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Patel AS, Ludwinski FE, Kerr A, Farkas S, Kapoor P, Bertolaccini L, Fernandes R, Jones PR, McLornan D, Livieratos L, Saha P, Smith A, Modarai B. A subpopulation of tissue remodeling monocytes stimulates revascularization of the ischemic limb. Sci Transl Med 2024; 16:eadf0555. [PMID: 38896604 DOI: 10.1126/scitranslmed.adf0555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 05/30/2024] [Indexed: 06/21/2024]
Abstract
Despite decades of effort aimed at developing clinically effective cell therapies, including mixed population mononuclear cells, to revascularize the ischemic limb, there remains a paucity of patient-based studies that inform the function and fate of candidate cell types. In this study, we showed that circulating proangiogenic/arteriogenic monocytes (PAMs) expressing the FcγIIIA receptor CD16 were elevated in patients with chronic limb-threatening ischemia (CLTI), and these amounts decreased after revascularization. Unlike CD16-negative monocytes, PAMs showed large vessel remodeling properties in vitro when cultured with endothelial cells and smooth muscle cells and promoted salvage of the ischemic limb in vivo in a mouse model of hindlimb ischemia. PAMs showed a propensity to migrate toward and bind to ischemic muscle and to secrete angiogenic/arteriogenic factors, vascular endothelial growth factor A (VEGF-A) and heparin-binding epidermal growth factor. We instigated a first-in-human single-arm cohort study in which autologous PAMs were injected into the ischemic limbs of five patients with CLTI. Greater than 25% of injected cells were retained in the leg for at least 72 hours, of which greater than 80% were viable, with evidence of enhanced large vessel remodeling in the injected muscle area. In summary, we identified up-regulation of a circulatory PAM subpopulation as an endogenous response to limb ischemia in CLTI and tested a potentially clinically relevant therapeutic strategy.
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Affiliation(s)
- Ashish S Patel
- Academic Department of Vascular Surgery, South Bank Section, School of Cardiovascular and Metabolic Medicine & Sciences, BHF Centre of Excellence, King's College London, London SE1 7EH, UK
- Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, London SE1 7EH, UK
| | - Francesca E Ludwinski
- Academic Department of Vascular Surgery, South Bank Section, School of Cardiovascular and Metabolic Medicine & Sciences, BHF Centre of Excellence, King's College London, London SE1 7EH, UK
- Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, London SE1 7EH, UK
| | - Alexander Kerr
- Academic Department of Vascular Surgery, South Bank Section, School of Cardiovascular and Metabolic Medicine & Sciences, BHF Centre of Excellence, King's College London, London SE1 7EH, UK
- Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, London SE1 7EH, UK
| | - Simon Farkas
- Academic Department of Vascular Surgery, South Bank Section, School of Cardiovascular and Metabolic Medicine & Sciences, BHF Centre of Excellence, King's College London, London SE1 7EH, UK
- Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, London SE1 7EH, UK
| | - Puja Kapoor
- Academic Department of Vascular Surgery, South Bank Section, School of Cardiovascular and Metabolic Medicine & Sciences, BHF Centre of Excellence, King's College London, London SE1 7EH, UK
- Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, London SE1 7EH, UK
| | - Laura Bertolaccini
- Academic Department of Vascular Surgery, South Bank Section, School of Cardiovascular and Metabolic Medicine & Sciences, BHF Centre of Excellence, King's College London, London SE1 7EH, UK
- Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, London SE1 7EH, UK
| | - Ramon Fernandes
- Academic Department of Vascular Surgery, South Bank Section, School of Cardiovascular and Metabolic Medicine & Sciences, BHF Centre of Excellence, King's College London, London SE1 7EH, UK
- Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, London SE1 7EH, UK
| | - Paul R Jones
- Academic Department of Vascular Surgery, South Bank Section, School of Cardiovascular and Metabolic Medicine & Sciences, BHF Centre of Excellence, King's College London, London SE1 7EH, UK
- Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, London SE1 7EH, UK
| | - Donal McLornan
- Department of Haematology, Guy's & St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Lefteris Livieratos
- Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Sciences, King's College London, London SE1 7EH, UK
- Department of Nuclear Medicine, Guy's & St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Prakash Saha
- Academic Department of Vascular Surgery, South Bank Section, School of Cardiovascular and Metabolic Medicine & Sciences, BHF Centre of Excellence, King's College London, London SE1 7EH, UK
- Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, London SE1 7EH, UK
| | - Alberto Smith
- Academic Department of Vascular Surgery, South Bank Section, School of Cardiovascular and Metabolic Medicine & Sciences, BHF Centre of Excellence, King's College London, London SE1 7EH, UK
- Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, London SE1 7EH, UK
| | - Bijan Modarai
- Academic Department of Vascular Surgery, South Bank Section, School of Cardiovascular and Metabolic Medicine & Sciences, BHF Centre of Excellence, King's College London, London SE1 7EH, UK
- Biomedical Research Centre at Guy's & St Thomas' NHS Foundation Trust and King's College London, London SE1 7EH, UK
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Menard MT, Farber A, Powell RJ, Rosenfield K, Conte MS, Hamza TH, Kaufman JA, Cziraky MJ, Creager MA, Dake MD, Jaff MR, Reid D, Sopko G, White CJ, Strong MB, van Over M, Chisci E, Goodney PP, Gray B, Kayssi A, Siracuse JJ, Choudhry NK. Quality of Life in Patients With Chronic Limb-Threatening Ischemia Treated With Revascularization. Circulation 2024; 149:1241-1253. [PMID: 38597097 DOI: 10.1161/circulationaha.123.065277] [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: 04/27/2023] [Accepted: 02/20/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND In the BEST-CLI trial (Best Endovascular Versus Best Surgical Therapy for Patients With Chronic Limb-Threatening Ischemia), a prespecified secondary objective was to assess the effects of revascularization strategy on health-related quality of life (HRQoL). METHODS Patients with chronic limb-threatening ischemia were randomized to surgical bypass (Bypass) or endovascular intervention (Endo) in 2 parallel trials. Cohort 1 included patients with single-segment great saphenous vein; cohort 2 included those lacking suitable single-segment great saphenous vein. HRQoL was assessed over the trial duration using Vascular Quality-of-Life (VascuQoL), European Quality-of-Life-5D (EQ-5D), the Short Form-12 (SF-12) Physical Component Summary (SF-12 PCS), SF-12 Mental Component Summary (SF-12 MCS), Utility Index Score (SF-6D R2), and numeric rating scales of pain. HRQoL was summarized by cohort and compared within and between groups using mixed-model linear regression. RESULTS A total of 1193 and 335 patients in cohorts 1 and 2 with a mean follow-up of 2.9 and 2.0 years, respectively, were analyzed. In cohort 1, HRQoL significantly improved from baseline to follow-up for both groups across all measures. For example, mean (SD) VascuQoL scores were 3.0 (1.3) and 3.0 (1.2) for Bypass and Endo at baseline and 4.7 (1.4) and 4.8 (1.5) over follow-up. There were significant group differences favoring Endo when assessed with VascuQoL (difference, -0.14 [95% CI, -0.25 to -0.02]; P=0.02), SF-12 MCS (difference, -1.03 [95% CI, -1.89 to -0.18]; P=0.02), SF-6D R2 (difference, -0.01 [95% CI, -0.02 to -0.001]; P=0.03), numeric rating scale pain at present (difference, 0.26 [95% CI, 0.03 to 0.49]; P=0.03), usual level during previous week (difference, 0.26 [95% CI, 0.04 to 0.48]; P=0.02), and worst level during previous week (difference, 0.29 [95% CI, 0.02 to 0.56]; P=0.04). There was no difference between treatment arms on the basis of EQ-5D (difference, -0.01 [95% CI, -0.03 to 0.004]; P=0.12) or SF-12 PCS (difference, -0.41 [95% CI, -1.2 to 0.37]; P=0.31). In cohort 2, HRQoL also significantly improved from baseline to the end of follow-up for both groups based on all measures, but there were no differences between Bypass and Endo on any measure. CONCLUSIONS Among patients with chronic limb-threatening ischemia deemed eligible for either Bypass or Endo, revascularization resulted in significant and clinically meaningful improvements in HRQoL. In patients with an available single-segment great saphenous vein for bypass, but not among those without one, Endo was statistically superior on some HRQoL measures; however, these differences were below the threshold of clinically meaningful difference.
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Affiliation(s)
- Matthew T Menard
- Division of Vascular and Endovascular Surgery (M.T.M., M.B.S.), Harvard Medical School, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA (A.F., J.J.S.)
| | - Richard J Powell
- Division of Vascular and Endovascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH (R.J.P., M.A.C., P.P.G.)
| | - Kenneth Rosenfield
- Brigham and Women's Hospital, Section of Vascular Medicine and Intervention, Massachusetts General Hospital (K.R.), Harvard Medical School, Boston, MA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco (M.S.C.)
| | - Taye H Hamza
- HealthCore, Inc, Watertown, MA (T.H.H., M.J.C., M.v.O.)
| | - John A Kaufman
- Department of Interventional Radiology, Human Performance Laboratory, Oregon Health and Science University, Portland (J.A.K.)
| | | | - Mark A Creager
- Division of Vascular and Endovascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH (R.J.P., M.A.C., P.P.G.)
| | - Michael D Dake
- Department of Medical Imaging, University of Arizona Health System, University of Arizona, Tucson (M.D.D.)
| | - Michael R Jaff
- Professor of Medicine, Harvard Medical School (retired), Cambridge, MA (M.R.J.)
| | - Diane Reid
- National Heart, Lung & Blood Institute, Division of Cardiovascular Sciences, National Institutes of Health, Bethesda, MD (D.R., G.S.)
| | - George Sopko
- National Heart, Lung & Blood Institute, Division of Cardiovascular Sciences, National Institutes of Health, Bethesda, MD (D.R., G.S.)
| | - Christopher J White
- Department of Cardiovascular Diseases, The Ochsner Clinical School, University of Queensland, Australia (C.J.W.)
| | - Michael B Strong
- Division of Vascular and Endovascular Surgery (M.T.M., M.B.S.), Harvard Medical School, Boston, MA
| | - Max van Over
- HealthCore, Inc, Watertown, MA (T.H.H., M.J.C., M.v.O.)
| | - Emiliano Chisci
- Division of Vascular Surgery, Ospedale San Giovanni di Dio, Florence, Italy (E.C.)
| | - Philip P Goodney
- Division of Vascular and Endovascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH (R.J.P., M.A.C., P.P.G.)
| | - Bruce Gray
- Division of Vascular Medicine, Prisma Health, Greenville, SC (B.G.)
| | - Ahmed Kayssi
- Division of Vascular Surgery, University of Toronto, Canada (A.K.)
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA (A.F., J.J.S.)
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da Silva KTB, Manhanelli MAB, Morad JFM, Linardi F, Costa JA. Superficial venous arterialization with the great saphenous vein in situ: a single-center experience. J Vasc Bras 2024; 23:e20230077. [PMID: 38562125 PMCID: PMC10984586 DOI: 10.1590/1677-5449.202300772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/20/2023] [Indexed: 04/04/2024] Open
Abstract
Background Arterialization of the dorsal venous arch of the foot is a technique indicated in cases of critical lower limb ischemia that do not have a distal bed that is adequate to enable conventional treatment such as revascularization, angioplasty, or clinical treatment. Objectives The purpose of this study is to present the result of arterialization of the venous arch of the foot in 16 patients who underwent treatment with this technique. Methods This is a cross-sectional retrospective descriptive analytical study based on a review of the medical records of 16 patients who underwent arterialization of the dorsal venous arch of the foot for limb salvage from January 2016 to January 2021. Results Four (25%) of the 16 patients who underwent arterialization of the venous arch of the foot underwent a major amputation during the same hospital stay and one patient (6.25%) had a major amputation within 6 months. The other 11 patients (68.75%) had their limbs preserved, with 10 undergoing minor amputations (toes and forefoot) and one patient having no additional procedures. Conclusions We conclude that the technique of arterialization of the dorsal venous arch of the foot should be considered in selected cases. It is a valid alternative for limb salvage when conventional treatment is impossible.
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Affiliation(s)
| | | | - José Francisco Moron Morad
- Pontifícia Universidade Católica de São Paulo - PUC-SP, Faculdade de Ciências Médicas e da Saúde, São Paulo, SP, Brasil.
| | - Fábio Linardi
- Pontifícia Universidade Católica de São Paulo - PUC-SP, Faculdade de Ciências Médicas e da Saúde, São Paulo, SP, Brasil.
| | - José Augusto Costa
- Pontifícia Universidade Católica de São Paulo - PUC-SP, Faculdade de Ciências Médicas e da Saúde, São Paulo, SP, Brasil.
