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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2497-2604. [PMID: 38752899 DOI: 10.1016/j.jacc.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Davies H, Russell DA, Mees BME, Scott DJA. End of life care in vascular surgery. Br J Surg 2024; 111:znae124. [PMID: 38757906 DOI: 10.1093/bjs/znae124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 03/23/2024] [Accepted: 04/27/2024] [Indexed: 05/18/2024]
Affiliation(s)
- Henry Davies
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - David A Russell
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Barend M E Mees
- Department of Vascular Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - D Julian A Scott
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Pelletier J, Koyfman A, Long B. Acute aortic occlusion: A narrative review for emergency clinicians. Am J Emerg Med 2024; 79:192-197. [PMID: 38460466 DOI: 10.1016/j.ajem.2024.02.033] [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: 01/18/2024] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 03/11/2024] Open
Abstract
INTRODUCTION Acute aortic occlusion (AAO) is a rare but serious condition associated with significant morbidity and mortality. OBJECTIVE This review provides an emergency medicine focused evaluation of AAO, including presentation, assessment, and emergency department (ED) management based on current evidence. DISCUSSION AAO refers to obstruction of blood flow through the aorta due to either thrombosis or embolism. This condition primarily affects older adults ages 60-70 with cardiovascular comorbidities and most commonly presents with signs and symptoms of acute limb ischemia, though the gastrointestinal tract, kidneys, and spinal cord may be affected. The first line imaging modality includes computed tomography angiography of the chest, abdomen, and pelvis. ED resuscitative management consists of avoiding extremes of blood pressure or heart rate, maintaining normal oxygen saturation and euvolemic status, anticoagulation with heparin, and pain control. Emergent consultation with the vascular surgery specialist is recommended to establish a plan for restoration of perfusion to ischemic tissues via endovascular or open techniques. High rates of baseline comorbidities present in the affected population as well as ischemic and reperfusion injuries place AAO patients at high risk for complications in an immediate and delayed fashion after surgical management. CONCLUSIONS An understanding of AAO can assist emergency clinicians in diagnosing and managing this rare but devastating disease.
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Affiliation(s)
- Jessica Pelletier
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Kanai A, Ara M, Saito R, Mishima T, Takahashi Y. Subcutaneous injection of lidocaine around ischemic ankle provides safe and effective foot analgesia in patients with critical limb ischemia. Vascular 2024:17085381241238841. [PMID: 38452400 DOI: 10.1177/17085381241238841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVE It is often difficult to alleviate foot pain associated with critical limb ischemia (CLI) using common analgesics. Neuraxial block is contraindicated in anticoagulant therapy. This study was designed to determine the response to subcutaneous injection of lidocaine around the network of peripheral nerves around the ankle in patients with CLI pain on anticoagulants and antiplatelets. METHODS Sixteen patients with CLI pain in the foot were enrolled in this double-blind placebo-controlled crossover study. Patients were randomized to receive either 2% lidocaine or saline via catheters inserted into the subcutaneous area around the ankle. After recurrence of pain, the patients were crossed over to receive the alternative treatment. Pain was assessed with a numerical rating scale (NRS) before and 15 min after injection. Patients used a descriptive scale to grade pain control and were asked to determine the duration of analgesia in each arm of the study. RESULTS No serious complications including protracted bleeding occurred. Lidocaine significantly decreased the NRS on movement from 10 (6, 10) [median (range)] to 2 (0, 10) (p < .001), and the differences in the Δ change in NRS between lidocaine and placebo were significant (p = .009). Of the 16 patients, 14 patients were very satisfied after lidocaine but only one described the same after saline. The effect of lidocaine and placebo lasted 11 (0, 28) and 1 (0, 22) h, respectively. CONCLUSION Subcutaneous injection of lidocaine around the ischemic ankle affectively alleviated pain in patients with CLI without serious adverse effects under anticoagulant therapy.
