 5-year primary ulcer recurrence-free survival rate was 48.7%. High activity level and selection of the posterior tibial artery as the recipient artery were significantly associated with ulcer recurrence [hazard ratio, 3.59 and 9.81; P = .046 and P < .001, respectively]. Activity levels were not significantly different before and 1 year after surgery. In conclusion, survival analysis revealed that ulcer recurrence is most likely to occur within the first 2 years after surgery. Although recurrence occurred in approximately half of the patients, most patients maintained activity levels comparable to their preoperative levels.

Noninvasive therapeutic ultrasound to increase perfusion in chronic limb-threatening ischemia: An early feasibility study

BACKGROUND

Preclinical studies have demonstrated that therapeutic ultrasound (TUS) increases perfusion in peripheral artery disease (PAD). This pilot study assessed the safety and effectiveness of a noninvasive TUS device in patients with advanced PAD.

METHODS

A phased array of TUS transducers was fabricated on a wearable sleeve, designed to sonicate the posterior and anterior tibial arteries (and their collaterals) at the calf level. Twelve patients with PAD (Rutherford classes 3-5) were enrolled in a single-arm study in which they underwent 30-40 daily 90-minute TUS sessions to the diseased limb. Changes in pedal flow and tissue oxygenation (StO2) were measured by laser speckle and spatial frequency domain imaging, respectively. A subset of five patients underwent evaluation by laser Doppler, transcutaneous oximetry (TcPO2), and quality of life questionnaires (Vascular Quality of Life Questionnaire [VascuQoL] and the Walking Impairment Questionnaire [WIQ]).

RESULTS

Eleven out of 12 enrolled patients completed the study. During 90-minute TUS sessions pedal flow improved by 180% (p < 0.001) on laser speckle imaging, and 18% (p = 0.12) on laser Doppler. Tissue oxygenation improved by 18% (p = 0.43) on TcPO2 and by 6% (p = 0.097) on StO2. After all sessions, tissue oxygenation improved by 17% (p = 0.020) on StO2, without significant changes in laser Doppler (+39%, p = 0.41) or TcPO2 (-3%, p = 0.70), which was largely in the normal range (56 ± 15 mmHg) at baseline. VascuQoL improved by 2.4 points (14%, p = 0.080) and WIQ improved by 8.2 points (11%, p = 0.053).

CONCLUSIONS

TUS for patients with symptomatic PAD was safe and well tolerated. Most metrics of tissue perfusion and oxygenation improved, but future sham-controlled studies are needed and planned.

Incidence of Angiographic Deterioration Following Inframalleolar Angioplasty and Its Impact on Outcomes in Patients With Chronic Limb-Threatening Ischemia Requiring Repeat Intervention

Background

Clinical impact of inframalleolar (IM) angioplasty in patients with chronic limb-threatening ischemia (CLTI) is still controversial.

Methods and Results

This single-center, retrospective study included 168 patients with CLTI and tissue loss who underwent angioplasty for IM lesions. Angiographic follow up was performed at reintervention between April 2010 and December 2020. The outcome measure was the incidence of angiographic deterioration characterized by severe restenosis or occlusion of mildly stenotic lesions, occlusion of severely stenotic lesions, or extension of the occlusion length at reintervention. Angiographic deterioration was observed in 47.7% of patients, with the majority attributed to occlusion in severely stenotic lesions. Multivariate analysis revealed that a distal reference vessel diameter ≤1.0 mm in the initial angioplasty (hazard ratio 1.91 [95% confidence interval 1.20-3.04]; P=0.006) was significantly associated with angiographic deterioration of IM lesions at reintervention.

Conclusions

Angiographic deterioration occurred in approximately half of the patients with CLTI who underwent IM angioplasty and reintervention.

Exploring the Other Side of the River: Early and Midterm Outcomes of Endovascular Pedal Arch Revascularization in Patients with Chronic Limb-Threatening Ischemia

OBJECTIVE

This study investigated the effect of patency of the pedal arch (PA) on wound healing rate and time, amputation-free survival (AFS), limb salvage, and limb-based patency (LBP) in chronic limb-threatening ischemia (CLTI) patients undergoing endovascular revascularization of infrainguinal arterial lesions.

METHODS

This prospective study included all CLTI patients presenting with wound, ischemia, and foot infection (WIfI) stages 2 to 4 (WIfI ischemia grades 2-3) who underwent endovascular revascularization of infrainguinal arterial disease between April 2019 and April 2021. Pedal angioplasty was attempted in all patients with significant steno-occlusive pedal artery disease. Patients were stratified according to Kawarada PA types. Successful PA revascularization (PAR) was counted when at least 1 pedal vessel is patent. Wound healing rate and time and Kaplan-Meier estimate of AFS and LBP at 2 years were evaluated and compared among the patient groups.

RESULTS

A total of 120 patients were categorized according to PA type into type 1 (n = 34; 28.3%), type 2 (n = 64; 53.3%), and type 3 (n = 22; 18.3%). Pedal angioplasty was attempted in 97 patients and was technically successful in 75 patients (77.3%). Successful PAR (with or without pedal angioplasty) was achieved in 98 patients (81.7%). During the follow-up, successful PAR resulted in a better wound healing rate (86.7% vs 59.1%; P = 0.007), major amputation rates (5.1% vs 40.9%; P ≤ 0.001), and AFS (92.9% vs 72.7%; P = 0.018) compared with unsuccessful PAR. There were no significant differences between the 2 groups in wound healing time (3.76 ± 1.99 months vs 3.64 ± 1.94 months; P = 0.798, respectively) or LBP (80.6% vs 72.7%; P = 0.594, respectively). Global Limb Anatomic Staging System (GLASS) stage (odds ratio [OR] = 6.84; 95% CI, 1.30-36.03; P = 0.023) and unsuccessful PAR (OR = 21.64; 95% CI, 4.01-116.69; P ≤ 0.001) were independently associated with failure of wound healing, whereas site of wound lesion (OR = 5.52; 95% CI, 1.15-26.48; P = 0.033), GLASS stage (OR = 24.93; 95% CI, 2.84-218.69; P = 0.004), and unsuccessful PAR (OR = 22.44; 95% CI, 3.53-142.67; P = 0.001) were significant predictors of major amputation.

CONCLUSION

Successful PAR is important for improving clinical outcomes of endovascular revascularization of CLTI patients such as wound healing, amputation-free survival, and limb salvage. Predictors of limb salvage were site of foot lesion, GLASS stage, and successful PAR, whereas GLASS stage and successful PAR were independently associated with improved wound healing.