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4
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Powell RJ, Mullin CM, Clair DG, Shishehbor MH, Dua A. Comparison of Transcatheter Arterialization of Deep Veins to Standard of Care in Patients with No-Option Chronic Limb Threatening Ischemia. Ann Vasc Surg 2024; 99:50-57. [PMID: 37858666 DOI: 10.1016/j.avsg.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/28/2023] [Accepted: 08/04/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Patients with no-option chronic limb-threatening ischemia (no-option CLTI) have limited therapeutic options. The PROMISE II study evaluated, transcatheter arterialization of deep veins (TADV) as a treatment option for no-option CLTI. In the current study patients from PROMISE II were compared to patients from a registry of untreated no-option CLTI patients (CLariTI: Natural Progression of High-Risk Chronic Limb-Threatening Ischemia). METHODS We used propensity matching to compare patients from the PROMISE II prospective study of the TADV intervention with simultaneously enrolled CLTI patients that were note candidates for PROMISE II but were enrolled in to CLariTI natural history registry. Untreated no-option CLTI (CLariTI) patients could either be no-option or patients who did not meet PROMISE II entry criteria. Risk difference between groups was calculated using common risk difference and P values were provided by propensity-score stratified Mantel-Haenszel test. The primary endpoint was amputation-free survival (AFS). RESULTS Diabetes was present in over 75% of patients. All patients had tissue loss and 35-46% had extensive tissue loss (Rutherford 6). The unadjusted AFS at 6 months, was 66.1% by Kaplan-Meier estimate for PROMISE II patients (n = 105) compared to 39.1% in the no-option cohort of CLariTI (n = 121) and 44.0% in the full cohort (no-option and patients not meeting entry criteria combine, n = 180). The treatment group who underwent TADV for no-option CLTI had an absolute difference of 29% improved (P < 0.0001) propensity-adjusted risk difference in AFS and a relative event rate reduction of 45% compared to the no-option control patients. CONCLUSIONS Transcatheter arterialization of deep veins (TADV) resulted in improved 6 month AFS in no-option CLTI patients and appears to be a promising therapy in patients with no-option CLTI.
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Affiliation(s)
- Richard J Powell
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | | | - Daniel G Clair
- Department of Vascular Surgery, Vanderbilt School of Medicine, Nashville, TN
| | - Mehdi H Shishehbor
- University Hospitals Harrington Heart and Vascular Institute, Cleveland, OH
| | - Anahita Dua
- Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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5
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van Overhagen H, Nakamura M, Geraghty PJ, Rao S, Arroyo M, Soga Y, Iida O, Armstrong E, Nakama T, Fujihara M, Ansari MM, Mathews SJ, Gouëffic Y, Jaff MR, Weinberg I, Pinto DS, Ohura N, Couch K, Mustapha JA. Primary results of the SAVAL randomized trial of a paclitaxel-eluting nitinol stent versus percutaneous transluminal angioplasty in infrapopliteal arteries. Vasc Med 2023; 28:571-580. [PMID: 37844137 PMCID: PMC10693734 DOI: 10.1177/1358863x231199489] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
BACKGROUND Effective and durable options for infrapopliteal artery revascularization for patients with chronic limb-threatening ischemia (CLTI) are limited. METHODS The SAVAL trial is a prospective, multicenter, randomized trial of patients with CLTI and infrapopliteal artery lesions with total lesion length ⩽ 140 mm, stenosis ⩾ 70%, and Rutherford category 4-5 assigned 2:1 to treatment with the SAVAL self-expandable paclitaxel drug-eluting stent (DES) or percutaneous transluminal angioplasty (PTA) with an uncoated balloon. The primary effectiveness endpoint was primary vessel patency (i.e., core lab-adjudicated duplex ultrasound-based flow at 12 months in the absence of clinically driven target lesion revascularization or surgical bypass of the target lesion). The primary safety endpoint was the 12-month major adverse event (MAE)-free rate; MAEs were defined as a composite of above-ankle index limb amputation, major reintervention, and 30-day mortality. The endpoints were prespecified for superiority (effectiveness) and noninferiority (safety) at a one-sided significance level of 2.5%. RESULTS A total of 201 patients were enrolled and randomly assigned to treatment (N = 130 DES, N = 71 PTA). Target lesion length was 68.1 ± 35.2 mm for the DES group and 68.7 ± 49.2 mm for the PTA group, and 31.0% and 27.6% of patients, respectively, had occlusions. The 12-month primary patency rates were 68.0% for the DES group and 76.0% for the PTA group (Psuperiority = 0.8552). The MAE-free rates were 91.6% and 95.3%, respectively (Pnoninferiority = 0.0433). CONCLUSION The SAVAL trial did not show benefit related to effectiveness and safety with the nitinol DES compared with PTA in infrapopliteal artery lesions up to 140 mm in length. Continued innovation to provide optimal treatments for CLTI is needed. (ClinicalTrials.gov Identifier: NCT03551496).
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Affiliation(s)
| | | | | | - Sid Rao
- Vascular Solutions of North Carolina, Cary, NC, USA
| | - Max Arroyo
- St Bernard’s Heart and Vascular, Jonesboro, AR, USA
| | | | - Osamu Iida
- Kansai Rosai Hospital, Hyogo, Amagasaki, Japan
| | - Ehrin Armstrong
- Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
- Adventist Heart and Vascular Institute, Adventist Health, St Helena, CA, USA (current)
| | | | | | | | - Santhosh J Mathews
- Bradenton Cardiology Center, Manatee Memorial Hospital, Bradenton, FL, USA
| | - Yann Gouëffic
- Groupe Hospitalier Paris Saint Joseph, Paris, Île-de-France, France
| | | | - Ido Weinberg
- VasCore – The Vascular Imaging Core Laboratory, Boston, MA, USA
| | - Duane S Pinto
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Norihiko Ohura
- Kyorin University School of Medicine, Mitaka, Tokyo, Japan
| | - Kara Couch
- George Washington University Hospital, Washington, DC, USA
| | - Jihad A Mustapha
- Michigan State University College of Human Medicine, East Lansing, MI, USA
- Advanced Cardiac and Vascular Centers for Amputation Prevention, Grand Rapids, MI, USA
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Jansen S, de Borst GJ, Hinchliffe R, Teraa M. Peripheral Artery Disease: Underappreciated Impact and Residual Cardiovascular Risk Despite Revascularization. Clin Ther 2023; 45:1019-1022. [PMID: 37940497 DOI: 10.1016/j.clinthera.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 09/18/2023] [Accepted: 09/26/2023] [Indexed: 11/10/2023]
Abstract
This Commentary highlights the under-recognized prevalence and heavy burden of peripheral artery disease (PAD) and its important role as a harbinger of complications of atherosclerotic cardiovascular disease. Although increasing in prevalence globally, PAD is being further accelerated with diabetes, and patients with advanced PAD are at high risk for chronic limb-threatening ischemia. The need for (repeated) revascularization and amputation places a heavy social burden on patients and family, and a heavy financial burden on the health care system, exceeding the cost of coronary artery and cerebrovascular diseases. Clinical trial research in PAD will be enhanced by widely agreed-upon definitions of major adverse cardiovascular events and major adverse limb events. Antithrombotic and lipid-lowering therapies are recommended but underutilized, while the optimal peri-interventional antithrombotic regimen is still under debate. Additional antiinflammatory treatment is currently an unaddressed strategy in the management of patients with PAD, and there is a strong case for the evaluation of widely available antiinflammatory agents such as colchicine.
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Affiliation(s)
- Shirley Jansen
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital; Harry Perkins Institute of Medical Research; Curtin University Medical School; and the; Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia.
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Robert Hinchliffe
- Bristol Centre for Surgical Research, Bristol NIHR Biomedical Research Centre, University of Bristol, Bristol, United Kingdom
| | - Martin Teraa
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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7
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Perlander A, Broeren M, Österberg K, Svensson M, Nordanstig J. Disease Specific Health Related Quality of Life in Patients With Chronic Limb Threatening Ischaemia Undergoing Revascularisation of Femoropopliteal Lesions. Eur J Vasc Endovasc Surg 2023; 66:245-251. [PMID: 37201719 DOI: 10.1016/j.ejvs.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 04/16/2023] [Accepted: 05/10/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE Patients with chronic limb threatening ischaemia (CLTI) suffer from pain and non-healing ulcers, which impact negatively on both their physical and mental health. While maintaining and improving quality of life is a principal aim with all treatments, little is known about the health related quality of life (HRQoL) of CLTI patients and how revascularisation procedures impact on HRQoL endpoints. The aim of this study was to investigate disease specific HRQoL before and after revascularisation in patients with CLTI undergoing femoropopliteal revascularisation. METHODS HRQoL was prospectively analysed in 190 CLTI patients with main atherosclerotic target lesions in the femoropopliteal segment, who were planned for endovascular or open revascularisation. The choice of revascularisation method was made by the vascular team, represented by both open and endovascular expertise. The Vascular Quality of Life (VascuQoL) questionnaire was used to assess disease specific HRQoL before revascularisation and one month, one year, and two years after the procedure. Main endpoints were mean VascuQoL score changes, effect sizes of observed changes and the proportion reaching a minimally important difference (half a standard deviation change from baseline) during two years after revascularisation. RESULTS Patient reported VascuQoL scores were low at baseline (mean 2.68, 95% CI 1.18 - 4.17). After revascularisation, the mean VascuQoL score improved statistically significantly over time, with the largest improvement observed after one year (difference from baseline 2.02, 95% CI 1.75 - 2.29; p < .001). No differences in HRQoL change over time were observed between patients treated with endovascular approaches compared with bypass surgery. Approximately half the patients reached the minimally important threshold at one year (53%), which was largely maintained also at two years (41%). CONCLUSION While CLTI profoundly affected HRQoL, a large and clinically meaningful HRQoL increase was observed after revascularisation. This confirms the value of CLTI revascularisation on HRQoL and underlines the importance of including patient reported outcomes when evaluating revascularisation procedures in CLTI patients.
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Affiliation(s)
- Angelica Perlander
- Department of Vascular Surgery, Sahlgrenska University Hospital and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Monica Broeren
- Department of Vascular Surgery, Sahlgrenska University Hospital and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Klas Österberg
- Department of Vascular Surgery, Sahlgrenska University Hospital and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Mikael Svensson
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Joakim Nordanstig
- Department of Vascular Surgery, Sahlgrenska University Hospital and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
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8
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Siracuse JJ, Rowe VL, Menard MT, Rosenfield K, Conte MS, Powell R, Clavijo LC, Giles KA, Hamza TH, Van Over M, Cziraky M, White CJ, Strong MB, Farber A. Relationship between WIfI stage and quality of life at revascularization in the BEST-CLI trial. J Vasc Surg 2023; 77:1099-1106.e4. [PMID: 36435274 DOI: 10.1016/j.jvs.2022.11.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The WIfI (Wound, Ischemia, foot Infection) stage measures the extent of wounds, ischemia, and foot infection in patients with chronic limb threatening ischemia (CLTI) and has been associated with the risk of major amputation. Patients with CLTI have impaired health-related quality of life (HRQoL), which can be multifactorial. We hypothesized that the severity of the limb threat (WIfI stage) would be associated with poor HRQoL among patients with CLTI presenting for revascularization. METHODS The dataset of the BEST-CLI (best endovascular versus best surgical therapy in patients with CLTI) trial, a prospective, randomized trial comparing open and endovascular revascularization strategies, was queried for HRQoL assessments at patient enrollment. The HRQoL assessments included (1) Vascular Quality of Life; (2) 12-item short form survey (SF-12), containing the utility index score (short-form six-dimension R2 utility index, incorporating physical, emotional, and mental well-being) and mental and physical components; and (3) the EQ-5D. Multivariable regression analysis was used to identify the independent associations with the baseline HRQoL assessments. RESULTS A total of 1568 patients with complete WIfI data were analyzed, of whom 71.5% were men. The WIfI distribution was 35.5% with stage 4, 29.6% with stage 3, 28.6% with stage 2, and 6.3% with stage 1. Patients presenting with WIfI stage 4, compared with stage 1 to 3, were more often men (74.9% vs 69.6%) and current smokers (25.4% vs. 17.6%), had had end-stage renal disease (13.3% vs 8.5%) and diabetes (83.6% vs 60.2%), were not independently ambulatory (56.8% vs 38.5%), and had had higher median morbidity scores (4 vs 3; P < .05 for all). On multivariable analysis, WIfI stage 4, compared with stage 1 to 3, was associated with lower SF-12 mental component scale scores (estimate, -2.43; 95% confidence interval, -3.73 to -1.13; P < .001) and short-form six-dimension R2 utility index scores (estimate, -0.02; 95% confidence interval, -0.03 to 0.001; P = .04). The WIfI stage was not independently associated with the baseline Vascular Quality of Life, SF-12 physical component scale, or EQ-5D assessments. CONCLUSIONS WIfI stage was independently associated with poorer quality of life because of mental, rather than physical, health for patients with CLTI. Clinicians should be aware of the burden of mental stress borne by those with the greatest limb impairment.
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Affiliation(s)
- Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
| | - Vincent L Rowe
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California, Los Angeles, CA
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kenneth Rosenfield
- Section of Vascular Medicine and Intervention, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Richard Powell
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Leonardo C Clavijo
- Division of Cardiology, French Hospital Medical Center, San Luis Obispo, CA
| | - Kristina A Giles
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, ME
| | | | | | | | - Christopher J White
- Department of Cardiology, Ochsner Clinical School, University of Queensland, Brisbane, QLD, Australia; Department of Cardiology, The John Ochsner Heart and Vascular Institute, New Orleans, LA
| | - Michael B Strong
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
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Sarkar A, Nagarsheth KH. Deep Venous Arterialization for Limb Salvage. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00340-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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10
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Lee RE, Patel A, Soon SXY, Chan SL, Yap CJQ, Chandramohan S, Tay LHT, Chong TT, Tang TY. One year clinical outcomes of Rutherford 6 chronic limb threatening ischemia patients undergoing lower limb endovascular revascularisation from Singapore. CVIR Endovasc 2022; 5:32. [PMID: 35792985 PMCID: PMC9259774 DOI: 10.1186/s42155-022-00306-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/07/2022] [Indexed: 12/03/2022] Open
Abstract
Background Percutaneous transluminal angioplasty (PTA) is widely used as a first-line revascularisation option in patients with chronic limb threatening ischemia (CLTI). This study aimed to evaluate the short-term endovascular revascularisation treatment outcomes of a cohort of Rutherford 6 (R6) CLTI patients, from a multi-ethnic Asian population in Singapore. Patients with R6 CLTI who underwent endovascular revascularisation from June 2019 to February 2020 at Singapore General Hospital, a tertiary vascular centre in Singapore, were included and followed up for one year. Primary outcome measures included number and type of reinterventions required, 3-, 6- and 12-month mortality, 6- and 12-month amputation free survival (AFS), wound healing success and changes in Rutherford staging after 3, 6 and 12 months. Results Two hundred fifty-five procedures were performed on 86 patients, of whom 78 (90.7%) were diabetics, 54 (62.8%) had coronary artery disease (CAD) and 54 (62.8%) had chronic kidney disease (CKD). 42 patients (48.8%) required reintervention within 6 months. Multivariate analysis revealed that the presence of CAD was a significant independent predictor for reintervention. Mortality was 15.1%, 20.9% and 33.7% at 3, 6 and 12 months respectively. AFS was 64.0% and 49.4% at 6 and 12 months. Inability to ambulate, congestive heart failure (CHF), dysrhythmia and CKD were significant independent predictors of lower 12-month AFS. Conclusions PTA for R6 CLTI patients was associated with relatively high mortality and reintervention rates at one year. CAD was an independent predictor of reintervention. More research is required to help risk stratify which CLTI patients would benefit from an endovascular-first approach versus conservative treatment or an immediate major lower extremity amputation policy.