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Affiliation(s)
- Akifumi Kanai
- Department of Research and Development Centre for New Medical Frontiers, Kitasato University School of Medicine, Sagamihara, Japan
| | - Masatomo Ara
- Department of Anesthesiology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Ryusei Saito
- Department of Anesthesiology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Toshiaki Mishima
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yuichiro Takahashi
- Department of Anesthesiology, Kitasato University School of Medicine, Sagamihara, Japan
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Sakaguchi T, Kajiyama T. Pharmacological pain management of critical limb ischaemia. BMJ Support Palliat Care 2024; 13:e759-e760. [PMID: 36347568 DOI: 10.1136/spcare-2022-004046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 10/28/2022] [Indexed: 11/09/2022]
Affiliation(s)
| | - Toru Kajiyama
- Department of Palliative Care, Kitano Hospital, Osaka, Japan
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Chen Y, Wang E, Sites BD, Cohen SP. Integrating mechanistic-based and classification-based concepts into perioperative pain management: an educational guide for acute pain physicians. Reg Anesth Pain Med 2023:rapm-2022-104203. [PMID: 36707224 DOI: 10.1136/rapm-2022-104203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/13/2023] [Indexed: 01/28/2023]
Abstract
Chronic pain begins with acute pain. Physicians tend to classify pain by duration (acute vs chronic) and mechanism (nociceptive, neuropathic and nociplastic). Although this taxonomy may facilitate diagnosis and documentation, such categories are to some degree arbitrary constructs, with significant overlap in terms of mechanisms and treatments. In clinical practice, there are myriad different definitions for chronic pain and a substantial portion of chronic pain involves mixed phenotypes. Classification of pain based on acuity and mechanisms informs management at all levels and constitutes a critical part of guidelines and treatment for chronic pain care. Yet specialty care is often siloed, with advances in understanding lagging years behind in some areas in which these developments should be at the forefront of clinical practice. For example, in perioperative pain management, enhanced recovery protocols are not standardized and tend to drive treatment without consideration of mechanisms, which in many cases may be incongruent with personalized medicine and mechanism-based treatment. In this educational document, we discuss mechanisms and classification of pain as it pertains to commonly performed surgical procedures. Our goal is to provide a clinical reference for the acute pain physician to facilitate pain management decision-making (both diagnosis and therapy) in the perioperative period.
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Affiliation(s)
- Yian Chen
- Anesthesiology, Stanford University School of Medicine, Stanford, California, USA
| | - Eric Wang
- Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Brian D Sites
- Anesthesiology and Orthopaedics, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Steven P Cohen
- Anesthesiology, Neurology, Physical Medicine & Rehabilitation and Psychiatry & Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Cortiñas-Sáenz M, Dámaso Fernández-Ginés F, Selva-Sevilla C, Gerónimo-Pardo M. At-home Topical Sevoflurane Added to the Conventional Analgesic Treatment for Painful leg Ulcers Greatly Improved the Analgesic Effectiveness and Reduced Opioid Consumption in a Single-Center Retrospective Comparative Study with one-Year Follow-up. INT J LOW EXTR WOUND 2022:15347346221111418. [PMID: 35833331 DOI: 10.1177/15347346221111418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The general anesthetic sevoflurane is being repurposed as a topical analgesic for painful chronic wounds. This study was aimed to compare the analgesic effectiveness and safety of systemic analgesics alone or plus at-home topical sevoflurane for the management of patients with painful nonrevascularizable leg ulcers who were referred to a Pain Clinic by their attending vascular surgeons. We reviewed charts of patients treated in a single Pain Clinic with analgesic Standard of Care either alone (group SoC) or plus at-home topical sevoflurane (group SoC + Sevo), according to safety criteria. The area under the curve of pain over a year (AUC-Pain) was the primary outcome for analgesic effectiveness. Opioids were converted into Oral Morphine Milligram Equivalents. Groups SoC (n = 26) and SoC + Sevo (n = 38) were similar in baseline characteristics. Compared to SoC, median values [interquartile range] of area under the curve of pain for one-year follow-up were markedly lower for SoC + Sevo (54 [35-65] vs. 15 [11-23]; p < 0.000001, U Mann-Whitney test). Oral Morphine Milligram Equivalents were similar at baseline (SoC: 78.5 [22.5-135] vs. SoC + Sevo: 101.3 [30-160]; p = 0.753), but significantly lower for SoC + Sevo at three (120 [22.5-202.5] vs. 30 [0-80]; p = 0.005), six (120 [11.3-160] vs. 20 [0-67.5]; p = 0.004), nine (114.4 [0-154] vs. 0 [0-37]; p = 0.018), and 12 months (114.4 [0-154] vs. 0 [0-20]; p = 0.001). Multiple linear regression analysis revealed the addition of sevoflurane to be the most likely variable to explain this difference in outcome (ß:-33.408; p < 0.000001). Nine patients (24%) in SoC + Sevo had adverse effects attributed to sevoflurane, but only one patient needed to stop using sevoflurane due severe dermatitis. In conclusion, the addition of topical sevoflurane to the analgesic standard of care in patients with painful nonrevascularizable leg ulcers was a well-tolerated therapy that significantly improved pain control and allowed for a significant reduction in opioid consumption.