CLINICAL IMPACT

Pedal arch patency positively influences clinical outcomes in patients with chronic limb-threatening ischemia who have ischemic wounds undergoing endovascular revascularization. This study demonstrated that successful pedal arch revascularization (PAR) significantly improved wound healing, amputation-free survival, and limb salvage rates when compared to patients who did not achieve successful PAR. Additionally, the study identified the predictors of limb salvage as the site of foot lesions, GLASS staging, and successful PAR, while both GLASS staging and successful PAR were found to be independently associated with improved wound healing.

Outcomes of revascularization of stenotic inframalleolar lesions in chronic limb-threatening ischemia

BACKGROUND

For chronic limb-threatening ischemia, revascularization has been reported for occlusions but not for stenosis in the inframalleolar (IM) lesions. We investigated the clinical outcomes of balloon dilation for stenotic IM lesions distal to the treatment target in the infrapopliteal (IP) legion.

METHODS

We conducted a retrospective analysis of patients who had chronic limb-threatening ischemia and underwent revascularization of stenotic IM lesions distal to the target IP lesions between January 2015 and August 2022. The outcome measures were amputation-free survival, wound healing rate, and freedom from target IM reintervention.

RESULTS

The 87 patients had a mean age of 72.7 ± 10.7 years and comprised 67.8% men, 74.7% with diabetes mellitus, 55.2% on dialysis, 33.3% who had Rutherford six classification. The amputation-free survival (AFS), wound healing, and freedom from target IM reintervention rates at 1 year were 82.9%, 53.3%, and 58.4%, respectively. On Cox proportional multivariate analysis, the predictors were Wound, Ischemia, and foot Infection (WIfI) ≥3 and diffuse stenosis in the target IM vessels for delayed wound healing and Global Limb Anatomic Staging System stage Ⅲ and ≥3 diseased IM vessels before endovascular therapy for target IM reintervention. At the time of reintervention, the lesion morphology had progressed from stenosis to occlusion in 50% of cases.

CONCLUSIONS

In patients with chronic limb-threatening ischemia, revascularization of stenosis in IM lesions showed a high reintervention rate and progression of lesion morphology, although AFS and wound-healing rates were acceptable.

Infrapopliteal Surgical and Endovascular Intervention

Infrapopliteal revascularization is generally performed for patients with chronic limb-threatening ischemia. As with revascularization in other fields, the indications for endovascular treatment (EVT) have expanded in recent years due to advances in endovascular devices and techniques. However, the optimal revascularization method must be selected based on (1) patient risk, (2) limb severity, and (3) anatomical pattern of disease. Therefore, vascular surgeons need to understand the characteristics of EVT and surgical treatment and improve their technical skills in both procedures. Here is an overview of the current methods of revascularization. (This is a translation of Jpn J Vasc Surg 2024; 33: 61-65).

Pedal medial arterial calcification influences the outcomes of isolated infra-malleolar interventions for chronic limb-threatening ischemia

OBJECTIVE

Inframalleolar disease is present in most diabetic patients presenting with tissue loss. Inframalleolar (pedal) artery disease and pedal medial arterial calcification (pMAC) are associated with major amputation in patients with chronic limb-threatening ischemia (CLTI). This study aimed to examine the impact of pMAC on the outcomes after isolated inframalleolar (pedal artery) interventions.

METHODS

A database of lower extremity endovascular intervention for patients with tissue loss between 2007 and 2022 was retrospectively queried. Patients with CLTI were selected, and those undergoing isolated inframalleolar intervention on the dorsalis pedis and medial and lateral tarsal arteries and who had foot x-rays were identified. X-rays were assessed blindly for pMAC and scored on a scale of 0 to 5. Patients with concomitant superficial femoral artery and tibial interventions were excluded. Intention to treat analysis by the patient was performed. Amputation-free survival (survival without major amputation) was evaluated.

RESULTS

A total of 223 patients (51% female; 87% Hispanic; average age, 66 years; 323 vessels) underwent isolated infra-malleolar intervention for tissue loss. All patients had diabetes, 96% had hypertension, 79% had hyperlipidemia, and 63% had chronic renal insufficiency (55% of these were on hemodialysis). Most of the patients had Wound, Ischemia, and foot Infection (WIfI) stage 3 disease and had various stages of pMAC: severe (score = 5) in 48%, moderate (score = 2-4) in 31%, and mild (score = 0-1) in 21% of the patients. Technical success was 94%, with a median of one vessel treated per patient. All failures were in severe pMAC. Overall, major adverse cardiovascular events was 0.9% at 90 days after the procedure. Following the intervention, most patients underwent a planned forefoot amputation (single digit, multiple digits, ray amputation, or trans-metatarsal amputation). WIfI ischemic grade was improved by 51%. Wound healing at 3 months was 69%. Those not healing underwent below-knee amputations. The overall 5-year amputation-free survival rate was 35% ± 9%. The severity of pMAC was associated with decreased AFS.

CONCLUSIONS

Increasing severity of pMAC influences the technical and long-term outcomes of infra-malleolar intervention in diabetes. Severe pMAC is associated with amputation and should be considered as a variable in the shared decision-making of diabetic patients with CLTI.

Below-the-Ankle Antegrade Teleferic Technique: New Approach for Below-the-Ankle Revascularization in Challenging Cases of Chronic Limb-Threatening Ischemia

PURPOSE

To describe a novel bailout technique to approach below-the-ankle (BTA) chronic total occlusions or plantar-arch severe disease where the balloon/catheter is unable to follow the crossing guidewire and no other described recanalization approach is feasible.

TECHNIQUE

When facing a complex BTA revascularization, if the guidewire crosses but the balloon cannot progress due to a lack of pushability, an antegrade puncture of the infrapopliteal vessel where the tip of the guidewire lays is performed. The guidewire is then carefully navigated through this distal BTA vessel into the needle to achieve its rendezvous and externalization. A low-profile balloon is inserted through the femoral access and advanced till the non-crossable point of the BTA vessels. A torque device is then attached to the proximal hub of the balloon, and the through-and-through guidewire is subsequently pulled from the new distal access, allowing the balloon to be dragged across the lesion together with the wire.

CONCLUSION

The below-the-ankle antegrade teleferic (BAT) technique may be considered for highly complex BTA revascularization procedures where the wire crosses the lesion, but no other device can be tracked over it.

CLINICAL IMPACT

The clinical impact of this article lies in the description of a bailout technique for BTA revascularization where the guidewire crosses, but no device can be advanced. This technique can be helpful in scenarios where failure to achieve success could result in limb loss. The BAT technique provides a solution in extremely challenging cases, enhancing technical success, improving outcomes and potentially preserving the limbs of patients who would otherwise face amputation, if not revascularized.The video shows the BAT technique performed with a support catheter under fluoroscopy: antegrate puncture of the DP, advancement of the support catheter over the wire, rendezvous of the guidewire in the catheter and subsequent externalization of the wire.