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11
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Powell RJ, Choudhry N, Conte M, Cziraky M, Giles K, Hamza T, Menard M, Rosenfeld K, Rowe V, Siracuse J, Strong M, Van Over M, Villarreal M, White C, Farber A. Factors Associated with Lower Preoperative Quality of Life in Patients with Chronic Limb Threatening Ischemia in the BEST-CLI Trial. J Vasc Surg 2022; 76:1642-1650. [PMID: 35714891 DOI: 10.1016/j.jvs.2022.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/01/2022] [Accepted: 06/06/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES There is limited contemporary data regarding health-related quality of life (HRQOL) measures in patients with chronic limb-threatening ischemia (CLI). METHODS The Best Endovascular versus Best Surgical Therapy in Patients with CLI (BEST-CLI) trial is an ongoing, NIH-sponsored, multicenter, randomized controlled trial comparing revascularization strategies in patients with CLI. BEST-CLI baseline HRQOL measures were evaluated for patient-specific variables that were associated with poor HRQOL and then compared with published outcomes. The HRQOL measures VascQOL (Vascular Quality of Life Questionnaire), EQ-5D (EuroHRQOL 5D), and SF-12 Index, physical component (PCS) and mental component (MCS) scores were aggregated from preoperative questionnaires completed by trial subjects at baseline visits. Multivariable linear regression models were fit to determine which baseline characteristics were associated with poor HRQOL. RESULTS 1830 subjects were randomized into BEST-CLI. The majority (94.9%, 95.8%, and 95.8%) completed the VascQOL, EQ5D, and SF-12 instruments at baseline. In VascQOL, female sex, smoking history, opioid use, and non-independent ambulation predicted lower HRQOL scores. Overall, VascuQOL scores were similar to those of participants in the Bypass versus Angioplasty in Severe Ischemia of the Leg (BASIL) [(3.07(1.2)) vs 2.9(1.1)), P=.07]. In EQ5D, non-independent ambulation predicted lower HRQOL scores. In SF-12, female sex, opioid use, non-independent ambulation and history of smoking predicted lower HRQOL scores. The mean (standard deviation) SF-12 PCS for all patients in the study was 33.0(8.5) and for MCS was 46.4(12.0), significantly lower than the national SF-12 scores for US population over 60 years of age which is PCS of 46.5(11.4) and MCS of 52.9 (8.7). CONCLUSIONS Patients with CLI entering the BEST-CLI trial have very low HRQOL scores comparable to patients suffering from other chronic conditions characterized by physical limitation and chronic pain. A history of smoking, impaired ambulation, opioid use, and female sex predicted lower HRQOL in CLI patients, using multiple HRQOL measurement tools.
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Affiliation(s)
- Richard J Powell
- Professor and Chief Section of Vascular Surgery Dartmouth Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon and Hanover, NH.
| | - Niteesh Choudhry
- Professor, Department of Medicine, Harvard Medical School, Boston, MA
| | - Michael Conte
- Professor and Chief Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA
| | | | - Kristina Giles
- Section Chief of Vascular Surgery, Maine Medical Center, Portland, ME
| | | | - Matthew Menard
- Associate Professor, Brigham and Women's Hospital, Boston, MA
| | - Kenneth Rosenfeld
- Assistant Professor and Section Head Vascular Medicine and Interventional Cardiology, Massachusetts General Hospital, Boston, MA
| | - Vincent Rowe
- Professor of Clinical Surgery, Division of Vascular Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Jeffrey Siracuse
- Associate Professor, Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA
| | - Michael Strong
- Senior Trial Manager, Brigham and Woman's Hospital, Boston, MA
| | | | | | - Chris White
- Professor, System Chairman for Cardiovascular Disease, John Ochsner Heart and Vascular Institute, New Orleans, LA
| | - Alik Farber
- Professor and Chief of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA
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Miranda JA, Pallister Z, Sharath S, Ferrer L, Chung J, Lepow B, Mills JL, Montero-Baker M. Early Experience with Venous Arterialization for Limb Salvage in No-Option Patients with Chronic Limb-Threatening Ischemia. J Vasc Surg 2022; 76:987-996.e3. [PMID: 35705119 DOI: 10.1016/j.jvs.2022.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 04/14/2022] [Accepted: 05/09/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Chronic limb-threatening ischemia (CLTI) is associated with adverse limb outcomes and increased mortality. In a small subset of the CLTI population, there are no feasible conventional means of revascularization. In such cases, venous arterialization (VA) provides an alternative for limb salvage. The objective of this study was to review the outcomes of venous arterialization (VA) at our institution. METHODS This is a single institution review of 41 patients followed prospectively who underwent either superficial or deep VA. Data collected included: patient demographics, co-morbidities, VA technique (endovascular vs. hybrid) and WIfI (wound ischemia foot infection) limb staging. Data were collected at 1 month, 6 months and 1-year intervals and included the following outcomes: patency, wound healing, major adverse limb event (MALE), major amputation and death. Descriptive statistics were used for analysis. RESULTS The study group includes 41 patients who underwent successful open hybrid superficial or deep endovascular VA; 21 (51.2%) underwent a purely endovascular procedure and 20 (48.8%) had hybrid VA. The WIfI clinical stages were as follows: 33 (80.5%) stage 4, 6 (14.6%) stage 3, and 1 (2.4%) stage 2. Twenty-four (58.5%) patients completed follow-up at 6 months and 16 (39%) at 1 year. VA primary patency at 12 months was 28.6% (95% CI 0.15-0.43), primary assisted patency at 12 months was 44.3% (95% CI 0.27-0.60) and secondary patency at 12 months was 67% (95% CI 0.49-0.80). Complete wound healing rates were 2.7% (1) at 1 month; 62.5% (15) at 6 months; and 18.8% (3) at 1 year. Overall wound healing at 1 year was 46.3% (19). MALE rate at 1 year was 36.5% (15) comprised of 19.5% (8) re-interventions and 17% (7) major amputations. There were 0 (0%) deaths at 1 month and 4 (19%) deaths at 6 months; 2 (9.5%) deaths were attributed to COVID-19. There were no further deaths within 1 year. The limb salvage survival probability at 1 year was 81%. CONCLUSIONS These findings suggest that for a select subset of CLTI patients presenting with high WIfI clinical limb stage CLTI and no viable options for conventional open or endovascular arterial revascularization, superficial and deep venous arterialization are feasible options to achieve limb salvage.
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Affiliation(s)
- Jorge A Miranda
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Zachary Pallister
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Sherene Sharath
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Lucas Ferrer
- Division of Vascular Surgery, Dell Seton Medical Center, University of Texas at Austin, Austin, TX
| | - Jayer Chung
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Brian Lepow
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Miguel Montero-Baker
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
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13
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Geskin G, Mulock MD, Tomko NL, Dasta A, Gopalakrishnan S. Effects of Lower Limb Revascularization on the Microcirculation of the Foot: A Retrospective Cohort Study. Diagnostics (Basel) 2022; 12:diagnostics12061320. [PMID: 35741130 PMCID: PMC9221918 DOI: 10.3390/diagnostics12061320] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/18/2022] [Accepted: 05/22/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Current assessment standards in chronic limb-threatening ischemia (CLTI) focus on macrovascular function while neglecting the microcirculation. Multispectral near-infrared spectroscopy (NIRS) provides hemodynamic characteristics of the microcirculation (i.e., capillaries) and may be a powerful tool for monitoring CLTI and preventing extremity loss. The aims of this study were to (1) investigate the effects of lower limb revascularization on the microcirculation and (2) determine if macrovascular and microvascular assessments correlate. Methods: An observational, retrospective cohort study of 38 endovascular interventions in 30 CLTI subjects was analyzed pre- and post-intervention for arterial Doppler acceleration times (AcT; macrovascular) and NIRS metrics (microvascular). Pre-intervention ankle-brachial index (ABI) was also analyzed. Results: AcT significantly decreased (p = 0.009) while oxyhemoglobin (HbO) significantly increased (p < 0.04) after endovascular intervention, indicating treatment efficacy. However, macrovascular measurements (ABI, AcT) and NIRS metrics of oxygenation and perfusion did not correlate (p > 0.06, r2 < 0.15, n = 23) indicating that macro- and microvascular assessment are not congruent. Conclusion: These findings suggest that macrovascular and microvascular assessments can determine interventional efficacy in their corresponding vasculature. Their lack of correlation, however, suggests the need for simultaneous assessment as independent use may cause diagnostic information to be missed.
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Affiliation(s)
- Gennady Geskin
- Greater Pittsburgh Vascular Associates, Pittsburgh, PA 15025, USA
| | - Michael D Mulock
- Greater Pittsburgh Vascular Associates, Pittsburgh, PA 15025, USA
| | - Nicole L Tomko
- Greater Pittsburgh Vascular Associates, Pittsburgh, PA 15025, USA
| | - Anna Dasta
- Greater Pittsburgh Vascular Associates, Pittsburgh, PA 15025, USA
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14
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Eligibility of Patients with Chronic Limb Threatening Ischemia for Deep Venous Arterialization. Ann Vasc Surg 2022; 86:260-267. [PMID: 35589034 DOI: 10.1016/j.avsg.2022.04.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Percutaneous deep venous arterialization (pDVA) has emerged as a new modality for limb salvage in patients with chronic limb threatening ischemia (CLTI) and no standard option for revascularization. The proportion of patients facing major amputation that are eligible for this technology remains unknown. This study aims to provide a real-life estimate of patient eligibility for pDVA to reduce major amputations. METHODS Electronic medical records of 100 consecutive patients with peripheral arterial disease (PAD) who underwent major amputation of 106 limbs were reviewed. Angiograms performed ≤6 months before amputation were assessed by two vascular surgeons. Disease severity was categorized using the Global Limb Anatomic Staging System and patients were classified as ideal, possible, or not candidates for pDVA. Ideal candidates had ≥1 patent tibial artery, no target in the foot, and no proximal disease. Possible candidates had ≥1 patent tibial artery with PAD, no target in the foot, and proximal disease amenable to endovascular therapy. Patients were not eligible if there was no patent tibial artery, extensive PAD, or an arterial target in the foot for bypass. RESULTS Of 106 limbs reviewed, 35 (33%) did not undergo angiography ≤6 months before amputation because of infection (n=14), advanced tissue loss (n=10), failed revascularizations (n=8), advanced limb ischemia (n=2), and refusing revascularization (n=1). Thus, 69 lower extremity angiograms (2 incomplete excluded) in 68 patients were analyzed. 15 patients with 16 limbs (23.2%) were identified as candidates for pDVA (ideal=7, possible=9). There were no differences in demographics between the two groups, but candidates for pDVA were less likely to have hyperlipidemia and congestive heart failure than those who were not candidates. pDVA candidates underwent significantly fewer interventions prior to major amputation compared to patients who were not candidates (1.50 ± 0.73 vs 2.61 ± 2.57, p=0.007). Angiographically, patients who were pDVA candidates had significantly higher Inframalleolar GLASS grades (1.81 ± 0.40 vs 0.86 ± 0.41, p<0.0001) but lower Femoropopliteal Glass grades (0.73 ± 1.10 vs 2.43 ± 1.71, p<0.0001) than patients who were not candidates. There was no significant difference in GLASS stage between these two groups (p=0.368). After mean follow-up of 48 months, there was no difference in mortality between both groups (40% vs 32.1%, p=0.567). CONCLUSION Among patients considered for revascularization, 23.2% had favorable angiography and 14.7% could have benefited for pDVA as a new therapeutic modality for limb salvage. 33% of major amputations were performed for clinically-deemed unsalvageable CLTI.