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Affiliation(s)
- Manuel Cortiñas-Sáenz
- Department of Anesthesiology, 16815Complejo Hospitalario Torrecárdenas, Almería, Spain
- Department of Anesthesiology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - F Dámaso Fernández-Ginés
- Department of Hospital Pharmacy, 16815Complejo Hospitalario Torrecárdenas, Almería, Spain
- Hospital La Inmaculada, Huércal Overa, Almería, Spain
| | - Carmen Selva-Sevilla
- Department of Applied Economy, Facultad de Ciencias Económicas y Empresariales de Albacete, 73073Castilla-La Mancha University, Spain
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Davies H, Waduud MA, Laloo R, Wyld L, Wallace T, de Siqueira JR, Bennett MI, Scott DJA. Palliative Care Interventions for Peripheral Artery Disease: A Systematic Review and Narrative Synthesis. J Palliat Med 2021; 25:319-326. [PMID: 34860585 DOI: 10.1089/jpm.2021.0393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Peripheral artery disease (PAD) encompasses conditions with poor outcome and severe suffering, both mentally and physically, yet utilization and research into palliative care interventions remain sparse. Objective: The purpose of this study is to identify existing evidence on palliative care intervention for chronic limb threatening ischaemia (CLTI) and abdominal aortic aneurysm (AAA). Design: We conducted a PROSPERO-registered systematic review of studies published between 1991 and 2020 in which people with PAD received palliative care interventions and at least one patient outcome was recorded. For the purpose of this study, a palliative care intervention was defined as one which aims primarily to reduce negative impact of PAD on patients' and/or caregivers' physical, emotional, psychological, social, or spiritual condition. Results: A total of 8 studies involving 87,024 patients met the inclusion criteria (4 cohort studies and 4 cross-sectional studies). Methodological quality ranged from low to moderate. The small number of studies and study heterogeneity precluded meta-analysis. Regarding our primary outcomes, only two articles recorded patient-reported outcomes. Five articles found an association between palliative care and reduction in health care utilization, a secondary outcome of the study. Most of the studies reported that palliative care was likely underused. Only two of the studies included non-hospital patients. Conclusion: Despite high mortality and morbidity associated with PAD, evidence of the effectiveness of palliative care in this group of patients is lacking. There are only a handful of articles on palliative care for people with PAD, and the majority are small, methodologically flawed and lack meaningful patient-reported outcomes. High-quality research of palliative care interventions in patients with PAD is urgently needed to better understand the impact of palliative care on quality of end of life and to develop and evaluate service-level interventions.