Clinical efficacy of endovascular revascularization combined with vacuum-assisted closure for the treatment of diabetic foot

BACKGROUND

The diabetic foot is a common cause of disability and death, and comorbid foot infections usually lead to prolonged hospitalization, high healthcare costs, and a significant increase in amputation rates. And most diabetic foot trauma is complicated by lower extremity arteriopathy, which becomes an independent risk factor for major amputation in diabetic foot patients.

AIM

To establish the efficacy and safety of endovascular revascularization (ER) combined with vacuum-assisted closure (VAC) for the treatment of diabetic foot.

METHODS

Clinical data were collected from 40 patients with diabetic foot admitted to the Second Affiliated Hospital of Soochow University from April 2018 to April 2022. Diabetic foot lesions were graded according to Wagner's classification, and blood flow to the lower extremity was evaluated using the ankle-brachial index test and computerized tomography angiography of the lower extremity arteries. Continuous subcutaneous insulin infusion pumps were used to achieve glycemic control. Lower limb revascularization was facilitated by percutaneous tran-sluminal balloon angioplasty (BA) or stenting. Wounds were cleaned by nibbling debridement. Wound granulation tissue growth was induced by VAC, and wound repair was performed by skin grafting or skin flap transplantation.

RESULTS

Of the 35 cases treated with lower limb revascularization, 34 were successful with a revascularization success rate of 97%. Of these, 6 cases underwent stenting after BA of the superficial femoral artery, and 1 received popliteal artery stent implantation. In the 25 cases treated with infrapopliteal artery revascularization, 39 arteries were reconstructed, 7 of which were treated by drug-coated BA and the remaining 32 with plain old BA. VAC was performed in 32 wounds. Twenty-four cases of skin grafting and 2 cases of skin flap transplantation were performed. Two patients underwent major amputations, whereas 17 had minor amputations, accounting for a success limb salvage rate of 95%.

CONCLUSION

ER in combination with VAC is a safe and effective treatment for diabetic foot that can significantly improve limb salvage rates. The use of VAC after ER simplifies and facilitates wound repair.

Successful Revascularization, Angiosome Concept, and Multivessel Revascularization: Effects on Wound Healing: An Asian Perspective

Endovascular treatment for revascularization in patients with chronic limb-threatening ischemia (CLTI), which is commonly found in patients with diabetes mellitus demonstrates a variable result of vessel patency, wound healing rate, and limb salvage rate. The angiosome concept has been adopted to determine the best target arterial path (TAP) for revascularization for wound healing in CLTI patients. Recent publications demonstrated the benefit of angiosome-targeted revascularization to guide the endovascular treatment in patients CLTI. The best TAP under angiosome concept by direct revascularization with at least 2 of 3 below-the-knee arteries runoff to restore in-line pulsatile blood flow to the ischemic tissue shows the best patency and high rate of wound healing. However, the clinical evidence and application of the angiosome concept in daily practice are difficult and not well established. The vascular territories, collateral vessel, wound area, and locations which associated with angiosome are varied. This article review aims to summarize the concept of angiosome-targeted revascularization and multivessel revascularization for application to the real-world practice under the evidence-based data.

Proximal Arterial Inflow Revascularization Improves Pedal Arch Quality and Its Impact on Ischemic Diabetic Foot Ulcer Healing

BACKGROUND

Arterial perfusion is a key factor in diabetic foot ulcer (DFU) healing. Although it is associated with pedal arch patency, not all patients are amenable to pedal artery angioplasty. This study aims to determine the impact of angiographic improvement of the pedal arch quality after proximal arterial inflow revascularization (PAIR) and its association with wound healing.

METHODS

One hundred and fifty diabetic patients with tissue loss in 163 limbs who had digital subtraction angiography were studied. Cox regression analysis was used to determine independent predictors of wound healing. Wound healing rates in association with pedal arch patency were calculated by Kaplan-Meier analysis.

RESULTS

End-stage renal disease, minor amputation, and complete pedal arch patency were significant independent predictors of wound healing following PAIR with hazard ratios for failure: 3.02 (P = 0.008), 0.54 (P = 0.023), and 0.40 (P = 0.039), respectively. The prevalence of complete pedal arches increased by 24.1% with successful intervention (P < 0.001). The overall rates of wound healing at 6, 12, and 24 months were 36%, 64%, and 72%, respectively. The wound healing rate at 1 year in patients with a complete pedal arch was 73% compared to 45% in those with an absent pedal arch (P = 0.017).

CONCLUSIONS

PAIR increases complete pedal arch patency, a significant predictor of wound healing in DFU.

Current Status and Principles for the Treatment and Prevention of Diabetic Foot Ulcers in the Cardiovascular Patient Population: A Scientific Statement From the American Heart Association

Despite the known higher risk of cardiovascular disease in individuals with type 2 diabetes, the pathophysiology and optimal management of diabetic foot ulcers (DFUs), a leading complication associated with diabetes, is complex and continues to evolve. Complications of type 2 diabetes, such as DFUs, are a major cause of morbidity and mortality and the leading cause of major lower extremity amputation in the United States. There has recently been a strong focus on the prevention and early treatment of DFUs, leading to the development of multidisciplinary diabetic wound and amputation prevention clinics across the country. Mounting evidence has shown that, despite these efforts, amputations associated with DFUs continue to increase. Furthermore, due to increasing patient complexity of management secondary to comorbid conditions, such as cardiovascular disease, the management of peripheral artery disease associated with DFUs has become increasingly difficult, and care delivery is often episodic and fragmented. Although structured, process-specific approaches exist at individual institutions for the management of DFUs in the cardiovascular patient population, there is insufficient awareness of these principles in the general medicine communities. Furthermore, there is growing interest in better understanding the mechanistic underpinnings of DFUs to better define personalized medicine to improve outcomes. The goals of this scientific statement are to provide salient background information on the complex pathogenesis and current management of DFUs in cardiovascular patients, to guide therapeutic and preventive strategies and future research directions, and to inform public policy makers on health disparities and other barriers to improving and advancing care in this expanding patient population.

Autologous angiogenic therapy with cultured mesenchymal stromal cells in platelet-rich plasma for critical limb ischemia

Introduction

The prevalence of diabetes mellitus is increasing globally, including in Japan. Patients with diabetes often experience microangiopathy and macroangiopathy, which lead to difficult-to-treat foot ulcers and diabetic gangrene. Conventional cellular therapies have limited safety and are invasive. In this study, we investigated the use of cultured autologous mesenchymal stromal cells derived from the bone marrow and grown in platelet-rich plasma as a potential treatment for diabetic complications.

Methods

A prospective clinical trial was conducted to assess safety as the primary endpoint and efficacy as the secondary endpoint of the aforementioned therapy in five patients with critical limb ischemia, with or without hemodialysis.