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15
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Ilyas S, Powell RJ. Management of the no-option foot: Deep vein arterialization. Semin Vasc Surg 2022; 35:210-218. [DOI: 10.1053/j.semvascsurg.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 11/11/2022]
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Goodney P, Shah S, Hu YD, Suckow B, Kinlay S, Armstrong DG, Geraghty P, Patterson M, Menard M, Patel MR, Conte MS. A systematic review of patient-reported outcome measures patients with chronic limb-threatening ischemia. J Vasc Surg 2022; 75:1762-1775. [PMID: 35085747 PMCID: PMC9524582 DOI: 10.1016/j.jvs.2021.11.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/08/2021] [Indexed: 01/23/2023]
Abstract
Chronic limb-threatening ischemia (CLTI) causes significant morbidity with profound negative effects on health-related quality of life. As the prevalence of peripheral artery disease and diabetes continue to rise in our aging population, the public health impact of CLTI has escalated. Patient-reported outcome measures (PROMs) have become common and important measures for clinical evaluation in both clinical care and research. PROMs are important for the measurement of clinical effectiveness and cost effectiveness and for shared decision-making on treatment options. However, the PROMs used to describe the experience of patients with CLTI are heterogeneous, incomplete, and lack specific applicability to the underlying disease processes and diverse populations. For example, certain PROMs exist for patients with extremity wounds, and other PROMs exist for patients with pain, and still others exist for patients with vascular disease. Despite this multiplicity of tools, no single PROM encompasses all of the components necessary to describe the experiences of patients with CLTI. This significant unmet need is evident from both published reports and contemporary large-scale clinical trials in the field. In this systematic review, we review the current use of PROMs for patients with CLTI in clinical practice and in research trials and highlight the gaps that need to be addressed to develop a unifying PROM instrument for CLTI.
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Affiliation(s)
- Philip Goodney
- Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
| | - Samir Shah
- Vascular Surgery, University of Florida, Gainesville, Fla
| | - Yiyuan David Hu
- Geisel School of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Bjoern Suckow
- Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Scott Kinlay
- Cardiovascular Medicine, Boston Medical Center, Boston, Mass
| | - David G Armstrong
- Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, Calif
| | - Patrick Geraghty
- Vascular Surgery, Washington University in St. Louis, St. Louis, Mo
| | | | - Matthew Menard
- Vascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | | | - Michael S Conte
- Vascular Surgery, University of California, San Francisco, San Francisco, Calif
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17
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Ruemenapf G, Morbach S, Sigl M. Therapeutic Alternatives in Diabetic Foot Patients without an Option for Revascularization: A Narrative Review. J Clin Med 2022; 11:jcm11082155. [PMID: 35456247 PMCID: PMC9032488 DOI: 10.3390/jcm11082155] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/05/2022] [Accepted: 04/08/2022] [Indexed: 12/30/2022] Open
Abstract
Background: The healing of foot wounds in patients with diabetes mellitus is frequently complicated by critical limb threatening ischemia (neuro-ischemic diabetic foot syndrome, DFS). In this situation, imminent arterial revascularization is imperative in order to avoid amputation. However, in many patients this is no longer possible (“too late”, “too sick”, “no technical option”). Besides conservative treatment or major amputation, many alternative methods supposed to decrease pain, promote wound healing, and avoid amputations are employed. We performed a narrative review in order to stress their efficiency and evidence. Methods: The literature research for the 2014 revision of the German evidenced-based S3-PAD-guidelines was extended to 2020. Results: If revascularization is impossible, there is not enough evidence for gene- and stem-cell therapy, hyperbaric oxygen, sympathectomy, spinal cord stimulation, prostanoids etc. to be able to recommend them. Risk factor management is recommended for all CLTI patients. With appropriate wound care and strict offloading, conservative treatment may be an effective alternative. Timely amputation can accelerate mobilization and improve the quality of life. Conclusions: Alternative treatments said to decrease the amputation rate by improving arterial perfusion and wound healing in case revascularization is impossible and lack both efficiency and evidence. Conservative therapy can yield acceptable results, but early amputation may be a beneficial alternative. Patients unfit for revascularization or major amputation should receive palliative wound care and pain therapy. New treatment strategies for no-option CLTI are urgently needed.
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Affiliation(s)
- Gerhard Ruemenapf
- Vascular Center Oberrhein Speyer-Mannheim, Department of Vascular Surgery, Diakonissen-Stiftungs-Krankenhaus, 67346 Speyer, Germany
- Correspondence: ; Tel.: +49-6232-22-1955; Fax: +49-6232-22-1994
| | - Stephan Morbach
- Department of Diabetology und Angiology, Marienkrankenhaus, 59494 Soest, Germany;
| | - Martin Sigl
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site, 68199 Mannheim, Germany;
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18
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Kodama A, Takahara M, Iida O, Soga Y, Mii S, Kitano I, Deguchi J, Fukui D, Komori K, Azuma N. Health Related Quality of Life Over Time After Revascularisation in Patients With Chronic Limb Threatening Ischaemia. Eur J Vasc Endovasc Surg 2021; 62:777-785. [PMID: 34531117 DOI: 10.1016/j.ejvs.2021.06.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 06/07/2021] [Accepted: 06/30/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Chronic limb threatening ischaemia (CLTI) decreases life expectancy and impairs health related quality of life (HR-QOL). Revascularisation is needed to relieve ischaemia and salvage limbs. Although a major goal of CLTI treatment is maintaining QOL, little information is available about changes of HR-QOL over time after revascularisation. HR-QOL with survival after revascularisation for CLTI was assessed. METHODS The clinical database of the Surgical reconstruction versus Peripheral INtervention in pAtients with critical limb isCHemia (SPINACH), a prospective multicentre observational study, was analysed. Outcome measures were disease specific QOL per the Vascular Quality of Life (VascuQOL) questionnaire and the Short Form (SF) 36 evaluated generic QOL, which were assessed at baseline and three, 12, 24, and 36 months. The outcome measure was change of QOL from baseline. The minimally important difference (half a standard deviation from baseline) was used as the cut off point for improved, worsened, and unchanged QOL. RESULTS Overall QOL was improved in 61% of patients for the VascuQOL and approximately 40% for the SF-36 component summaries at three months. However, these proportion gradually decreased to 21% - 31% at three years. In contrast, the proportion of deceased patients gradually increased over the three year follow up. Multivariable analysis revealed that pre-operative non-ambulatory status was inversely associated with improved QOL for the three month VascuQOL and SF-36 mental component summary, and surgical reconstruction was positively associated with these measurements. Advanced age and renal failure were inversely associated with improved QOL for the SF-36 mental component summary and VascuQOL at one to three years. CONCLUSION Revascularisation improved QOL. However, patients with non-ambulatory status exhibited a negative association with improved QOL at three months, and advanced age and renal failure limited benefits one to three years after revascularisation. Accumulating QOL data will be essential for post-revascularisation QOL estimation. Pre-operative assessment, including estimated QOL, is important in shared decision making for patient oriented outcomes in the treatment of CLTI patients.
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Affiliation(s)
- Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University School of Medicine Nagoya, Japan.
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, and Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Osamu Iida
- Cardiovascular Centre, Kansai Rosai Hospital, Amagasaki, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Shinsuke Mii
- Department of Vascular Surgery, Saiseikai Yahata Hopspital, Yahata, Kitakyushu, Japan
| | - Ikuro Kitano
- Wound Treatment Centre, Shin-Suma General Hospital, Kobe, Japan
| | - Juno Deguchi
- Department of Vascular Surgery, Saitama Medical Centre, Kawagoe, Japan
| | | | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University School of Medicine Nagoya, Japan
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Japan
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Constantinides C, Landis SH, Jarrett J, Quinn J, Ireland PJ. Quality of life, physical functioning, and psychosocial function among patients with achondroplasia : a targeted literature review. Disabil Rehabil 2021; 44:6166-6178. [PMID: 34403286 DOI: 10.1080/09638288.2021.1963853] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE Achondroplasia (ACH) is the most common form of skeletal dysplasia, resulting in disproportionate short stature and medical complications. We review the literature on physical functioning, psychosocial function, and quality of life (QoL) in ACH individuals compared to average stature individuals or other short stature conditions. Studies that assess the association between these outcomes and height, limb length/lengthening surgery in ACH patients are also summarized. MATERIALS AND METHODS PubMed/MEDLINE and Embase were searched through April 2021. Study inclusion criteria were: (1) quantitative design; (2) study population consisting solely/mainly of ACH patients; (3) reports of physical functioning, psychosocial functioning, and/or QoL. Included studies were summarized separately for pediatric and adult populations. RESULTS Of 1664 records identified, 23 primary studies (sample size 8-437 participants) were included. Multiple tools were used across studies, including the generic PedsQL and SF-36 and height-specific QoLISSY. CONCLUSIONS The literature demonstrates that ACH patients experience limitations in physical functioning and poorer QoL outcomes compared to average stature people across the life span. This appeared to be at least in part due to disproportionate short stature. Future research to better characterize QoL in ACH patients will assist clinicians to better evaluate the effectiveness of management programs including novel interventions.IMPLICATIONS FOR REHABILITATIONPatients with achondroplasia experience limitations in physical functioning and poorer quality of life throughout their life course when compared to average statured individuals.Psychosocial issues are also heightened in adults with achondroplasia compared to average statured peers but are observed less frequently in children and adolescents with achondroplasia.The overall impact that limb lengthening has on physical functioning and QoL remains unclear, although there is some evidence that greater height or upper limb length may lead to an improvement in these parameters.Rehabilitation professionals should regularly assess physical functioning, psychosocial wellbeing, and quality of life in individuals with achondroplasia using condition-specific tools.
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Affiliation(s)
| | | | | | | | - Penelope J Ireland
- Children's Health Queensland Hospital & Health Service, Brisbane, Australia
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20
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Tarantul VZ, Gavrilenko AV. Gene therapy for critical limb ischemia: Per aspera ad astra. Curr Gene Ther 2021; 22:214-227. [PMID: 34254916 DOI: 10.2174/1566523221666210712185742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 05/24/2021] [Accepted: 06/02/2021] [Indexed: 11/22/2022]
Abstract
Peripheral artery diseases remain a serious public health problem. Although there are many traditional methods for their treatment using conservative therapeutic techniques and surgery, gene therapy is an alternative and potentially more effective treatment option especially for "no option" patients. This review treats the results of many years of research and application of gene therapy as an example of treatment of patients with critical limb ischemia. Data on successful and unsuccessful attempts to use this technology for treating this disease are presented. Trends in changing the paradigm of approaches to therapeutic angiogenesis are noted: from viral vectors to non-viral vectors, from gene transfer to the whole organism to targeted transfer to cells and tissues, from single gene use to combination of genes; from DNA therapy to RNA therapy, from in vivo therapy to ex vivo therapy.
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Affiliation(s)
- Vyacheslav Z Tarantul
- National Research Center "Kurchatov Institute", Institute of Molecular Genetics, Moscow 123182, Russian Federation
| | - Alexander V Gavrilenko
- A.V.¬ Petrovsky Russian Scientific Center for Surgery, Moscow 119991, Russian Federation
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21
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De Stefano F, Rios LHP, Fiani B, Fareed J, Tafur A. National Trends for Peripheral Artery Disease and End Stage Renal Disease From the National Inpatient Sample Database. Clin Appl Thromb Hemost 2021; 27:10760296211025625. [PMID: 34151608 PMCID: PMC8221664 DOI: 10.1177/10760296211025625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Peripheral artery disease (PAD), and subsequent chronic limb-threatening ischemia (CLTI), are frequently encountered among patients with end-stage renal disease (ESRD). Their coexistence is less favorable in comparison to patients with ESRD alone. We sought to investigate trends, comorbidities, determinants for cost, and prognostic outcomes in patients with concomitant ESRD and PAD. A retrospective analysis was performed using data from the National Inpatient Sample database from the years 2005-2014. ICD-9 codes were used to identify patients with diagnoses of PAD, CLTI, and ESRD. Pearson’s Chi-square, T-test, ANOVA, and multivariate binary logistic regression were used in this analysis. 7,214,843 patients with ESRD were identified. Of these, 123,499 patients were diagnosed with PAD and 102,447 with CLTI. Compared to ESRD alone, mortality rates increased with PAD and CLTI (5.7% vs. 13.9% vs. 15.9%, P < 0.001). Length of stay in days (7.3 vs. 10.2 vs. 11.1, P < 0.001) and in-hospital costs (59,872 vs. 85,866 vs. 89,016, P < 0.001) were higher with PAD and CLTI, respectively. CLTI demonstrated the highest independent predictor of mortality [OR = 6.93 (6.43-7.46), P < 0.001]. A decreasing trend in the rate of PAD (2005: 1.9% vs. 2014: 1.4%, P < 0.001) and CLTI (2005: 1.6% vs. 2014: 1.1%, P < 0.001) was noted. The presence of coexisting PAD, and furthermore CLTI, in patients with ESRD significantly raised in-hospital mortality, cost, and length of stay. A negative trend in rates of PAD and CLTI were observed. Proactive identification of this high-risk population may lead to accurate diagnosis and tailored therapeutic strategies.
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Affiliation(s)
- Frank De Stefano
- Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
| | - Luis H Paz Rios
- Northshore University Health Systems Cardiovascular Institute, Evanston, IL, USA
| | - Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Jawed Fareed
- Department of Pathology, Loyola University, Chicago, IL, USA
| | - Alfonso Tafur
- Northshore University Health Systems Cardiovascular Institute, Evanston, IL, USA
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22
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BENEDETTO D, FERRARESI R, SANGIORGI G. Attempting mini-invasiveness in the critically ill patient. The endovascular first act: the below-the-knee challenges. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.23736/s1824-4777.21.01503-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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23
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Klein AJ, Hawkins BM. Addressing disparities in chronic limb-threatening ischemia care: What are we waiting for? Vasc Med 2021; 26:123-125. [PMID: 33606966 DOI: 10.1177/1358863x21992432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Beau M Hawkins
- Department of Internal Medicine, Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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24
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Rümenapf G, Morbach S, Rother U, Uhl C, Görtz H, Böckler D, Behrendt CA, Hochlenert D, Engels G, Hohneck A, Sigl M. [Diabetic foot syndrome-Part 2 : Revascularization, treatment alternatives, care structures, recurrency prophylaxis]. Chirurg 2021; 92:173-186. [PMID: 33237367 PMCID: PMC7875854 DOI: 10.1007/s00104-020-01313-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Diabetic foot syndrome (DFS) is the most frequent reason for major amputations in Germany. The majority of foot lesions are triggered by repetitive pressure in diabetic polyneuropathy. Peripheral arterial occlusive disease (PAOD) impairs wound healing and is the main risk factor for amputations. The treatment of wounds and infections as well as timely revascularization are decisive. The use of endovascular and vascular surgical methods depends on the distribution pattern and length of the occlusion processes. Both procedures are complementary. Bypass surgery is of great importance for neuroischemic DFS. Multidisciplinary centers that provide revascularization in DFS can achieve an improvement of arterial blood flow in 90% of the cases and reduce the amputation rate by up to 80%. Due to the high recurrence rate of diabetic foot lesions, measures for secondary prophylaxis are of exceptional importance (podological and orthopedic technical care, foot surgery).