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Affiliation(s)
- Henry Davies
- Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Mohammed A Waduud
- Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Ryan Laloo
- Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Lucy Wyld
- Palliative Care, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Tom Wallace
- Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Jonathan R de Siqueira
- Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Michael I Bennett
- Leeds Institute of Health Science, University of Leeds, Leeds, United Kingdom
| | - D Julian A Scott
- Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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10
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Selva-Sevilla C, Fernández-Ginés FD, Cortiñas-Sáenz M, Gerónimo-Pardo M. Cost-effectiveness analysis of domiciliary topical sevoflurane for painful leg ulcers. PLoS One 2021; 16:e0257494. [PMID: 34543330 PMCID: PMC8452083 DOI: 10.1371/journal.pone.0257494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 09/02/2021] [Indexed: 11/19/2022] Open
Abstract
Objectives The general anesthetic sevoflurane is being repurposed as a topical analgesic for painful chronic wounds. We conducted a Bayesian cost-effectiveness analysis (CEA) comparing the addition of domiciliary topical sevoflurane to conventional analgesics (SEVOFLURANE, n = 38) versus conventional analgesics alone (CONVENTIONAL, n = 26) for the treatment of nonrevascularizable painful leg ulcers in an outpatient Pain Clinic of a Spanish tertiary hospital. Methods We used real-world data collected from charts to conduct this CEA from a public healthcare perspective and with a one-year time horizon. Costs of analgesics, visits and admissions were considered, expressed in €2016. Analgesic effectiveness was measured with SPID (Sum of Pain Intensity Difference). A Bayesian regression model was constructed, including “treatment” and baseline characteristics for patients (“arterial hypertension”) and ulcers (“duration”, “number”, “depth”, “pain”) as covariates. The findings were summarized as a cost-effectiveness plane and a cost-effectiveness acceptability curve. One-way sensitivity analyses, a re-analysis excluding those patients who died or suffered from leg amputation, and an extreme scenario analysis were conducted to reduce uncertainty. Results Compared to CONVENTIONAL, SEVOFLURANE was associated with a 46% reduction in costs, and the mean incremental effectiveness (28.15±3.70 effectiveness units) was favorable to SEVOFLURANE. The estimated probability for SEVOFLURANE being dominant was 99%. The regression model showed that costs were barely influenced by any covariate, whereas effectiveness was noticeably influenced by “treatment”. All sensitivity analyses showed the robustness of the model, even in the extreme scenario analysis against SEVOFLURANE. Conclusions SEVOFLURANE was dominant over CONVENTIONAL as it was less expensive and much more effective.
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Affiliation(s)
- Carmen Selva-Sevilla
- Department of Applied Economics, Faculty of Economics, University of Castilla La Mancha, Albacete, Spain
| | | | - Manuel Cortiñas-Sáenz
- Unit of Pain—Department of Anesthesiology, Torrecárdenas Hospital Complex, Almería, Spain
| | - Manuel Gerónimo-Pardo
- Department of Anesthesiology, Complejo Hospitalario Universitario, Albacete, Spain
- * E-mail: ,
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Gonçalves PEO, Milanez M, Flumignan RLG, Machado J, Navarro TP, Cisneros LDL. Transcutaneous Electric Nerve Stimulation on ischemic rest pain in inpatients: randomised trial. ACTA ACUST UNITED AC 2021; 67:213-217. [PMID: 34406244 DOI: 10.1590/1806-9282.67.02.20200535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/14/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate the efficacy of a short-term application of Transcutaneous Electric Nerve Stimulation to relieve rest pain in patients with chronic limb-threatening ischemia. METHODS In patients ³18 years old, with chronic limb-threatening ischemia and rest pain ³3 in the Visual Analogue Scale, without diabetic neuropathy were randomly assigned to 1) Transcutaneous Electric Nerve Stimulation (100 Hz, 200 μs) or 2) sham intervention, both during one or two 20 min treatment sessions. The primary outcome was pain intensity, assessed by the visual analogue scale (0-10 cm) and described by the McGill Pain Questionnaire. We used a t-test for difference of means. RESULTS A total of 169 patients were assessed, 23 met the study criteria and were randomized. Thirty-four applications were performed in two days: in the 17 Transcutaneous Nerve Stimulation and 17 sham. The within-group analysis indicated a pain decrease in both groups (Transcutaneous Electric Nerve Stimulation, from 7-3.9 cm, p<0.0001, and sham from 5.8-3.2 cm, p<0.0001). No statistically significant difference was verified between-groups (p=0.5). CONCLUSIONS Both groups showed a decrease in rest pain of 54 and 55%, respectively. However, there was no difference between short-term high-frequency Transcutaneous Electric Nerve Stimulation and sham intervention to relieve ischemic rest pain in chronic limb-threatening ischemia patients.
