On the Cutting Edge: Wound Care for the Endovascular Specialist

Understanding Gangrene in the Context of Peripheral Vascular Disease: Prevalence, Etiology, and Considerations for Amputation-Level Determination

Gangrene is a grave complication of peripheral vascular disease (PVD), characterised by tissue necrosis due to inadequate blood supply. This review article comprehensively explores gangrene in PVD, encompassing its prevalence, aetiology, clinical presentation, diagnostic modalities, management strategies, prognosis, and future directions. Key factors influencing outcomes, including the timeliness of intervention and the choice between limb salvage and amputation, are identified. Moreover, this review underscores the importance of early detection and multidisciplinary care, emphasising the significance of patient-centred approaches. It also calls for increased awareness, continued research, and innovative solutions to improve the lives of individuals grappling with gangrene in the context of PVD.

Below Knee Angioplasty Using Drug-Eluting Balloons in Patients with Critical Limb Ischemia with Six Months Follow-Up: Single-Center Experience at Tertiary Care Hospital

Aims and Objective The aim of this study was to evaluate 6 monthly safety and primary patency rates of drug-eluting balloons (DEB) angioplasty in below-the-knee (BTK) arteries in critical limb ischemia (CLI) patients.

Methods A prospective observational study was conducted over 2 years in a tertiary care center. A total of 25 patients with CLI were enrolled in this study. Inclusion criteria were patients presenting with CLI (Rutherford class 4 or greater), equal to or more than 50% luminal stenosis or occlusion of at least one tibial artery, and agreement to 6-month evaluation. Exclusion criteria were life expectancy less than 1 year, allergy to paclitaxel, and contraindication to antiplatelet treatment.

Follow-up was performed by clinical and Doppler assessment. The primary endpoint was a 6-month primary patency rate, and secondary endpoints were changes in the Rutherford class and incidence of major amputation. Restenosis rate is defined as a reduction in the luminal diameter by 50% or greater by duplex ultrasound.

Results Six-month primary patency was achieved in 19 (76%) patients. Both Rutherford category improvement and reduction in the percentage of stenosis after angioplasty were statistically significant (p-value <0.0001). At 6 months, better patency rates were seen among diabetics (88.8%) than smokers (69.2%). Limb salvage was observed in 24 (96%) patients with one major amputation (above the ankle).

Conclusion DEBs have shown safe and promising clinical outcomes with successful performance in infrapopliteal arteries in the short-term follow-up. DEB had a substantial 6-month primary patency rate. DEB angioplasty is a safe and effective treatment option for CLI patients with BTK vascular disease.

Use of autologous conditioned serum dressings in hard-to-heal wounds: a randomised prospective clinical trial

OBJECTIVE

In this study, we aimed to assess both the efficacy and tolerability of autologous conditioned serum (ACS) as an innovative wound dressing in the local management of hard-to-heal wounds.

METHOD

In this single-blinded randomised controlled trial, patients with hard-to-heal wounds were randomly assigned to receive either ACS treatment or normal saline (NS) dressings. The treatment was applied once a week for three weeks with a final assessment at three weeks from the first ACS application.

RESULTS

A total of 30 patients took part in the study. Analysis of wound assessment data demonstrated statistically significant differences for wound surface area and Pressure Ulcer Scale for Healing scores (area score, exudate and tissue) from baseline to the end of the study in patients who received the ACS dressing, but not in patients who received the normal saline dressing. There were statistically significant differences in changes in: the wound surface area at week three (-6.4±2.69cm² versus +0.4±2.52cm²); area score at week three (-2.2±1.08 versus +0.2±0.86); exudate at week two (-1.2±0.70 versus +0.0±0.45) and at week 3 (-1.3±0.72 versus -0.1±0.63); tissue at week two (-1.1±0.35 versus +0.0±0.53) and at week three (-1.8±0.65 versus -0.1±0.63); and the PUSH total score at week one (-1.6±0.98 versus +0.4±1.22), week two (-3.2±0.86 versus +0.4±0.98) and week three (-5.3±1.17 versus -0.0±1.33) between the ACS and NS groups, respectively.

CONCLUSION

This trial revealed a significant decrease in wound surface area as well as a considerable improvement in wound healing in the ACS dressing group.