Results

Five patients with critical limb ischemia were enrolled between 2016 and 2019, three of whom underwent hemodialysis. Platelet-rich plasma was obtained from 288 ± 39.6 mL of blood/patient, yielding 31.6 ± 1.67 mL of platelet-rich plasma. Bone marrow aspiration yielded 18.4 ± 4.77 mL/patient, and 4.64 ± 1.51 × 107 cells were incubated for 16 ± 2.8 days to obtain 3.26 ± 0.33 × 107 mesenchymal stromal cells. Although several adverse events were observed, none were directly attributed to cell therapy. Clinical severity, as assessed by both the Fontaine stage and Rutherford category, improved significantly following therapy. This improvement was accompanied by enhancements in the 6-min walking distance, dorsal skin perfusion pressure, ankle transcutaneous partial oxygen pressure, and ankle brachial pressure index.

Conclusion

Autologous angiogenic therapy with cultured mesenchymal stromal cells derived from the bone marrow and grown in platelet-rich plasma is a safe and feasible, and was expected as a potential treatment for critical limb ischemia.

Clinical feasibility of endovascular recanalization with intravascular ultrasound-guided wiring for chronic total occlusion of below-the-knee arteries

BACKGROUND

Revascularization with endovascular therapy (EVT) for complex below-the-knee (BTK) chronic total occlusion (CTO) remains a challenging problem. The Japanese-BTK (J-BTK) CTO score is reported as an indicator of the difficulty of BTK CTO, with the guidewire (GW) passage success rate decreasing as the grade increases. We previously reported an effective GW crossing method for the intravascular ultrasound (IVUS)-guided parallel wiring of complex BTK CTO. In this study, we investigated the feasibility of EVT using IVUS-guided wiring for BTK CTO.

MATERIALS AND METHODS

This single center, retrospective study analyzed 65 consecutive BTK CTO vessels in which IVUS-guided wiring was attempted after the failure of a conventional antegrade wiring approach from November 2020 to November 2022. The primary endpoint was the clinical success of the target CTO vessel. The secondary endpoints were the GW success rate per grade based on the J-BTK CTO score, number of GW used for CTO crossing, fluoroscopy time, and complications.

RESULTS

Target vessels were the anterior tibial artery (66.2% of cases), peroneal artery (9.2%), and posterior tibial artery (24.6%). Blunt type CTO entry was performed in 55.4% of cases, calcification of entry was observed in 24.6% of cases, the mean occlusion length was 228.2 ± 93.7 mm, mean reference vessel diameter was 2.1 ± 0.71 mm, and outflow was absent in 38.5% of cases. J-BTK CTO scores of 0/1 (grade A), 2/3 (grade B), 4/5 (grade C), and 6 (grade D) were seen in 18.5%, 43.1%, 36.3%, and 1.5% of cases, respectively. The clinical success rate was 95.4%. The GW success rate by J-BTK CTO grade was as follows: grade A (100%), B (100%), C (91.7%), and D (0%). The mean number of GW used was 3.4 ± 1.4, the mean fluoroscopy time was 72.3 ± 32.5 min, and complications occurred in 7.7% of cases.

CONCLUSION

This study showed a very high clinical success rate despite the difficulty of BTK CTO. IVUS-guided EVT might be a feasible strategy for complex BTK CTO.

Prediction of Wound Recurrence in Patients With Chronic Limb-Threatening Ischemia Undergoing Endovascular Treatment

PURPOSE

Chronic limb-threatening ischemia due to isolated below-the-knee lesions is a factor associated with wound recurrence. However, there is a lack of data regarding wound recurrence in such cases. This study aimed to determine the predictors of wound recurrence in patients with chronic limb-threatening ischemia undergoing endovascular treatment.

PATIENTS AND METHODS

This was a single-center, retrospective, observational study. We enrolled 152 consecutive patients with chronic limb-threatening ischemia (172 limbs) who achieved complete wound healing after undergoing endovascular treatment for isolated below-the-knee lesions between February 2008 and December 2017. Of these, the wound had recurred in 56 limbs (33%), and we divided the patients into 2 groups based on wound recurrence. We evaluated the recurrence rate of chronic limb-threatening ischemia and predictors of wound recurrence. Wound recurrence was defined as recurrence of the wound within 2 years of complete wound healing.

RESULTS

Patients' backgrounds were similar in both groups, including mean age (72±9 vs 72±11; p=0.76) and hemodialysis (43% vs 40%; p=0.66). Pre-pedal arch type 2 (52% vs 8%; p<0.01), infrapopliteal grade 4 of the Global Limb Anatomic Staging System (77% vs 59%; p=0.02), and Wound, Ischemia, and foot Infection criteria stage 4 (43% vs 28%; p=0.04) were more common in the wound recurrence group. Multivariate Cox proportional hazard analysis identified pre-pedal arch type 2 (hazard ratio, 5.28; 95% confidence interval, 3.08-9.10; p<0.01) and Wound, Ischemia, and foot Infection criteria stage 4 (hazard ratio, 1.98; 95% confidence interval, 1.15-3.36; p=0.01) as predictors of wound recurrence after complete wound healing.

CONCLUSION

Pre-pedal arch type 2 and Wound, Ischemia, and foot Infection classification system stage 4 were associated with wound recurrence in patients with chronic limb-threatening ischemia who achieved complete wound healing after undergoing endovascular treatment for isolated below-the-knee lesions.

Clinical Outcomes of Additional Below-The-Ankle Intervention Compared to Below-The-Knee Intervention Alone: A Post-Hoc Analysis of a Prospective Multicenter Study

PURPOSE

To investigate the clinical implication of additional below-the-ankle (BTA) intervention in patients with chronic limb-threatening ischemia (CLTI) undergoing below-the-knee (BTK) intervention.

MATERIALS AND METHODS

A sub-analysis was performed using data from the LIBERTY trial (ClinicalTrials.gov identifier NCT01855412), a prospective, observational, core-laboratory adjudicated, multicenter study of endovascular intervention in 1204 patients. Patients with CLTI (Rutherford Classification 4-6) who underwent BTK intervention were included in this sub-analysis. Participants were then stratified into 2 treatment groups according to whether at least one lesion intervened on was BTA (n=66) or not (n=273). The decision on whether and where to intervene was made during the procedure. The main outcome measures included major amputation, target vessel revascularization (TVR), major adverse events (MAE), survival, amputation-free survival, major adverse limb events or peri-operative death (MALE-POD), and all-cause death. Other outcome measures included procedural success, procedural complications, and wound healing rate.