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Affiliation(s)
| | - Matheus Milanez
- Universidade Federal de Minas Gerais, Department of Physical Therapy - Belo Horizonte (MG), Brazil
| | - Ronald Luiz Gomes Flumignan
- Universidade Federal de São Paulo, Division of Vascular and Endovascular Surgery, Department of Surgery - São Paulo (SP), Brazil
| | - Jorge Machado
- Universidade Federal de Minas Gerais, Department of Preventive and Social Medicine, School of Medicine - Belo Horizonte (MG), Brazil
| | - Tulio Pinho Navarro
- Universidade Federal de Minas Gerais, School of Medicine, Department of Surgery - Belo Horizonte (MG), Brazil
| | - Ligia de Loiola Cisneros
- Universidade Federal de Minas Gerais, Department of Physical Therapy - Belo Horizonte (MG), Brazil
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Jiang X, Yuan Y, Ma Y, Zhong M, Du C, Boey J, Armstrong DG, Deng W, Duan X. Pain Management in People with Diabetes-Related Chronic Limb-Threatening Ischemia. J Diabetes Res 2021; 2021:6699292. [PMID: 34046505 PMCID: PMC8128546 DOI: 10.1155/2021/6699292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/19/2021] [Accepted: 05/03/2021] [Indexed: 12/24/2022] Open
Abstract
Management of neuropathic pain in people with diabetes has been widely investigated. However, little attention was paid to address ischemic-related pain in patients with diabetes mellitus who suffered from chronic limb-threatening ischemia (CLTI), the end stage of lower extremity arterial disease (LEAD). Pain management has a tremendous influence on patients' quality of life and prognosis. Poor management of this type of pain owing to the lack of full understanding undermines patients' physical and mental quality of life, which often results in a grim prognosis, such as depression, myocardial infarction, lower limb amputation, and even mortality. In the present article, we review the current strategy in the pain management of diabetes-related CLTI. The endovascular therapy, pharmacological therapies, and other optional methods could be selected following comprehensive assessments to mitigate ischemic-related pain, in line with our current clinical practice. It is very important for clinicians and patients to strengthen the understanding and build intervention strategy in ischemic pain management and possible adverse consequence.
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Affiliation(s)
- Xiaoyan Jiang
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Yi Yuan
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Yu Ma
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Miao Zhong
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Chenzhen Du
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Johnson Boey
- Department of Podiatry, National University of Hospital Singapore, Singapore 169608
| | - David G. Armstrong
- Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, USA
| | - Wuquan Deng
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Xiaodong Duan
- Department of Rehabilitation, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
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13
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Chen S, Xu Z, Liu H, Zhang Y, Zhang J, Chen Y, Zheng Y, Huang Y. Perioperative patient-controlled regional analgesia versus patient-controlled intravenous analgesia for patients with critical limb ischaemia: a study protocol for a randomised controlled trial. BMJ Open 2020; 10:e037879. [PMID: 33033091 PMCID: PMC7545635 DOI: 10.1136/bmjopen-2020-037879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Both regional analgesia and intravenous analgesia are frequently used perioperatively for patients with critical limb ischaemia (CLI). Nevertheless, the comparison of perioperative effect of regional and intravenous analgesia has not yet been thoroughly illustrated. This study will comprehensively compare patient-controlled regional analgesia (PCRA) and patient-controlled intravenous analgesia (PCIA) as two different perioperative analgesia approaches for patients with CLI. It investigates their effects on analgesia, reperfusion and the quality of recovery perioperatively, also aims to provide clinical evidence to those non-surgical patients with non-reconstructable arteries. METHODS AND ANALYSIS This trial is a randomised, single-centre, open-label, parallel trial with target sample size of 52 in total. Eligible participants will be randomly allocated to the PCRA group (group R) or the PCIA group (group I) after admission. Participants in group R will receive ultrasound-guided subgluteal sciatic catheterisation, followed by continuous PCRA infusion (0.2% ropivacaine 15 mL as loading dose, 8 mL/hour as background with a patient-controlled bolus of 6 mL). Participants in group I will receive PCIA (morphine is given in boluses of 1 mg as needed, background infusion at 1 mg/hour). Data will be collected at baseline (T0), 2 hours before revascularisation treatment (T1) and 2 hours before discharge (T2). The primary outcomes include the Numerical Rating Scale pain score at T1 and T2. The secondary outcomes include the perioperative transcutaneous oxygen pressure, the Tissue Haemoglobin Index, Hospital Anxiety and Depression Scale at T1 and T2; the Patient Global Impression of Change and patient satisfaction at T1 and T2; the perioperative cumulative morphine consumption, the length of postoperative hospital stay and adverse events. ETHICS AND DISSEMINATION This study received authorisation from the Institutional Review Board of Peking Union Medical College Hospital on 21 March 2017 (approval no. ZS-1289X). Study findings will be disseminated through presentations at scientific conferences or publications in peer-reviewed journals. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Registry (ChiCTR2000029298). PROTOCOL VERSION V.4CP.B2 (15 June 2020).