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Affiliation(s)
- G Rümenapf
- Oberrheinisches Gefäßzentrum Speyer, Diakonissen-Stiftungs-Krankenhaus Speyer, Paul-Egell-Straße 33, 67346, Speyer, Deutschland.
| | - S Morbach
- Abteilung Diabetologie und Angiologie, Fachbereich , Innere Medizin, Marienkrankenhaus gGmbH Soest, Soest, Deutschland
| | - U Rother
- Gefäßchirurgische Abteilung, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - C Uhl
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - H Görtz
- Klinik für Gefäßchirurgie, Bonifatius Hospital Lingen, Lingen, Deutschland
| | - D Böckler
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C A Behrendt
- Klinik und Poliklinik für Gefäßmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - D Hochlenert
- Centrum für Diabetologie, Endoskopie und Wundheilung Köln, Köln, Deutschland
| | - G Engels
- Chirurgische Praxis am Bayenthalgürtel, Köln, Deutschland
| | - A Hohneck
- Abteilung für Angiologie, 1. Medizinische Klinik, Universitätsklinik Mannheim, Mannheim, Deutschland
| | - M Sigl
- Abteilung für Angiologie, 1. Medizinische Klinik, Universitätsklinik Mannheim, Mannheim, Deutschland
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25
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Nieuwstraten JA, van Doorn LP, Gebhardt WA, Hamming JF. Stakeholder Values and Preferences in Lower Limb Amputation for No-Option Chronic Limb Threatening Ischemia. Patient Prefer Adherence 2021; 15:1051-1059. [PMID: 34045851 PMCID: PMC8144360 DOI: 10.2147/ppa.s309366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/15/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE This study focusses on identifying values and preferences of patients, caregivers and healthcare professionals who have dealt with lower limb amputation for no-option chronic limb threatening ischemia. No-option chronic limb threatening ischemia is defined as limb ischemia for which no treatment options exist and where lower limb amputation is necessary in the short term. The values and preferences identified in this study can help improve decision-making processes. PATIENTS AND METHODS This was a qualitative study, using semi-structured interviews to gather data from patients, caregivers and healthcare professionals. Participants were selected from the patient and employee population of an academic medical center in The Netherlands. Nine patients and seven caregivers who dealt with lower limb amputation for no-option chronic limb threatening ischemia six to twelve months prior to the interview and were not cognitively impaired were selected. Nine healthcare professionals dealing with patients with no-option chronic limb threatening ischemia and lower limb amputation were selected. RESULTS Lower limb amputation was explicitly discussed late in the disease process, sometimes during an emergency setting. Patients stated goals were never discussed, healthcare professionals stated they were. The most important goal for patients was to live independently after lower limb amputation. Patients and caregivers feel healthcare professionals should be upfront about the possible necessity of lower limb amputation. Reasons to undergo lower limb amputation were absence of treatment options, pain and wanting to enjoy life again. Participants indicated accelerating lower limb amputation was not a viable option. CONCLUSION All stakeholders reported overlapping values and preferences regarding main reasons for lower limb amputation, the primary goals after lower limb amputation, and the absence of a desire to accelerate lower limb amputation. The main difference in values and preferences is the preferred timing of discussing lower limb amputation.
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Affiliation(s)
- Jelle A Nieuwstraten
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
- Correspondence: Jelle A Nieuwstraten Department of Vascular Surgery, Leiden University Medical Center, Postzone K6-R, Postbus 9600, Leiden, RC, 2300, the NetherlandsTel +31 618849873 Email
| | - Louk P van Doorn
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Winifred A Gebhardt
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands
| | - Jaap F Hamming
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands
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26
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Tochikubo A, Koya A, Uchida D, Tada Y, Kikuchi S, Azuma N. Collateral artery bypass in the infrapopliteal segment. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 7:30-34. [PMID: 33665528 PMCID: PMC7902279 DOI: 10.1016/j.jvscit.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/09/2020] [Indexed: 11/26/2022]
Abstract
A 74-year-old man with diabetes and end-stage renal failure on regular dialysis required revascularization for gangrene of multiple toes and a heel ulcer on the right foot with chronic limb-threatening ischemia. However, the anterior tibial artery, posterior tibial artery, and peroneal artery, which are the usual targets below the knee, showed obstruction or calcification and were considered inappropriate bypass targets. Instead, a collateral artery developed along the area of the posterior tibial artery, and bypass surgery was performed with this artery. This is a case report showing successful collateral artery bypass grafting in the distal infrapopliteal segment.
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Affiliation(s)
- Ai Tochikubo
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Atsuhiro Koya
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Daiki Uchida
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Yuki Tada
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Shinsuke Kikuchi
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Japan
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27
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Sharma S, Pandey NN, Sinha M, Kumar S, Jagia P, Gulati GS, Gond K, Mohanty S, Bhargava B. Randomized, Double-Blind, Placebo-Controlled Trial to Evaluate Safety and Therapeutic Efficacy of Angiogenesis Induced by Intraarterial Autologous Bone Marrow-Derived Stem Cells in Patients with Severe Peripheral Arterial Disease. J Vasc Interv Radiol 2020; 32:157-163. [PMID: 33248918 DOI: 10.1016/j.jvir.2020.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To evaluate safety and efficacy of angiogenesis induced by intraarterial autologous bone marrow-derived stem cell (BMSC) injection in patients with severe peripheral arterial disease (PAD). MATERIALS AND METHODS Eighty-one patients with severe PAD (77 men), including 56 with critical limb ischemia (CLI) and 25 with severe claudication, were randomized to receive sham injection (group A) or intraarterial BMSC injection at the site of occlusion (group B). Primary endpoints included improvement in ankle-brachial index (ABI) of > 0.1 and transcutaneous pressure of oxygen (TcPO2) of > 15% at mid- and lower foot at 6 mo. Secondary endpoints included relief from rest pain, > 30% reduction in ulcer size, and reduction in major amputation in patients with CLI and > 50% improvement in pain-free walking distance in patients with severe claudication. RESULTS Technical success was achieved in all patients, without complications. At 6 mo, group B showed more improvements in ABI of > 0.1 (35 of 41 [85.37%] vs 13 of 40 [32.50%]; P < .0001) and TcPO2 of > 15% at the midfoot (35 of 41 [85.37%] vs 17 of 40 [42.50%]; P = .0001] and lower foot (37 of 41 [90.24%] vs 19 of 40 [47.50%]; P < .0001). No patients with CLI underwent major amputation in group B, compared with 4 in group A (P = .0390). No significant difference was observed in relief from rest pain or > 30% reduction in ulcer size among patients with CLI or in > 50% improvement in pain-free walking distance among patients with severe claudication. CONCLUSIONS Intraarterial delivery of autologous BMSCs is safe and effective in the management of severe PAD.
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Affiliation(s)
- Sanjiv Sharma
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
| | - Niraj Nirmal Pandey
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Mumun Sinha
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Sanjeev Kumar
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Priya Jagia
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Gurpreet Singh Gulati
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Kalpnath Gond
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Sujata Mohanty
- Stem Cell Facility, DBT-Centre of Excellence for Stem Cell Research, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Balram Bhargava
- Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
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A Comparison of Quality of Life in Elderly Patients with Intermittent Claudication and Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2020; 69:285-291. [PMID: 32502674 DOI: 10.1016/j.avsg.2020.05.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI) are both associated with a decreased health status and possibly quality of life (QOL). A better understanding of the differences in QOL between patients with IC and CLTI could be of additional value in shared decision-making. The aim of this study was to compare the QOL at baseline between patients with IC and patients with CLTI. METHODS The study population was based on 2 study cohorts, 1 cohort consisted of patients with IC (ELECT registry) and the other cohort of patients with CLTI (KOP-study). Patients with an age of ≥70 years were included. QOL at baseline was measured by the WHOQOL-BREF questionnaire. Nonresponders were excluded from data analyses. Student's t-tests and analysis of covariance (ANCOVA) analyses were used to compare QOL between the 2 groups. Outcomes of the ANCOVA analyses were expressed as estimated marginal means. RESULTS In total, 308 patients were included, 115 patients with IC and 193 patients with CLTI. Patients with CLTI were older (median age 80 years vs. 75 years, P < 0.001) and had more comorbidities. Patients with IC had a statistically significant higher QOL regarding physical health (mean 13.7 [standard deviation (SD) 2.3] vs. 10.8 [SD 2.8], P < 0.001), psychological health (mean 15.3 [SD 2.1] vs. 14.1 [SD 2.4], P < 0.001), environment (mean 16.3 [SD 2.4] vs. 15.5 [SD 2.0], P < 0.002), and the overall domain (mean 3.5 [SD 0.7] vs. 3.1 [SD 0.9], P < 0.001). After correcting for the confounding effect of age and sex, patients with IC still had a statistically significant higher QOL in the physical, psychological, environment, and overall domain. CONCLUSIONS Patients with IC had a significantly higher QOL in the physical, psychological, environment, and overall domains of the WHOQOL-BREF questionnaire compared with patients with CLTI. This underlines the importance of strategies that reduce disease progression as disease progression is associated with a decrease in QOL.
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29
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Kim TI, Schneider PA. New Innovations and Devices in the Management of Chronic Limb-Threatening Ischemia. J Endovasc Ther 2020; 27:524-539. [PMID: 32419596 DOI: 10.1177/1526602820921555] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
As the number of patients afflicted by chronic limb-threatening ischemia (CLTI) continues to grow, new solutions are necessary to provide effective, durable treatment options that will lead to improved outcomes. The diagnosis of CLTI remains mostly clinical, and endovascular revascularization remains mostly balloon-based. Multiple innovative techniques and technologies are in development or in early usage that may provide new solutions. This review categorizes areas of advancement, highlights recent developments in the management of CLTI and looks forward to novel devices that are currently under investigation.
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Affiliation(s)
- Tanner I Kim
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California at San Francisco School of Medicine, San Francisco, CA, USA
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Sasajima T, Sasajima Y, Akazawa K, Saito Y. Arterial Reconstruction for Patients with Chronic Limb Ischemia Improves Ambulatory Function and Health-related Quality of Life. Ann Vasc Surg 2020; 66:518-528. [PMID: 32035265 DOI: 10.1016/j.avsg.2020.01.103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/02/2020] [Accepted: 01/26/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Arterial reconstruction (AR) for limb ischemia may improve ambulatory function (AF) and health-related quality of life (HR-QoL). However, the efficacy of AR in terms of HR-QoL varies in studies, probably because of cohort differences in disease severity, hemodynamic outcomes, and observation duration. We assessed HR-QoL for patients with various severities of ischemia in a 3-year observational study. METHODS We conducted a single-center 3-year observational study using Short Form 36 in patients with chronic limb ischemia. Between 2001 and 2009, 515 consecutive patients had AR, and 330 who underwent elective AR consented to the study. Of the 330 patients (claudicants 49%, critical limb ischemia [CLI] 51%), 307 underwent bypass and 23 endovascular therapy. Postal questionnaires were sent after AR, and 8 domains, the physical and mental component summary (PCS and MCS) scores, and the patient-reported AF were compared, and negative predictors were identified. RESULTS Overall, the MCS was minimally affected, but AF and the PCS were impaired. After AR, these measures were significantly improved, and maximum recovery was attained at 6 months. In subgroup analysis, significant predictors of a negative impact on postoperative PCS included age ≥80, CLI, physical aftereffects of stroke (PAS), and previous major amputation (PMA). Of these, PMA was associated with the lowest PCS score, followed by PAS; for these patients, AR contributed minimally to HR-QoL recovery. PCS scores of claudicants attained a maximum value at 6 months; however, PCS scores of CLI patients were significantly lower than intermittent claudication patients (P < 0.0001), and patients with major tissue loss required 2 years to attain maximum PCS recovery. CONCLUSIONS This 3-year observational study verified the efficacy of AR in improving AF and HR-QoL. Age ≥80, CLI, PAS, and PMA were definitive predictors, and for patients with the latter 2, AR contributed minimally to improving HR-QoL.