RESULTS

There were no differences in procedural success or severe angiographic complications between the 2 groups. At 1-year post-procedure, patients in the BTK group had a higher rate of freedom from major amputation (95.0% vs. 86.9%, respectively; HR: 2.87, 95% CI: 1.17-7.03), a higher rate of freedom from TVR (80.1% vs. 66.9%, respectively; HR: 1.94, 95% CI: 1.14-3.32), a higher rate of freedom from MALE-POD (94.6% vs. 86.9%, respectively; HR: 2.65, 95% CI: 1.10-6.41), and a higher rate of freedom from MAE at both 1 (76.0% vs. 60.1%, respectively; HR: 2.00, 95% CI: 1.24-3.22) and 3 years post procedure (67.5% vs. 55.8%, respectively; HR: 1.69, 95% CI: 1.08-2.65). There was a significantly lower rate of survival in the BTK group at 3 years (74.3% vs. 91.1%, respectively; HR: 0.35, 95% CI: 0.14-0.87). After risk adjustment, there was a higher rate of all-cause death in the BTK group at 3 years (19.4% vs. 9.1%, respectively; p=0.023) post-intervention.

CONCLUSION

Patients with disease requiring intervention to BTA lesions have a potential increased amputation rate in the short term, but BTA intervention carries a potential survival benefit in the long term when compared to BTK intervention alone.

How I do it: Pedal access and pedal loop revascularization for patients with chronic limb-threatening ischemia

An increasing proportion of patients with chronic limb-threatening ischemia are older and have multiple comorbidities, including diabetes and renal failure. For those who are not candidates for a surgical bypass, this set of patients presents a challenge to vascular surgeons and interventionalists owing to the complex below-the-knee and increasingly below-the-ankle disease pattern that can fail traditional approaches for endovascular intervention. Two techniques, the retrograde pedal access and the pedal-plantar loop technique, can be useful in these settings and in skilled hands can be used safely, with a high technical success rate. In patients with chronic limb-threatening ischemia who are not candidates for a single-segment saphenous vein bypass, the retrograde pedal access technique can be used not only in the setting of failed antegrade treatment, but also primarily when faced with a difficult groin or as an adjunct during a planned antegrade-retrograde intervention. The pedal plantar loop technique allows for retrograde access to tibial vessels without retrograde vessel puncture and additionally offers the ability to treat the pedal-plantar arch, which may have added benefit in wound healing. We describe the tips and tricks for these two techniques used in our limb salvage practice.

Advanced Endovascular Techniques for Limb Salvage

As the number of patients affected by peripheral arterial disease continues to increase, new technical approaches and devices have been developed to provide effective and durable treatment options that will lead to improved outcomes. While the mainstay of endovascular intervention remains mostly balloon-based, several innovative techniques and technologies are in development that may provide new solutions. This review highlights recent endovascular advancements in the management of chronic limb-threatening ischemia and additional adjunctive devices that are needed to improve lesion patency, reduce the need for reintervention, and lead to better patient-centered functional outcomes.

Inframalleolar thrice distal puncture in a single endovascular treatment session for successful revascularization

BACKGROUND

Most patients with chronic limb-threatening ischemia (CLTI) have infrapopliteal arterial disease, which are often challenging to treat. In endovascular treatment (EVT) for these complex lesions, establishing retrograde access is an essential option not only for guidewire crossing but also for device delivery. However, no EVT case has yet been reported requiring inframalleolar thrice distal puncture in a single EVT session so far.

CASE PRESENTATION

A 60-year-old CLTI patient with grade 3 Wound, Ischemia and foot Infection (WIfI) classification underwent EVT for occluded dorsal artery and posterior tibial artery. First, we conducted successful balloon angioplasty of the posterior tibial artery by establishing a retrograde approach via the lateral plantar artery. To treat the occlusion of the dorsal artery, we punctured the first dorsal metatarsal artery, and retrogradely advanced a guidewire to the dorsal artery occlusion; however, the microcatheter could not follow the guidewire. Therefore, we punctured the occluded distal anterior tibial artery and introduced the retrograde guidewire into the puncture needle. After guidewire externalization, we pulled up the retrograde microcatheter into the occlusion of dorsal artery using the "balloon deployment using forcible manner" technique. Thereafter, we were able to advance the antegrade guidewire into the retrograde microcatheter. After guidewire externalization, an antegrade balloon catheter was delivered and inflated for the purpose of dorsal artery dilation and hemostasis at the "needle rendezvous" point. Consecutively, balloon dilation was performed for puncture site hemostasis of the first dorsal metatarsal artery and complete hemostasis was achieved. Finally, we confirmed good vascular patency and favorable blood flow. After revascularization, transmetatarsal amputation was performed and the wound healed favorably.

CONCLUSIONS

We can markedly increase the success rate of revascularization by effectively utilizing the retrograde approach in EVT for complex chronic total occlusions in infrapopliteal arterial diseases.

Revascularization Strategies for Patients With Femoropopliteal Peripheral Artery Disease

BACKGROUND

No adequately powered studies exist to compare major clinical outcomes after endovascular therapy (EVT) with stent implantation vs bypass surgery (BSx) for symptomatic femoropopliteal peripheral artery disease.

OBJECTIVES

This study sought to perform a pooled analysis of individual patient data from all randomized controlled trials comparing EVT vs BSx.

METHODS

Principal investigators of 5 of 6 available randomized controlled trials agreed to pool individual patient data. The primary endpoint was major adverse limb events, a composite of all-cause death, major amputation, or target limb reintervention. Secondary endpoints included amputation-free survival, individual major adverse limb event components, and primary patency. Early complications were bleeding, infection, or all-cause death within 30 days.

RESULTS

A total of 639 patients were analyzed with a mean age of 68.1 ± 9.1 years and 29.0% women. Baseline characteristics were comparable between groups. At 2 years, there were no significant differences between patients who received EVT and those who received BSx regarding major adverse limb events (40.1% vs 36.4%; log-rank P = 0.447; adjusted HR [aHR]: 1.04; 95% CI: 0.80-1.36), amputation-free survival (88.1% vs 90.0%; log-rank P = 0.455; aHR for death or amputation: 1.04; 95% CI: 0.63-1.71) and the other secondary endpoints except for primary patency, which was lower in patients who received EVT vs those who received BSx (51.2% vs 61.3%; log-rank P = 0.024; aHR for loss of primary patency: 1.31; 95% CI: 1.02-1.69). EVT was associated with significantly lower rates of early complications (6.8% vs 22.6%; P < 0.001) and shorter hospital stay (3.1 ± 4.2 days vs 7.4 ± 4.9 days; P < 0.001).

CONCLUSIONS

These findings further support the efficacy and safety of EVT as an alternative to BSx in patients with symptomatic femoropopliteal peripheral artery disease.