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Affiliation(s)
- Si Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Zhonghuang Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Hongju Liu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Beijing, China
| | - Jiao Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Yuexin Chen
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Yuehong Zheng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
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Pei X, Kim H, Lee M, Wang N, Shin J, Lee S, Yoon M, Yang VC, He H. Local delivery of cardiac stem cells overexpressing HIF-1α promotes angiogenesis and muscular tissue repair in a hind limb ischemia model. J Control Release 2020; 322:610-621. [DOI: 10.1016/j.jconrel.2020.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/23/2020] [Accepted: 03/13/2020] [Indexed: 12/14/2022]
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15
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Blanco-Antona F, González-Sarmiento R, García-Cenador B, Lozano FS. Transdermal Buprenorphine for Controlling Pain in Patients with Critical Lower-Limb Ischemia. PAIN MEDICINE 2020; 21:1083-1085. [PMID: 31313809 DOI: 10.1093/pm/pnz165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Francisco Blanco-Antona
- Department of Vascular Surgery, Clinical Hospital, University of Salamanca and Institute of Biomedical Research of Salamanca, Salamanca, Spain
| | - Rogelio González-Sarmiento
- Department of Vascular Surgery, Clinical Hospital, University of Salamanca and Institute of Biomedical Research of Salamanca, Salamanca, Spain
| | - Begoña García-Cenador
- Department of Vascular Surgery, Clinical Hospital, University of Salamanca and Institute of Biomedical Research of Salamanca, Salamanca, Spain
| | - Francisco S Lozano
- Department of Vascular Surgery, Clinical Hospital, University of Salamanca and Institute of Biomedical Research of Salamanca, Salamanca, Spain
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D'Souza RS, Shen S, Ojukwu F, Gazelka HM, Pulos BP. Partnering with Palliative Care: A Case Report of Severe Pain in Critical Limb Ischemia Treated Successfully with a Continuous Popliteal Nerve Catheter. Case Rep Anesthesiol 2020; 2020:1054521. [PMID: 32318294 PMCID: PMC7166256 DOI: 10.1155/2020/1054521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 03/10/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Critical limb ischemia (CLI) is limb pain occurring at rest or impending limb loss as a result of lack of blood flow to the affected extremity. CLI pain is challenging to control despite multimodal pharmacologic analgesia and surgical intervention. We described the successful use of a continuous local anesthetic infusion via a popliteal nerve catheter to control severe refractory ischemic lower limb pain in a patient who failed surgical intervention and performed a brief narrative literature review on regional anesthesia for ischemic pain. Case Presentation. A 74-year-old female with acute myelogenous leukemia presented with CLI after experiencing left popliteal artery occlusion. Palliative medicine service was consulted for pain management in the setting of escalating narcotic dose requirements. She experienced a complicated hospital course with several failed attempts at surgical revascularization due to arterial rethrombosis. In accordance with the patient's goals of care, a continuous popliteal nerve catheter was placed, despite the high risk nature of an intervention in an immunocompromised patient with thrombocytopenia (platelet count of 30,000 platelets/microliter) and ongoing therapeutic anticoagulation. The patient experienced immediate relief while transitioning to comfort care. CONCLUSION This is the first report of successful analgesia for CLI via a continuous popliteal catheter in a patient with rethrombosis and failed surgical revascularization. Based on our collaborative experience, we recommend the development of partnerships between the acute pain service and palliative care service to facilitate the early evaluation and decision to utilize regional anesthesia for treatment of CLI.