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Affiliation(s)
- Tadahiro Sasajima
- Center of Vascular Diseases, Edogawa Hospital, Tokyo, Japan; Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Japan.
| | - Yumi Sasajima
- Health Care Center, Hokkaido University of Education, Asahikawa College, Asahikawa, Japan
| | - Kohhei Akazawa
- Department of Medical Information, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Yukihiro Saito
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Japan
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31
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Huizing E, Schreve MA, de Vries JPP, Ferraresi R, Kum S, Ünlü Ç. Below-the-Ankle Angioplasty in Patients with Critical Limb Ischemia: A Systematic Review and Meta-Analysis. J Vasc Interv Radiol 2019; 30:1361-1368.e2. [DOI: 10.1016/j.jvir.2019.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/29/2019] [Accepted: 05/01/2019] [Indexed: 12/16/2022] Open
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32
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Schreve MA, Lichtenberg M, Ünlü Ç, Branzan D, Schmidt A, van den Heuvel DAF, Blessing E, Brodmann M, Cabane V, Lin WTQ, Kum S. PROMISE international; a clinical post marketing trial investigating the percutaneous deep vein arterialization (LimFlow) in the treatment of no-option chronic limb ischemia patient. CVIR Endovasc 2019; 2:26. [PMID: 32026120 PMCID: PMC6966404 DOI: 10.1186/s42155-019-0067-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Critical limb ischemia (CLI) is the clinical end stage of peripheral artery disease and is associated with high amputation, mortality rates and poor quality of life. For CLI patients with no revascularization options, venous arterialization could be an alternative technique for limb salvage. A systematic review and meta-analysis published in 2017 concluded that venous arterialization may be considered a viable alternative. A recent development, is the Percutaneous Deep Vein Arterialization (pDVA), that is CE-marked and currently under investigation of the FDA. This procedure, called LimFlow, is a novel, minimally invasive, endovascular approach to perform a venous arterialization procedure. The limited evidence for its use necessitates a scientific judgement of the pDVA. Therefore, we initiated a prospective clinical post market trial to investigate the outcome of the pDVA in no-option critical limb ischemia. METHODS/DESIGN The objective of this prospective study is to collect "real-life" clinical data among a population of patients treated with the pDVA in order to evaluate the clinical effectiveness and safety of the LimFlow System in patients with no-option critical limb ischemia. This study is a single-arm, open-label, prospective, post-market follow-up study to be conducted on up to fifty (50) eligible patients with a twelve-month follow-up period. The Primary endpoint is measured by amputation free survival. Secondary endpoints are complete wound healing, primary and secondary patency, limb salvage, renal function and technical and procedural success. Patients will be assessed at regular intervals during one year after the initial percutaneous deep vein arterialization procedure through clinical evaluation and self-completed questionnaires. DISCUSSION The last decade several studies have been published with promising results and the number of treated patients has considerably grown. Venous arterialization could be a valuable treatment option in patients with often no other options than amputation of the affected limb. The first results in men are promising although more research and long term follow up is needed to establish the efficacy of this new treatment modality. With this prospective study, we evaluate the clinical effectiveness and safety in patients with no-option CLI treated with the pDVA (LimFlow System). TRIAL REGISTRATION NCT03321552 .
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Affiliation(s)
- Michiel A Schreve
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands, Wilhelminalaan 12, 1815 JD, Alkmaar, the Netherlands.
| | - Michael Lichtenberg
- Vascular Centre Arnsberg, Arnsberg Clinic, Arnsberg, Germany.,Standort Karolinen-Hospital, Stolte Ley 5, 59759, Arnsberg, Germany
| | - Çagdas Ünlü
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands, Wilhelminalaan 12, 1815 JD, Alkmaar, the Netherlands
| | - Daniela Branzan
- Department of Vascular Surgery, University Hospital Leipzig, Leipzig, Germany.,Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Germany
| | - Andrej Schmidt
- Department of Angiology, University Hospital Leipzig, Leipzig, Germany
| | - Daniel A F van den Heuvel
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands.,Ziekenhuis Nieuwegein, Koekoekslaan 1, 3435, CM, Nieuwegein, the Netherlands
| | - Erwin Blessing
- Department of Interventional Angiology, SRH Klinikum Karlsbad-Langensteinbach, Karlsbad, Germany.,SRH Klinikum Karlsbad-Langensteinbach GmbH, Guttmannstraße 1, 76307, Karlsbad, Germany
| | - Marianne Brodmann
- Angiologie, Medizinische Universtität Graz, Graz, Austria.,Medizinische Universtität Graz, Auenbruggerplatz 27, 8036, Graz, Austria
| | - Vincent Cabane
- LimFlow SA,Paris, France, 95 Boulevard Pereire, 75017, Paris, France
| | - William Tan Qing Lin
- Department of Surgery, Vascular Service, Changi General Hospital, Changi, Singapore.,Changi General Hospital Pte Ltd, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Steven Kum
- Department of Surgery, Vascular Service, Changi General Hospital, Changi, Singapore.,Changi General Hospital Pte Ltd, 2 Simei Street 3, Singapore, 529889, Singapore
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Klinkova AS, Kamenskaya OV, Ashurkov AV, Lomivorotov VN. [The effect of spinal card stimulation on quality of life in patients with critical lower limb ischemia]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2019; 83:57-63. [PMID: 31339497 DOI: 10.17116/neiro20198303157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Today, there are insufficient data on the dynamics of quality of life (QoL) in patients with critical lower limb ischemia after spinal cord stimulation. OBJECTIVE To study the dynamics of QoL in patients with critical lower limb ischemia one year after spinal cord stimulation. MATERIAL AND METHODS QoL analysis was performed in 43 patients with critical lower limb ischemia using the SF-36 questionnaire before and one year after spinal cord stimulation. RESULTS At baseline, we detected reduced QoL parameters corresponding to the physical function (≤30 points). The parameters of mental health corresponded to the moderate level (the score ranged between 42 and 59 points). The total score of physical well-being was reduced: 22.8 (20.2-29.3); the mean score of mental well-being was 41 (32.8-49.2) (p<0.001). One year after spinal cord stimulation, the level of all QoL parameters was increased but the total score of physical well-being remained low 33.2 (24-44.1). The mean score of mental well-being corresponded to the moderate level of QoL 56.5 (49-60.4) (p<0.001). Multivariate regression analysis showed that the physical parameters of QoL after spinal cord stimulation are adversely affected by such factors as age, the history of stroke, the ankle-brachial index (ABI), the presence of type 2 diabetes mellitus (DM), and ischemic heart disease (IHD) in combination with stenosis of brachiocephalic arteries (BCA). The mental health is affected by age and the presence of stenosis of brachiocephalic arteries. CONCLUSION When selecting patients with critical lower limb ischemia for spinal cord stimulation, such factors as the baseline clinical status (comorbidities), age, history of stroke, and the severity of peripheral artery ischemia need to be taken into account to improve treatment effectiveness and QoL.
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Affiliation(s)
- A S Klinkova
- Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - O V Kamenskaya
- Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - A V Ashurkov
- Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - V N Lomivorotov
- Meshalkin National Medical Research Center, Novosibirsk, Russia
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Miceli M, Baldi D, Cavaliere C, Soricelli A, Salvatore M, Napoli C. Peripheral artery disease: the new frontiers of imaging techniques to evaluate the evolution of regenerative medicine. Expert Rev Cardiovasc Ther 2019; 17:511-532. [PMID: 31220944 DOI: 10.1080/14779072.2019.1635012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Stem cells (ESC, iPSC, MSC) are known to have intrinsic regenerative properties. In the last decades numerous findings have favored the development of innovative therapeutic protocols based on the use of stem cells (Regenerative Medicine/Cell Therapy) for the treatment of numerous diseases including PAD, with promising results in preclinical studies. So far, several clinical studies have shown a general improvement of the patient's clinical outcome, however they possess many critical issues caused by the non-randomized design of the limited number of patients examined, the type cells to be used, their dosage, the short duration of treatment and also their delivery strategy. Areas covered: In this context, the use of the most advanced molecular imaging techniques will allow the visualization of very important physio-pathological processes otherwise invisible with conventional techniques, such as angiogenesis, also providing important structural and functional data. Expert opinion: The new frontier of cell therapy applied to PAD, potentially able to stop or even the process that causes the disease, with particular emphasis on the clinical aspects that different types of cells involve and on the use of more innovative molecular imaging techniques now available.
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Affiliation(s)
| | | | | | - Andrea Soricelli
- a IRCCS SDN , Naples , Italy.,b Department of Exercise and Wellness Sciences , University of Naples Parthenope , Naples , Italy
| | | | - Claudio Napoli
- a IRCCS SDN , Naples , Italy.,c University Department of Advanced Medical and Surgical Sciences, Clinical Department of Internal Medicine and Specialty Medicine , Università degli Studi della Campania 'Luigi Vanvitelli' , Napes , Italy
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Duff S, Mafilios MS, Bhounsule P, Hasegawa JT. The burden of critical limb ischemia: a review of recent literature. Vasc Health Risk Manag 2019; 15:187-208. [PMID: 31308682 PMCID: PMC6617560 DOI: 10.2147/vhrm.s209241] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/07/2019] [Indexed: 01/15/2023] Open
Abstract
Peripheral arterial disease is a chronic vascular disease characterized by impaired circulation to the lower extremities. Its most severe stage, known as critical limb ischemia (CLI), puts patients at an increased risk of cardiovascular events, amputation, and death. The objective of this literature review is to describe the burden of disease across a comprehensive set of domains—epidemiologic, clinical, humanistic, and economic—focusing on key studies published in the last decade. CLI prevalence in the United States is estimated to be approximately 2 million and is likely to rise in the coming years given trends in important risk factors such as age, diabetes, and smoking. Hospitalization for CLI patients is common and up to 60% are readmitted within 6 months. Amputation rates are unacceptably high with a disproportionate risk for certain demographic and socioeconomic groups. In addition to limb loss, CLI patients also have reduced life expectancy with mortality typically exceeding 50% by 5 years. Given the poor clinical prognosis, it is unsurprising that the quality of life burden associated with CLI is significant. Studies assessing quality of life in CLI patients have used a variety of generic and disease-specific measures and all document a substantial impact of the disease on the patient’s physical, social, and emotional health status compared to population norms. Finally, the poor clinical outcomes and increased medical resource use lead to a considerable economic burden for national health care systems. However, published cost studies are not comprehensive and, therefore, likely underestimate the true economic impact of CLI. Our summary documents a sobering assessment of CLI burden—a poor clinical prognosis translating into diminished quality of life and high costs for millions of patients. Continued prevention efforts and improved treatment strategies are the key to ameliorating the substantial morbidity and mortality associated with this disease.
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Affiliation(s)
- Steve Duff
- Veritas Health Economics Consulting , Carlsbad, CA, USA
| | | | - Prajakta Bhounsule
- Health Economics and Reimbursement, Abbott Vascular, Santa Clara, CA, USA
| | - James T Hasegawa
- Health Economics and Reimbursement, Abbott Vascular, Santa Clara, CA, USA
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Applications of Ultrasound to Stimulate Therapeutic Revascularization. Int J Mol Sci 2019; 20:ijms20123081. [PMID: 31238531 PMCID: PMC6627741 DOI: 10.3390/ijms20123081] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/20/2019] [Accepted: 06/21/2019] [Indexed: 12/13/2022] Open
Abstract
Many pathological conditions are characterized or caused by the presence of an insufficient or aberrant local vasculature. Thus, therapeutic approaches aimed at modulating the caliber and/or density of the vasculature by controlling angiogenesis and arteriogenesis have been under development for many years. As our understanding of the underlying cellular and molecular mechanisms of these vascular growth processes continues to grow, so too do the available targets for therapeutic intervention. Nonetheless, the tools needed to implement such therapies have often had inherent weaknesses (i.e., invasiveness, expense, poor targeting, and control) that preclude successful outcomes. Approximately 20 years ago, the potential for using ultrasound as a new tool for therapeutically manipulating angiogenesis and arteriogenesis began to emerge. Indeed, the ability of ultrasound, especially when used in combination with contrast agent microbubbles, to mechanically manipulate the microvasculature has opened several doors for exploration. In turn, multiple studies on the influence of ultrasound-mediated bioeffects on vascular growth and the use of ultrasound for the targeted stimulation of blood vessel growth via drug and gene delivery have been performed and published over the years. In this review article, we first discuss the basic principles of therapeutic ultrasound for stimulating angiogenesis and arteriogenesis. We then follow this with a comprehensive cataloging of studies that have used ultrasound for stimulating revascularization to date. Finally, we offer a brief perspective on the future of such approaches, in the context of both further research development and possible clinical translation.
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Haghighat L, Ionescu CN, Regan CJ, Altin SE, Attaran RR, Mena-Hurtado CI. Review of the Current Basic Science Strategies to Treat Critical Limb Ischemia. Vasc Endovascular Surg 2019; 53:316-324. [DOI: 10.1177/1538574419831489] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Critical limb ischemia (CLI) is a highly morbid disease with many patients considered poor surgical candidates. The lack of treatment options for CLI has driven interest in developing molecular therapies within recent years. Through these translational medicine studies in CLI, much has been learned about the pathophysiology of the disease. Here, we present an overview of the macrovascular and microvascular changes that lead to the development of CLI, including impairment of angiogenesis, vasculogenesis, and arteriogenesis. We summarize the randomized clinical controlled trials that have used molecular therapies in CLI, and discuss the novel imaging modalities being developed to assess the efficacy of these therapies.