Presence of a patent pedal arch is the primary predictor of transmetatarsal amputation healing and limb salvage

OBJECTIVE

Transmetatarsal amputation (TMA) is a durable and important functional limb salvage option. We have presented our results in identifying the angiographic predictors of TMA healing using single-institution retrospective data.

METHODS

Consecutive patients within our institution who had undergone TMA and lower extremity arteriography from 2012 to 2020 were included. Patients whose TMA had healed were compared with those whose TMA had not healed. Using pre- and perioperative patient factors, in addition to the Global Limb Anatomic Staging System (GLASS) and evaluation of the tibial runoff vessels, multivariate analysis was used to define the predictors of TMA healing at 30 days and 1 year. For those patients who had undergone an intervention after TMA, including repeat interventions, the postintervention GLASS stage was calculated. All patients were followed up by the vascular surgeon using standard ultrasound surveillance and clinical examinations. Once the predictors had been identified, an analysis was performed to correlate the 30-day and 1-year limb salvage rates.

RESULTS

A total of 89 patients had met the inclusion criteria for the study period. No difference was found in the GLASS femoropopliteal or infrapopliteal stages for those with a healed TMA and those without. After multivariate regression analysis, the presence of a patent pedal arch vs a nonintact arch had a 5.5 greater odds of TMA healing at 30 days but not at 1 year. Additionally, the presence of a patent arch was strongly associated with limb salvage at both 30 days (86% vs 49%; P < .01) and 1 year (79% vs 49%; P < .01).

CONCLUSIONS

In the present series of patients who had undergone TMA and arteriography, with appropriate GLASS staging, we found patency of the pedal arch was a significant predictor of healing and limb salvage. The GLASS femoropopliteal and infrapopliteal stages did not predict for TMA healing.

Drug-coated balloons in below-the-knee arteries

Background: The search for an optimal interventional treatment strategy in infrapopliteal peripheral artery disease remains in the focus of interest. Whether drug-coated balloons (DCB) might enhance interventional outcomes after crural interventions is a matter of debate, as studies yielded conflicting results on DCB safety and efficacy. Patients and methods: We analyzed a retrospective cohort of 75 infrapopliteal DCB interventions performed at our institution in 68 patients with peripheral artery disease in Rutherford category 3 to 6. Results: Despite a high rate of long complex lesions and multi-vessel disease, freedom from clinically driven target lesions revascularization (TLR) after 365 days was 68%. After six months, healing or significant improvement of the ischemic ulcer was observed in 78% of cases. Accordingly, freedom from major amputation and death after 365 days was 82%. Freedom from major amputation and death was 76.2% of cases in patients with diabetes mellitus as opposed to 91.5% in patients without diabetes mellitus (p=0.049). Conclusions: With this real-world analysis we would like to contribute to the ongoing discussion on the benefit and safety of DCB treatment in below-the-knee interventions.

Endovaskuläre Behandlung der Unterschenkel-PAVK bei kritischer Ischämie und diabetischem Fußsyndrom

Die kritische Ischämie der unteren Extremität aufgrund einer PAVK, bei der häufig eine Mitbeteiligung der Unterschenkelarterien besteht, ist ohne Revaskularisation mit einer schlechten Prognose vergesellschaftet. Für Patienten mit diabetischem Fußsyndrom trifft dies in besonderem Maße zu. Auch finden sich bei diesen Patienten nicht selten PAVK-Läsionen ausschließlich infrapopliteal. Die endovaskuläre Rekanalisation wird in diesem Bereich zunehmend als Therapie der ersten Wahl betrachtet. Der retrograde Zugang, spezielle Ballontechniken sowie Atherektomiesysteme haben die technischen Erfolgsraten verbessern können. Drug-eluting Stents und neue Drug-coated Ballons führen zu einer Verbesserung der Offenheitsrate. Bei schwerer distaler PAVK ist allerdings eine Revaskularisation häufig nicht möglich. Bei diesen sogenannten „no-option“-Patienten könnte eventuell die Arterialisierung des tiefen Venensystems in der Zukunft eine Rolle spielen.

Distal Bypass Versus Infrageniculate Endovascular Intervention for Chronic Limb-Threatening Ischemia

Chronic limb-threatening ischemia (CLTI) carries a high risk of amputation and warrants urgent intervention. CLTI involving the infrageniculate vessels, in particular, carries a considerably higher risk of major limb amputation. Open surgical bypass is the historical gold standard for the treatment of tibial arterial disease; however, endovascular therapy provides an attractive alternative in this high-risk patient population. In this article, we review the existing literature regarding distal bypass and infrageniculate endovascular intervention in patients with CLTI.

Overcoming ischemia in the diabetic foot: Minimally invasive treatment options

As the global burden of diabetes is rapidly increasing, the incidence of diabetic foot ulcers is continuously increasing as the mean age of the world population increases and the obesity epidemic advances. A significant percentage of diabetic foot ulcers are caused by mixed micro and macro-vascular dysfunction leading to impaired perfusion of foot tissue. Left untreated, chronic limb-threatening ischemia has a poor prognosis and is correlated with limb loss and increased mortality; prompt treatment is required. In this review, the diagnostic challenges in diabetic foot disease are discussed and available data on minimally invasive treatment options such as endovascular revascularization, stem cells, and gene therapy are examined.

Foot Revascularization Avoids Major Amputation in Persons with Diabetes and Ischaemic Foot Ulcers

The study aims to evaluate the effectiveness of foot revascularization in persons with diabetic foot ulcers (DFUs) and below-the-ankle (BTA) arterial disease. Consecutive patients referred for a new active ischaemic DFU requiring lower limb revascularization were considered. Among those, only patients with a BTA arterial disease were included. Revascularization procedures were retrospectively analysed: in the case of successful foot revascularization (recanalization of pedal artery, or plantar arteries or both) or not, patients were respectively divided in two groups, successful foot perfusion (SFP) and failed foot perfusion (FFP). Healing, minor and major amputation at 12 months of follow-up were evaluated and compared. Eighty patients (80) were included. The mean age was 70.5 ± 10.9 years, 55 (68.7%) were male, 72 (90%) were affected by type 2 diabetes with a mean duration of 22.7 ± 11.3 years. Overall 45 (56.2%) patients healed, 47 (58.7%) had minor amputation and 13 (16.2%) major amputation. Outcomes for SFP and FFP were respectively: healing (89.3 vs. 9.1%, p < 0.0001), minor amputation (44.7 vs. 78.8%, p = 0.0001), major amputation (2.1 vs. 36.3%, p < 0.0001). Failed foot revascularization resulted an independent predictor of non-healing, minor amputation, and major amputation. Foot revascularization is mandatory to achieve healing and avoid major amputation in persons with ischaemic DFU and BTA arterial disease.