Cold-Inducible RNA-Binding Protein but Not Its Antisense lncRNA Is a Direct Negative Regulator of Angiogenesis In Vitro and In Vivo via Regulation of the 14q32 angiomiRs-microRNA-329-3p and microRNA-495-3p

Inhibition of the 14q32 microRNAs, miR-329-3p and miR-495-3p, improves post-ischemic neovascularization. Cold-inducible RNA-binding protein (CIRBP) facilitates maturation of these microRNAs. We hypothesized that CIRBP deficiency improves post-ischemic angiogenesis via downregulation of 14q32 microRNA expression. We investigated these regulatory mechanisms both in vitro and in vivo. We induced hindlimb ischemia in Cirp^−/− and C57Bl/6-J mice, monitored blood flow recovery with laser Doppler perfusion imaging, and assessed neovascularization via immunohistochemistry. Post-ischemic angiogenesis was enhanced in Cirp^−/− mice by 34.3% with no effects on arteriogenesis. In vivo at day 7, miR-329-3p and miR-495-3p expression were downregulated in Cirp^−/− mice by 40.6% and 36.2%. In HUVECs, CIRBP expression was upregulated under hypothermia, while miR-329-3p and miR-495-3p expression remained unaffected. siRNA-mediated CIRBP knockdown led to the downregulation of CIRBP-splice-variant-1 (CIRBP-SV1), CIRBP antisense long noncoding RNA (lncRNA-CIRBP-AS1), and miR-495-3p with no effects on the expression of CIRBP-SV2-4 or miR-329-3p. siRNA-mediated CIRBP knockdown improved HUVEC migration and tube formation. SiRNA-mediated lncRNA-CIRBP-AS1 knockdown had similar long-term effects. After short incubation times, however, only CIRBP knockdown affected angiogenesis, indicating that the effects of lncRNA-CIRBP-AS1 knockdown were secondary to CIRBP-SV1 downregulation. CIRBP is a negative regulator of angiogenesis in vitro and in vivo and acts, at least in part, through the regulation of miR-329-3p and miR-495-3p.

Healing hard-to-heal diabetic foot ulcers: the role of dehydrated amniotic allograft with cross-linked bovine-tendon collagen and glycosaminoglycan matrix

The treatment of diabetic foot ulcers is complex and costly with an increased risk for infection, which may even lead to amputation. This prospective case series aims to assess the effectiveness of a dehydrated amniotic membrane allograft combined with a bilayer dermal matrix for healing complicated foot ulcers in patients with comorbidities. A total of six patients with complicated full-thickness ulcers and comorbidities, such as diabetes and peripheral vascular disease were treated with this technique. Each wound was measured intraoperatively just before graft application, at 14 days after application, and then at weeks 4, 8, and 12. Changes in wound volume and area were compared over time. One patient had complete wound closure by week eight, a second patient by week 12. The other four patients had wounds that decreased in size during the course of 12 weeks. The mean decrease in wound volume was 73.5% post-removal of the bilayer dermal matrix after two weeks of application. At week 12, the mean decrease in wound area and volume were 93.2% and 97.1%, respectively. This case series provides initial evidence that the combination of dehydrated amniotic membrane allograft with bilayer dermal matrix promotes complete wound closure in patients with comorbidities that may impede wound healing. Further clinical trials are needed to confirm these results.

Impact of prior endovascular interventions on outcomes of lower limb bypass surgery: A systematic review and meta-analysis

The aim of this meta-analysis was to evaluate the mortality, amputation and complication rates in patients with peripheral lower limb arterial disease undergoing bypass surgery with or without a prior history of endovascular operation. A systematic literature screen was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines on four academic databases, Medline, Scopus, Embase and Cochrane Central Register of Controlled Trials. Out of 1,072 records, six articles involving 11,420 patients (mean age, 68.1±2.0 years) met the inclusion criteria. The findings presented a 2b level of evidence (i.e. overall evidence represents data from individual cohort study or low quality randomized controlled trials) and suggested lower mortality, amputation and complication rates for patients undergoing bypass surgery without any history of endovascular operation, compared with those with a history of prior endovascular operation. Moreover, a random-effect meta-analysis suggested a small, positive reduction in mortality (Hedge's g=0.08), amputation (Hedge's g=0.18) and complication rates (Hedge's g=0.05) for patients undergoing bypass surgery without any history of endovascular operation. Nevertheless, owing to the scarcity of high-quality data, further studies and randomized clinical trials are needed to confirm these effects.