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Affiliation(s)
- Leila Haghighat
- Department of Internal Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Costin N. Ionescu
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher J. Regan
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Sophia Elissa Altin
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Robert R. Attaran
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Carlos I. Mena-Hurtado
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
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Dua A, Rothenberg KA, Lee JJ, Gologorsky R, Desai SS. Six-Month Freedom From Amputation Rates and Quality of Life Following Tibial and Pedal Endovascular Revascularization for Critical Limb Ischemia. Vasc Endovascular Surg 2019; 53:212-215. [DOI: 10.1177/1538574418823378] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Patients with critical limb ischemia (CLI) and gangrene have a 10% to 38% rate of major amputation at 6 months. The purpose of this study is to report short- and mid-term major and minor amputation rates for patients who underwent tibial and pedal revascularization in addition to quality-of-life (QoL) scores. Methods: All patients who presented to a single institution with CLI (defined as rest pain or nonhealing wounds) and underwent antegrade or retrograde tibial access, atherectomy and angioplasty of the tibial circulation, and angioplasty of pedal circulation (antegrade or retrograde) from June 2016 to September 2017 were included. The Stark QoL questionnaire was used at each visit. Patients were scored at 1, 3, and 6 months postprocedure. Amputation rates were recorded. Results: Forty-two patients with CLI and gangrene underwent 57 peripheral interventions for limb salvage between June 2016 and September 2017. Thirty-two limbs had dry gangrene along the dorsalis pedis angiosome, 14 limbs had dry gangrene along the posterior tibial angiogram, and 11 limbs had a combined disease pattern. Twelve limbs underwent angioplasty of the superficial femoral artery (SFA), 18 limbs underwent angioplasty and stenting of the SFA, and 14 limbs underwent atherectomy, angioplasty, and stenting of the SFA. All patients had 1 or 2 tibial vessel runoff and high-grade stenosis of the pedal circulation. Immediate technical success defined as 3-vessel outflow to the foot occurred in 49 limbs (86%) with zero 30-day complications (30-day readmission, major amputation, or sepsis). Major amputation rate at 1, 3, and 6 months was 0%, 2%, and 4%, respectively. Patient satisfaction in terms of QoL increased over the 6-month follow-up period. Conclusion: Aggressive tibial and pedal revascularization may improve freedom from minor and major amputation at 6 months and may be associated with a short- and mid-term higher QoL.
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Affiliation(s)
- Anahita Dua
- Division of Vascular Surgery, Department of Surgery, Stanford Hospital and Clinics, Palo Alto, CA, USA
| | - Kara A. Rothenberg
- Division of Vascular Surgery, Department of Surgery, Stanford Hospital and Clinics, Palo Alto, CA, USA
- Department of Surgery, University of California San Francisco–East Bay, Oakland, CA, USA
| | - Jisun J. Lee
- Division of Vascular Surgery, Department of Surgery, Stanford Hospital and Clinics, Palo Alto, CA, USA
| | - Rebecca Gologorsky
- Department of Surgery, University of California San Francisco–East Bay, Oakland, CA, USA
| | - Sapan S. Desai
- Division of Vascular Surgery, Department of Surgery, Northwest Hospital, Arlington, IL, USA
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Laoire ÁN, Murtagh FEM. Systematic review of pharmacological therapies for the management of ischaemic pain in patients with non-reconstructable critical limb ischaemia. BMJ Support Palliat Care 2018; 8:400-410. [PMID: 28835456 PMCID: PMC6287571 DOI: 10.1136/bmjspcare-2017-001359] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 07/07/2017] [Accepted: 07/19/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Critical limb ischaemia (CLI) is a severe manifestation of peripheral arterial disease, characterised by chronic ischaemic rest pain, ulcers or gangrene. Management of ischaemic pain is challenging in patients with no options for revascularisation and optimal pharmacological therapies have not been established. OBJECTIVES To identify and evaluate the effectiveness of pharmacological therapies to treat ischaemic pain secondary to non-reconstructable CLI. METHODS This systematic review was reported in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline. Comprehensive searches of three electronic databases, a PubMed-related articles link search, grey literature search and hand-searches of the bibliographies of relevant papers and textbooks were performed. Studies recruiting adult patients with CLI of any aetiology were eligible for inclusion. Surgical and revascularisation procedures, and all invasive interventions were excluded. RESULTS Of 792 studies, six met full inclusion criteria. These studies researched the use of intravenous lidocaine, intravenous ketamine, oral gabapentin and the combination of transdermal buprenorphine and epidural morphine/ropivacaine infusion. All studies showed an improvement in severity of ischaemic pain in CLI but with varying side effect profiles and quality. The extracted studies showed substantial heterogeneity and therefore a meta-analysis was not performed. CONCLUSION The pharmacological management of pain secondary to non-reconstructable CLI is a challenging review topic. No recommendations of pharmacological agents can be made following this review but a number of novel approaches to manage pain in this cohort have shown positive results and require further investigation.
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Affiliation(s)
| | - Fliss E M Murtagh
- Department of Palliative Care, Policy and Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
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Elkady R, Tawfick W, Hynes N, Kavanagh EP, Jordan F, Sultan S. Intermittent pneumatic compression for critical limb ischaemia. Hippokratia 2018. [DOI: 10.1002/14651858.cd013072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Ramy Elkady
- Western Vascular Institute, University College Hospital; Department of Vascular and Endovascular Surgery; Newcastle Road Galway Ireland
| | - Wael Tawfick
- Western Vascular Institute, University College Hospital; Department of Vascular and Endovascular Surgery; Newcastle Road Galway Ireland
| | - Niamh Hynes
- The Galway Clinic; Department of Vascular and Endovascular Surgery; Doughiska Galway Ireland
| | - Edel P Kavanagh
- The Galway Clinic; Department of Vascular and Endovascular Surgery; Doughiska Galway Ireland
| | - Fionnuala Jordan
- National University of Ireland Galway; School of Nursing and Midwifery; Arus Moyola Newcastle Road Galway Ireland
| | - Sherif Sultan
- Galway University Hospital; Vascular Surgery; Newcastle Galway Ireland
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Autologous Stem Cell Therapy in Critical Limb Ischemia: A Meta-Analysis of Randomized Controlled Trials. Stem Cells Int 2018; 2018:7528464. [PMID: 29977308 PMCID: PMC5994285 DOI: 10.1155/2018/7528464] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 04/16/2018] [Indexed: 01/13/2023] Open
Abstract
Objective Critical limb ischemia (CLI) is the most dangerous stage of peripheral artery disease (PAD). Many basic researches and clinical treatment had been focused on stem cell transplantation for CLI. This systematic review was performed to review evidence for safety and efficacy of autologous stem cell therapy in CLI. Methods A systematic literature search was performed in the SinoMed, PubMed, Embase, ClinicalTrials.gov, and Cochrane Controlled Trials Register databases from building database to January 2018. Results Meta-analysis showed that cell therapy significantly increased the probability of ulcer healing (RR = 1.73, 95% CI = 1.45–2.06), angiogenesis (RR = 5.91, 95% CI = 2.49–14.02), and reduced the amputation rates (RR = 0.59, 95% CI = 0.46–0.76). Ankle-brachial index (ABI) (MD = 0.13, 95% CI = 0.11–0.15), TcO2 (MD = 12.22, 95% CI = 5.03–19.41), and pain-free walking distance (MD = 144.84, 95% CI = 53.03–236.66) were significantly better in the cell therapy group than in the control group (P < 0.01). Conclusions The results of this meta-analysis indicate that autologous stem cell therapy is safe and effective in CLI. However, higher quality and larger RCTs are required for further investigation to support clinical application of stem cell transplantation.
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Abstract
BACKGROUND Peripheral arterial occlusive disease (PAOD) is a common cause of morbidity and mortality due to cardiovascular disease in the general population. Although numerous treatments have been adopted for patients at different disease stages, no option other than amputation is available for patients presenting with critical limb ischaemia (CLI) unsuitable for rescue or reconstructive intervention. In this regard, prostanoids have been proposed as a therapeutic alternative, with the aim of increasing blood supply to the limb with occluded arteries through their vasodilatory, antithrombotic, and anti-inflammatory effects. This is an update of a review first published in 2010. OBJECTIVES To determine the effectiveness and safety of prostanoids in patients with CLI unsuitable for rescue or reconstructive intervention. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Specialised Register (January 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1). In addition, we searched trials registries (January 2017) and contacted pharmaceutical manufacturers, in our efforts to identify unpublished data and ongoing trials. SELECTION CRITERIA Randomised controlled trials describing the efficacy and safety of prostanoids compared with placebo or other pharmacological control treatments for patients presenting with CLI without chance of rescue or reconstructive intervention. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed trials for eligibility and methodological quality, and extracted data. We resolved disagreements by consensus or by consultation with a third review author. MAIN RESULTS For this update, 15 additional studies fulfilled selection criteria. We included in this review 33 randomised controlled trials with 4477 participants; 21 compared different prostanoids versus placebo, seven compared prostanoids versus other agents, and five conducted head-to-head comparisons using two different prostanoids.We found low-quality evidence that suggests no clear difference in the incidence of cardiovascular mortality between patients receiving prostanoids and those given placebo (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.41 to 1.58). We found high-quality evidence showing that prostanoids have no effect on the incidence of total amputations when compared with placebo (RR 0.97, 95% CI 0.86 to 1.09). Adverse events were more frequent with prostanoids than with placebo (RR 2.11, 95% CI 1.79 to 2.50; moderate-quality evidence). The most commonly reported adverse events were headache, nausea, vomiting, diarrhoea, flushing, and hypotension. We found moderate-quality evidence showing that prostanoids reduced rest-pain (RR 1.30, 95% CI 1.06 to 1.59) and promoted ulcer healing (RR 1.24, 95% CI 1.04 to 1.48) when compared with placebo, although these small beneficial effects were diluted when we performed a sensitivity analysis that excluded studies at high risk of bias. Additionally, we found evidence of low to very low quality suggesting the effects of prostanoids versus other active agents or versus other prostanoids because studies conducting these comparisons were few and we judged them to be at high risk of bias. None of the included studies assessed quality of life. AUTHORS' CONCLUSIONS We found high-quality evidence showing that prostanoids have no effect on the incidence of total amputations when compared against placebo. Moderate-quality evidence showed small beneficial effects of prostanoids for rest-pain relief and ulcer healing when compared with placebo. Additionally, moderate-quality evidence showed a greater incidence of adverse effects with the use of prostanoids, and low-quality evidence suggests that prostanoids have no effect on cardiovascular mortality when compared with placebo. None of the included studies reported quality of life measurements. The balance between benefits and harms associated with use of prostanoids in patients with critical limb ischaemia with no chance of reconstructive intervention is uncertain; therefore careful assessment of therapeutic alternatives should be considered. Main reasons for downgrading the quality of evidence were high risk of attrition bias and imprecision of effect estimates.
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Affiliation(s)
- Valeria Vietto
- Hospital Italiano de Buenos AiresFamily and Community Medicine ServiceBuenos AiresArgentina
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentreBuenos AiresArgentina
| | - Juan VA Franco
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentreBuenos AiresArgentina
| | - Victoria Saenz
- Unidad Asistencial Dr. César MilsteinInternal MedicineLa Rioja 951Ciudad Autónoma de Buenos AiresBuenos AiresArgentinaC1221ACI
| | - Denise Cytryn
- Hospital Italiano de Buenos AiresFamily and Community Medicine ServiceBuenos AiresArgentina
| | - Jose Chas
- Hospital Italiano de Buenos AiresCardiovascular Surgery DepartmentBuenos AiresArgentinaPerón 4190
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
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Wijnand JGJ, Teraa M, Gremmels H, van Rhijn-Brouwer FCC, de Borst GJ, Verhaar MC. Rationale and design of the SAIL trial for intramuscular injection of allogeneic mesenchymal stromal cells in no-option critical limb ischemia. J Vasc Surg 2017; 67:656-661. [PMID: 29242062 DOI: 10.1016/j.jvs.2017.09.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 09/30/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Critical limb ischemia (CLI) represents the most severe form of peripheral artery disease and has an immense impact on quality of life, morbidity, and mortality. A considerable proportion of CLI patients are ineligible for revascularization, leaving amputation as the only option. Mesenchymal stromal cells (MSCs), because of their vasculoregenerative and immunomodulatory characteristics, have emerged as a potential new treatment. METHODS The primary objective of this trial is to investigate whether intramuscular administration of allogeneic bone marrow (BM)-derived MSCs is safe and potentially effective. The SAIL (allogeneic mesenchymal Stromal cells for Angiogenesis and neovascularization in no-option Ischemic Limbs) trial is a double-blind, placebo-controlled randomized clinical trial to investigate the effect of allogeneic BM-MSCs in patients with CLI who are not eligible for conventional revascularization. A total of 66 patients will be included and randomized (1:1) to undergo 30 intramuscular injections with either BM-MSCs (5 × 106 MSCs per injection) or placebo in the ischemic lower extremity. Primary outcome, that is, therapy success, a composite outcome consisting of mortality, limb status, clinical status, and changes in pain score, will be assessed at 6 months. All study-related procedures will take place in the University Medical Center Utrecht in The Netherlands. CONCLUSIONS If our results indicate that intramuscular allogeneic BM-MSC therapy for CLI is safe and potentially effective, this will have important consequences for treatment of patients with CLI. A large multicenter clinical trial with longer follow-up focusing on hard end points should then be initiated to confirm these findings.
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Affiliation(s)
- Joep G J Wijnand
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin Teraa
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hendrik Gremmels
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands.