CIRSE Standards of Practice on Below-the-Knee Revascularisation

The CIRSE Standards of Practice Committee established a writing group that was tasked with producing up-to-date recommendations for performing below-the-knee revascularisation, taking into account data on novel techniques, devices, and long-term outcomes that have emerged over the last decade. CIRSE Standards of Practice documents are not clinical practice guidelines or systematic reviews of the literature. This document is not intended to impose a standard of clinical patient care but recommends a reasonable approach to and best practices for performing below-the-knee revascularisation.

Advances in Revascularization for Peripheral Artery Disease: Revascularization in PAD

Effective revascularization of the patient with peripheral artery disease is about more than the procedure. The approach to the patient with symptom-limiting intermittent claudication or limb-threatening ischemia begins with understanding the population at risk and variation in clinical presentation. The urgency of revascularization varies significantly by presentation; from patients with intermittent claudication who should undergo structured exercise rehabilitation before revascularization (if needed) to those with acute limb ischemia, a medical emergency, who require revascularization within hours. Recent years have seen the rapid development of new tools including wires, catheters, drug-eluting technology, specialized balloons, and biomimetic stents. Open surgical bypass remains an important option for those with advanced disease. The strategy and techniques employed vary by clinical presentation, lesion location, and lesion severity. There is limited level 1 evidence to guide practice, but factors that determine technical success and anatomic durability are largely understood and incorporated into decision-making. Following revascularization, medical therapy to reduce adverse limb outcomes and a surveillance plan should be put in place. There are many hurdles to overcome to improve the efficacy of lower extremity revascularization, such as restenosis, calcification, microvascular disease, silent embolization, and tools for perfusion assessment. This review highlights the current state of revascularization in peripheral artery disease with an eye toward technologies at the cusp, which may significantly impact current practice.

Medial-to-lateral plantar loop technique for retrograde transcollateral recanalization of the lateral plantar artery in patients with type 3 plantar arch

A 89-year-old male presented with severe untreatable pain and ischemic non-healing ulcer in the left forefoot. The pre-procedural angiograms showed multiple stenosis of the superficial femoral and popliteal arteries, occlusion of anterior tibial artery, tibio-peroneal trunk (TTP) and distal posterior tibial artery (PTA), stenosis of the peroneal artery, and the patency of the medial plantar artery (MPA) as a single pedal artery, with very poor perfusion of the lateral aspect of the forefoot. The TTP and PTA were recanalized, and balloon angioplasty of superficial femoral artery and popliteal artery and peroneal artery was carried out. After unsuccessful antegrade attempts, the lateral plantar artery (LPA) was retrogradely recanalized performing the medial-to-lateral plantar loop, navigating from the deep branch of MPA to the plantar arch and reentering back in the common plantar artery through the LPA. Balloon angioplasty of LPA was performed though the retrograde and antegrade route. When the MPA is the single pedal artery, and the antegrade recanalization of the dorsalis pedis artery (DPA) and the LPA is not possible, the medial-to-lateral plantar loop is a feasible technique to recanalize the LPA retrogradely through the plantar arch.

Systematic review of inframalleolar endovascular interventions and rates of limb salvage, wound healing, restenosis, rest pain, reintervention and complications

Objectives

Peripheral artery disease is estimated to affect 237 million individuals worldwide. Critical limb ischaemia, also known as chronic limb threatening ischaemia is a consequence of the progression of peripheral artery disease which occurs in ∼21% of patients over a five-year period. The aim of this systematic review is to assess the use of additional below-the-ankle angioplasty in comparison to the use of above-the-ankle angioplasty alone, and the subsequent rates of amputation, wound healing, restenosis, rest pain, reintervention and complications.

Methods

This systematic review was undertaken in accordance with PRISMA guidelines following a registered protocol (CRD42019154893). Online databases were searched using a search strategy of 20 keywords. Included articles reported the outcome for inframalleolar (pedal artery, pedal arch, plantar arteries) angioplasty with additional proximal angioplasty in comparison to proximal angioplasty alone. GRADE assessment was applied to assess the quality of the evidence.

Results

After screening 1089 articles, 10 articles met the inclusion criteria. Comparative performance assessment of below-the-ankle with above-the-ankle versus above-the-ankle angioplasty alone was undertaken in 3 articles, with the remaining 7 articles reporting outcomes of below-the-ankle with above-the-ankle angioplasty with no distinct comparator group. Significant decrease in major lower limb amputation at the last follow-up in the below-the-ankle group when compared with the above-the-ankle angioplasty alone group was observed in a single study (3.45% vs. 14.9%, p < 0.05). Improved wound healing rate at follow-up in the below-the-ankle group versus above-the-ankle angioplasty alone group was also reported in a single study (59.3% vs. 38.1%, p < 0.05). Subsequent rate of amputation after below-the-ankle angioplasty has been estimated as 23.5%.

Conclusion

To date, there is a lack of studies assessing inframalleolar interventions and their use in improving limb salvage, wound healing and symptomatology. Prospective RCTs should be undertaken with adequate participant numbers to be sufficiently powered and report clinically important end-points.

Prediction of successful guidewire crossing of below-the-knee chronic total occlusions using a Japanese scoring system

OBJECTIVE

To develop a scoring system that can adequately predict a successful guidewire crossing (S-GC) of below-the-knee (BTK) chronic total occlusions (CTOs) in angiographic evaluation.

METHODS

A retrospective, multicenter, nonrandomized study examined 448 consecutive BTK CTOs in 299 patients treated with endovascular therapy in seven Japanese medical centers from April 2012 to April 2020. The cohort was classified into two groups: an S-GC group and a failed guidewire crossing group.

RESULTS

The final logistic regression model created by a backward stepwise multivariate logistic regression model included five variables: "No outflow of the target vessel," "CTO length ≥200 mm," "Reference vessel diameter <2.0 mm," "Calcification at the proximal entry point," and "Blunt type at entry point." Optimisms were adjusted using 1000 bootstrap samples with replacement and candidate's risk score models developed according to optimism-adjusted correlation coefficients of risk factors. Choosing the best model as the Japanese-BTK (J-BTK) CTO score by comparing the optimism-adjusted area under receiver-operating characteristic curves it was decided to assign one point to "Blunt type at the proximal entry point," one point to "Calcification at the proximal entry point," one point to "Reference vessel diameter <2.0 mm," one point to "CTO length ≥200 mm," and two points to "No outflow of the target vessel." This rule was then used to categorize BTK CTOs into four grades with varying probabilities of S-GC: grade A (J-BTK CTO score of 0 and 1), grade B (score of 2 and 3), grade C (score of 4 and 5), and grade D (score of 6). Rates of S-GC in each grade (grades A, B, C, and D) were 97.3%, 76.8%, 19.3%, and 0%, respectively. Lesions categorized as grade C or D have a lower chance of S-GC. Internal validation was performed using the Hosmer-Lemeshow test (P = .99).