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Affiliation(s)
- Ryan S. D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1 St SW, Rochester, MN 55904, USA
| | - Stephanie Shen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1 St SW, Rochester, MN 55904, USA
| | - Frederick Ojukwu
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1 St SW, Rochester, MN 55904, USA
| | - Halena M. Gazelka
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, 200 1 St SW, Rochester, MN 55904, USA
- Center for Palliative Medicine, Mayo Clinic, 200 1 St SW, Rochester, MN 55904, USA
| | - Bridget P. Pulos
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1 St SW, Rochester, MN 55904, USA
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Hassanshahi M, Khabbazi S, Peymanfar Y, Hassanshahi A, Hosseini-Khah Z, Su YW, Xian CJ. Critical limb ischemia: Current and novel therapeutic strategies. J Cell Physiol 2019; 234:14445-14459. [PMID: 30637723 DOI: 10.1002/jcp.28141] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 01/02/2019] [Indexed: 01/24/2023]
Abstract
Critical limb ischemia (CLI) is the advanced stage of peripheral artery disease spectrum and is defined by limb pain or impending limb loss because of compromised blood flow to the affected extremity. Current conventional therapies for CLI include amputation, bypass surgery, endovascular therapy, and pharmacological approaches. Although these conventional therapeutic strategies still remain as the mainstay of treatments for CLI, novel and promising therapeutic approaches such as proangiogenic gene/protein therapies and stem cell-based therapies have emerged to overcome, at least partially, the limitations and disadvantages of current conventional therapeutic approaches. Such novel CLI treatment options may become even more effective when other complementary approaches such as utilizing proper bioscaffolds are used to increase the survival and engraftment of delivered genes and stem cells. Therefore, herein, we address the benefits and disadvantages of current therapeutic strategies for CLI treatment and summarize the novel and promising therapeutic approaches for CLI treatment. Our analyses also suggest that these novel CLI therapeutic strategies show considerable advantages to be used when current conventional methods have failed for CLI treatment.
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Affiliation(s)
- Mohammadhossein Hassanshahi
- School of Pharmacy and Medical Sciences, University of South Australia Cancer Research Institute, University of South Australia, Adelaide, SA, Australia
| | - Samira Khabbazi
- School of Pharmacy and Medical Sciences, University of South Australia Cancer Research Institute, University of South Australia, Adelaide, SA, Australia
| | - Yaser Peymanfar
- School of Pharmacy and Medical Sciences, University of South Australia Cancer Research Institute, University of South Australia, Adelaide, SA, Australia
| | - Alireza Hassanshahi
- Department of Genetics, Faculty of Basic Sciences, Shahrekord Branch, Islamic Azad University, Shahrekord, Iran
| | - Zahra Hosseini-Khah
- Department of Immunology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Yu-Wen Su
- School of Pharmacy and Medical Sciences, University of South Australia Cancer Research Institute, University of South Australia, Adelaide, SA, Australia
| | - Cory J Xian
- School of Pharmacy and Medical Sciences, University of South Australia Cancer Research Institute, University of South Australia, Adelaide, SA, Australia
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Levin SR, Arinze N, Siracuse JJ. Lower extremity critical limb ischemia: A review of clinical features and management. Trends Cardiovasc Med 2019; 30:125-130. [PMID: 31005554 DOI: 10.1016/j.tcm.2019.04.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 04/09/2019] [Indexed: 12/19/2022]
Abstract
Lower extremity critical limb ischemia (CLI) represents symptoms related to end-stage atherosclerotic peripheral arterial disease manifested by rest pain and tissue loss. It is associated with increased risk of limb amputation and cardiovascular-related mortality. The prevalence and cost of CLI are expected to increase with both the aging of the U.S. population and continued influence of smoking and diabetes. Treatments encompass measures to reduce cardiovascular risk and preserve limb viability. Despite increasing popularity of endovascular modalities, revascularization with either surgical bypass or endovascular intervention is the cornerstone of therapy. Adequate Level I data to guide decisions regarding optimal strategies to treat CLI, particularly in patients who are candidates for both open and percutaneous approaches, are currently lacking. Ongoing randomized controlled trials aim to resolve the clinical equipoise.
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Affiliation(s)
- Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, 88 E. Newton Street C520, Boston, MA 02118, United States
| | - Nkiruka Arinze
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, 88 E. Newton Street C520, Boston, MA 02118, United States
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, 88 E. Newton Street C520, Boston, MA 02118, United States.
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