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Wang SK, Green LA, Motaganahalli RL, Wilson MG, Fajardo A, Murphy MP. Rationale and design of the MarrowStim PAD Kit for the Treatment of Critical Limb Ischemia in Subjects with Severe Peripheral Arterial Disease (MOBILE) trial investigating autologous bone marrow cell therapy for critical limb ischemia. J Vasc Surg 2017; 65:1850-1857.e2. [PMID: 28390770 DOI: 10.1016/j.jvs.2017.01.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/28/2017] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Critical limb ischemia (CLI) continues to place a significant encumbrance on patients and the health care system as it progresses to limb loss and long-term disability. Traditional methods of revascularization offer a significant benefit; however, for one-third of CLI patients, these surgical options are not technically possible or patency is severely limited by disease burden (deemed "poor-option" for revascularization). In a previous phase I trial, we demonstrated intramuscular injection of concentrated bone marrow aspirate (cBMA) via MarrowStim (Zimmer Biomet, Warsaw, Ind) harvest is safe and may decrease major amputation in patients with CLI unfit for surgical revascularization. Therefore, we describe and rationalize the MarrowStim PAD Kit for the Treatment of Critical Limb Ischemia in Subjects with Severe Peripheral Arterial Disease (MOBILE) trial, a study geared to provide the pivotal proof of efficacy of cBMA in CLI. METHODS MOBILE is a multicenter, randomized, double-blind, placebo-controlled trial designed to assess the efficacy of intramuscular injections of cBMA in promoting amputation-free survival in patients with poor-option CLI. Patients (aged >21 years) with rest pain or tissue loss resulting from advanced peripheral arterial disease, as characterized by ankle-brachial index (<0.6), toe-brachial index (<0.4), or transcutaneous pressure of oxygen (<50 mm Hg), were eligible for inclusion if surgical revascularization was not possible secondary to advanced disease. RESULTS Treatment and 1-year follow-up of 152 patients enrolled in MOBILE are completed. Long-term follow-up is ongoing. Currently, we are in the process of unblinding the initial results for preliminary data analysis. CONCLUSIONS If successful, MOBILE could add definitive, high-quality evidence in support of cBMA for the treatment of poor-option CLI patients and provide an additional modality for patients who face amputation secondary to advanced limb ischemia.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Linden A Green
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael G Wilson
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Ind
| | - Andres Fajardo
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael P Murphy
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind.
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Janas A, Buszman PP, Milewski KP, Wiernek S, Janas K, Pruski M, Wojakowski W, Błachut A, Picheta W, Buszman P, Kiesz S. Long-Term Outcomes After Percutaneous Lower Extremity Arterial Interventions With Atherectomy vs. Balloon Angioplasty ― Propensity Score-Matched Registry ―. Circ J 2017; 81:376-382. [DOI: 10.1253/circj.cj-16-0856] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Adam Janas
- Center of Cardiovascular Research and Development, American Heart of Poland
- San Antonio Endovascular and Heart Institute
| | - Piotr P. Buszman
- Center of Cardiovascular Research and Development, American Heart of Poland
- Third Clinical Department of Cardiology, Medical University of Silesia, Silesian Center for Heart Diseases
| | | | | | | | - Maciej Pruski
- Center of Cardiovascular Research and Development, American Heart of Poland
- San Antonio Endovascular and Heart Institute
| | | | - Aleksandra Błachut
- Center of Cardiovascular Research and Development, American Heart of Poland
| | - Wojciech Picheta
- Center of Cardiovascular Research and Development, American Heart of Poland
| | - Pawel Buszman
- Center of Cardiovascular Research and Development, American Heart of Poland
- Department of Internal Medicine, Autoimmunological and Metabolic Disease, Medical University of Silesia
| | - Stefan Kiesz
- Center of Cardiovascular Research and Development, American Heart of Poland
- San Antonio Endovascular and Heart Institute
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Schreve MA, Vos CG, Vahl AC, de Vries JPPM, Kum S, de Borst GJ, Ünlü Ç. Venous Arterialisation for Salvage of Critically Ischaemic Limbs: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2016; 53:387-402. [PMID: 28027892 DOI: 10.1016/j.ejvs.2016.11.007] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 11/07/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Critical limb ischaemia (CLI) is the end stage of peripheral artery disease (PAD) and is associated with high amputation and mortality rates and poor quality of life. For CLI patients with no revascularisation options, venous arterialisation could be a last resort for limb salvage. OBJECTIVE To review the literature on the clinical effectiveness of venous arterialisation for lower limb salvage in CLI patients with no revascularisation options. METHOD Different databases were searched for papers published between January 1966 and January 2016. The criteria for eligible articles were studies describing outcomes of venous arterialisation, published in English, human studies, and with the full text available. Additionally, studies were excluded if they did not report limb salvage, wound healing or amputation as outcome measures. The primary outcome measure was post-operative limb salvage at 12 months. Secondary outcome measures were 30 day or in-hospital mortality, survival, patency, technical success, and wound healing. RESULTS Fifteen articles met the inclusion criteria. The included studies described 768 patients. According to the MINORS score, methodological quality was moderate to poor. The estimated pooled limb salvage rate at one year was 75% (0.75, 95% CI 0.70-0.81). Thirty day or in-hospital mortality was reported in 12 studies and ranged from 0 to 10%. Overall survival was reported in 10 studies and ranged from 54% to 100% with a mean follow-up ranging from 5 to 60 months. Six studies reported on patency of the venous arterialisations performed, with a range of 59-71% at 12 months. CONCLUSION In this systematic review on venous arterialisation in patients with non-reconstructable critical limb ischaemia, the pooled proportion of limb salvage at 12 months was 75%. Venous arterialisation could be a valuable treatment option in patients facing amputation of the affected limb; however, the current evidence is of low quality.
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Affiliation(s)
- M A Schreve
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands.
| | - C G Vos
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - A C Vahl
- Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - J P P M de Vries
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - S Kum
- Department of Surgery, Changi General Hospital, Singapore
| | - G J de Borst
- Department of Surgery, UMCU, Utrecht, The Netherlands
| | - Ç Ünlü
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
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Alabi O, Roos M, Landry G, Moneta G. Quality-of-life assessment as an outcomes measure in critical limb ischemia. J Vasc Surg 2016; 65:571-578. [PMID: 27876523 DOI: 10.1016/j.jvs.2016.08.097] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/08/2016] [Indexed: 11/28/2022]
Abstract
Critical limb ischemia (CLI) is a diagnosis plagued by significant comorbidity and high mortality rates. Overall survival remains poor in this population regardless of the procedure-related success as demonstrated by freedom from amputation, intervention, and patency. The literature has traditionally focused on physician-centered and lesion-centered outcomes with regards to limb salvage procedures, but there remains a relative paucity of studies of CLI patients describing patient-centered outcomes such as quality of life (QoL), independent living, and ambulation status. Review of the available literature indicates patients do not always experience significant gains in their QoL after limb salvage interventions, despite reasonable graft patency, amputation-free survival, and limb salvage rates. Further research is required using QoL tools in a measurable and clinically relevant fashion to guide optimal quality care that maximizes patient-centered outcomes.
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Affiliation(s)
- Olamide Alabi
- Division of Vascular and Endovascular Surgery, Oregon Health & Science University, Portland, Ore.
| | - Matthew Roos
- Division of Vascular and Endovascular Surgery, Oregon Health & Science University, Portland, Ore
| | - Gregory Landry
- Division of Vascular and Endovascular Surgery, Oregon Health & Science University, Portland, Ore
| | - Gregory Moneta
- Division of Vascular and Endovascular Surgery, Oregon Health & Science University, Portland, Ore
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Fowkes FGR, Aboyans V, Fowkes FJI, McDermott MM, Sampson UKA, Criqui MH. Peripheral artery disease: epidemiology and global perspectives. Nat Rev Cardiol 2016; 14:156-170. [PMID: 27853158 DOI: 10.1038/nrcardio.2016.179] [Citation(s) in RCA: 404] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Global populations are undergoing a major epidemiological transition in which the burden of atherosclerotic cardiovascular diseases is shifting rapidly from high-income to low-income and middle-income countries (LMICs). Peripheral artery disease (PAD) is no exception, so that greater focus is now required on the prevention and management of this disease in less-advantaged countries. In this Review, we examine the epidemiology of PAD and, where feasible, take a global perspective. However, the dearth of publications in LMICs means an unavoidable over-reliance on studies in high-income countries. Research to date suggests that PAD might affect a greater proportion of women than men in LMICs. Although factors such as poverty, industrialization, and infection might conceivably influence the development of PAD in such settings, the ageing of the population and increase in traditional cardiovascular risk factors, such as smoking, diabetes mellitus, and hypertension, are likely to be the main driving forces.
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Affiliation(s)
- F Gerry R Fowkes
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, 2 Avenue Martin Luther King, 87000 Limoges, France
| | - Freya J I Fowkes
- Centre for Population Health, Burnet Institute, 85 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Mary M McDermott
- Department of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, 675 North Saint Clair, Chicago, Illinois 60611, USA
| | - Uchechukwu K A Sampson
- Center for Translational Research and Implementation Science, National Heart, Lung and Blood Institute, National Institutes of Health, 6705 Rockledge Drive, Bethesda, Maryland 20824, USA
| | - Michael H Criqui
- Department of Family Medicine and Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, California 92093, USA
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Matsumoto T, Tanaka M, Yoshiya K, Yoshiga R, Matsubara Y, Horiuchi-Yoshida K, Yonemitsu Y, Maehara Y. Improved quality of life in patients with no-option critical limb ischemia undergoing gene therapy with DVC1-0101. Sci Rep 2016; 6:30035. [PMID: 27418463 PMCID: PMC4945920 DOI: 10.1038/srep30035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 06/29/2016] [Indexed: 11/09/2022] Open
Abstract
Critical limb ischemia (CLI) has a poor prognosis and adversely affects patients' quality of life (QOL). Therapeutic angiogenesis may improve mobility, mortality, and QOL in CLI patients. However, the effectiveness of gene therapy on such patients' QOL is unknown. DVC1-0101, a non-transmissible recombinant Sendai virus vector expressing human fibroblast growth factor-2 gene, demonstrated safety and efficacy in a phase I/II study of CLI patients. We investigated the effects of DVC1-0101 on QOL in this cohort. QOL was assessed using the Short Form-36 health survey version 2 (SF-36) in 12 patients at pre-administration, 28 days, and 3, 6, and 12 months post-treatment. We examined differences between pre and post-administration QOL scores and correlations between QOL scores and vascular parameters. Patients demonstrated low baselines scores on every SF-36 dimension. Post-treatment scores showed significant improvements in physical functioning at 3 and 6 months (P < 0.05), role-physical at 3, 6, and 12 months (P < 0.05), bodily pain at 1, 3, 6, and 12 months (P < 0.05), vitality at 1, 6, and 12 months (P < 0.05), and physical component summary at 6 and 12 months (P < 0.05). DVC1-0101-based gene therapy may improve QOL in CLI patients over a 6-month period.
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Affiliation(s)
- Takuya Matsumoto
- Department of Surgery and Science, Graduate School of Medical Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Michiko Tanaka
- R&D Laboratory for Innovative Biotherapeutics Science, Graduate School of Pharmaceutical Sciences, Kyushu University, Rm. 601, Collaborative Research Station I, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Keiji Yoshiya
- Department of Surgery and Science, Graduate School of Medical Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Ryosuke Yoshiga
- Department of Surgery and Science, Graduate School of Medical Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Yutaka Matsubara
- Department of Surgery and Science, Graduate School of Medical Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Kumi Horiuchi-Yoshida
- R&D Laboratory for Innovative Biotherapeutics Science, Graduate School of Pharmaceutical Sciences, Kyushu University, Rm. 601, Collaborative Research Station I, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Yoshikazu Yonemitsu
- R&D Laboratory for Innovative Biotherapeutics Science, Graduate School of Pharmaceutical Sciences, Kyushu University, Rm. 601, Collaborative Research Station I, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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Liang TW, Jester A, Motaganahalli RL, Wilson MG, G'Sell P, Akingba GA, Fajardo A, Murphy MP. Autologous bone marrow mononuclear cell therapy for critical limb ischemia is effective and durable. J Vasc Surg 2016; 63:1541-5. [PMID: 27021379 DOI: 10.1016/j.jvs.2016.01.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 01/13/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We have previously shown that autologous bone marrow mononuclear cell (ABMNC) therapy improves measures of limb perfusion, rest pain, wound healing, and amputation-free survival (AFS) at 1 year in patients with critical limb ischemia (CLI). Long-term durability of ABMNC therapy for CLI remains unknown. The objective of the current study was to evaluate long-term clinical outcomes 5 years after treatment. METHODS Data were retrospectively gathered from a database and via a patient survey and review of medical records of patients previously enrolled in this phase I/II trial. AFS, freedom from major amputation, and freedom from major adverse limb events (MALE) were calculated using the product-limit estimate. The incidence of cardiac, malignant, and other medical events relevant to the safety of cell therapy were tabulated during the time from treatment to follow-up. RESULTS Twenty-one of the 24 patients (88%) who completed the initial 1-year phase I/II trial were available for the 5-year analysis; AFS was 74% (95% confidence interval [CI], 0.53-0.87), freedom from major amputation was 78% (95% CI, 0.58-0.90), and freedom from MALE was 65% (95% CI, 0.45-0.80). Three patients (14%) had major cardiac events. There were no incidences of malignancies or diagnoses of clinically significant proliferative retinopathy. Fifteen patients (71%) report continued improvement in pain-free walking. Nineteen (90%) patients believed that the study was of significant medical value and would participate again. CONCLUSIONS ABMNC therapy provides long-term freedom from AFS, major amputation, and MALE that are comparable with other reports of patients who underwent surgical and endovascular interventions for CLI. Furthermore, no patients developed tumorigenesis or clinically significant retinopathy. Because of the limited number of patients studied, our findings will need to be followed up in a larger phase III trial.
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Affiliation(s)
- Tiffany W Liang
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Andrea Jester
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael G Wilson
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Ind
| | - Patricia G'Sell
- Indiana Center for Vascular Biology and Medicine, Indiana University School of Medicine, Indianapolis, Ind
| | - George A Akingba
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Andres Fajardo
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael P Murphy
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind.
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