CONCLUSIONS

The J-BTK CTO score predicts the probability of an S-GC of BTK CTOs and stratifies the difficulty of endovascular therapy for BTK CTOs in angiographic evaluation.

Impact of Longer Hemodialysis Vintage with Higher Serum Phosphorus Level on Clinical Outcomes in Patients with Chronic Limb-Threatening Ischemia Presenting Tissue Loss after Endovascular Therapy

Aims: Hemodialysis vintage and serum phosphorus levels adversely affect outcomes in patients on hemodialysis. Whether these factors have a similar prognostic impact on patients who are on hemodialysis and have chronic limb-threatening ischemia (CLTI) has not been systematically studied. We aimed to explore the risk factors, including hemodialysis vintage and serum phosphorus levels, on clinical outcomes after endovascular therapy (EVT) in hemodialysis patients with CLTI.

Methods: The current study rerospectively analyzed 374 hemodialysis patients with CLTI presenting with ischemic tissue loss (age: 72.3±9.0 years, male: 73.3%, diabetes mellitus: 68.2%, Rutherford 5: 75.9%, 6: 24.1%, WIfI stage 4: 50.0%) primarily treated with EVT between April 2007 and December 2016. The primary outcome measure was 1-year amputation-free survival (AFS), while the secondary outcome measure was 1-year wound healing. Predictors for each outcome were evaluated by Cox proportional hazards model.

Results: Multivariate analysis significantly associated longer hemodialysis vintages with higher serum phosphorus levels (hazard ratio [HR], 0.599; 95% confidence interval [CI], 0.394-0.910; p =0.016) with 1-year AFS. Longer vintages for hemodialysis with higher serum phosphorus levels were marginally, but not significantly, associated with 1-year wound healing. (HR, 0.684; 95% CI, 0.467–1.000; p =0.050).

Conclusion: Longer hemodialysis vintages with higher serum phosphorus levels adversely affect outcomes after EVT for hemodialysis patients with CLTI presenting with ischemic tissue loss.

Peripheral Arterial Disease in Persons with Diabetic Foot Ulceration: a Current Comprehensive Overview

In developed countries, the prevalence of persons with diabetes and peripheral arterial disease (PAD) is approximately 50%. The presence of PAD is associated with non-healing ulcers, major amputation, cardiovascular morbidity, and mortality. It is estimated that persons with diabetes, foot ulceration and PAD have 50% of 5-years mortality rate. Therefore, subjects with ischemic diabetic foot ulcers (DFUs) should be considered a special group of patients with specific clinical characteristics, general health status and prognosis. In persons with ischemic DFUs, an early diagnosis and treatment are mandatory to reduce the risk of worse outcomes such as major amputation. Revascularization of occluded lower extremity arteries is the main treatment to restore blood flow in the foot and promote wound healing. Nonetheless, there are several unmet needs in the management of diabetic subjects with PAD and foot ulceration as medical therapy, diagnostic criteria and indications for revascularization, revascularization strategy and technical approach as well as the management of no-option critical limb ischemia patients. It is a common opinion that there is an evolution of PAD features in diabetic persons, which seems to present a more aggressive pattern. This may be related to the frequent presence of concomitant comorbidities such as renal failure which could influence the characteristics of atherosclerotic plaques and their distribution. The aim of this review is to commence a complete overview and state of the art in the treatment of patients with diabetes, PAD, and foot ulceration and to describe the current challenges and future perspectives.

An Extension of the Bollinger Scoring System to Analyse the Distribution of Macrovascular Disease of the Lower Limb in Diabetes

OBJECTIVE

While it is generally considered that patients with diabetes mellitus (DM) have more distal peripheral arterial disease (PAD), there is little information on how individual vessels are affected. The aim of this study was to adapt Bollinger's scoring system for lower limb angiograms (DSAs) to include the distal and planter vessels. The reliability of this extension was tested and was used to compare the distribution of disease in two cohorts of patients with and without DM.

METHODS

Patients who had undergone DSA ± angioplasty for PAD at a single centre between September 2010 and April 2014 were identified. Twenty-five patients' images were reviewed by four clinicians and scored using an extended version of the Bollinger score. A total of 153 patients with DM were matched, for age, sex, ethnicity, smoking, and hypertension, with 153 patients without DM. The infrainguinal vessels were divided into 16 arterial segments, including plantar vessels, and scored using the Bollinger score. The score ranges from 0 to 15. Fifteen represents an arterial segment with more than 50% of its length occluded. Interobserver reliability was tested using interclass correlation (ICC) and Cohen's kappa coefficient.

RESULTS

The ICC demonstrated good agreement between observers (0.76 [0.72-0.79]) with good internal consistency (Cronbach's alpha 0.93). When the Bollinger scores were categorised, the results were weaker, Cohen's kappa ranged from 0.39 (standard error 0.033) to 0.54 (0.030). Patients with DM had a higher burden of disease in the anterior tibial and posterior tibial arteries with relative sparing of the peroneal artery and no difference in the plantar vessels.

CONCLUSION

It has been demonstrated that the Bollinger score can be extended to include the distal vessels. This amended scoring system can be used to compare the burden of distal disease in patients with PAD. How the score relates to clinical presentation and outcomes needs further investigation.

Two effective cases of additional pedal artery angioplasty for severe lower limb ischemia following acute thrombotic artery occlusion with hypercoagulable state diseases

Background

Acute limb ischemia (ALI) and critical limb ischemia (CLI) following ALI are life-threatening diseases. The rare potential causes of ALI include hypercoagulable state diseases, such as antiphospholipid syndrome (APS) and essential thrombocythemia (ET). Hypercoagulability often make revascularization for arterial occlusion, especially associated with infrapopliteal lesions, difficult. This is because the vessels have poor run-off, and elevated peripheral vascular resistance associated with microcirculation failure, due to a high thrombus burden. There is no established treatment for this issue.

Case presentation

A 45 years-old and a 56 years-old male suffered from thrombotic arterial occlusion as a first manifestation of APS and ET, respectively. Combination therapy with aggressive anti-thrombotic therapy and revascularization, such as endovascular therapy and surgical thrombectomy based on the angiosome concept, was performed. However, the high thrombus burden caused a poor pedal outflow, and significant limb ischemia remained. Additional pedal artery angioplasty was performed to improve residual limb ischemia in each case and provided sufficient blood flow to the foot.

Conclusion

The pedal artery angioplasty for thrombotic pedal artery occlusion cases, associated with hypercoagulable state diseases, seems to be a treatment option for relieving residual limb ischemia.