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Migliara B, Feriani G, Mirandola M, Griso A, Cappellari TF, Nicoletti C. Percutaneous Deep Venous Arterialization Using an IVUS-Guided Technique in no-Option Patients with Chronic Limb-Threatening Ischemia: 24-Month Results. Cardiovasc Intervent Radiol 2024:10.1007/s00270-024-03828-4. [PMID: 39143335 DOI: 10.1007/s00270-024-03828-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 07/27/2024] [Indexed: 08/16/2024]
Abstract
PURPOSE In some patients, revascularization is not possible or is not effective. For these, percutaneous deep vein arterialization (p-DVA) could be considered an alternative treatment. The aim of this study is to evaluate the long-term results of an intravascular ultrasound (IVUS)-guided technique that has only one percutaneous access. MATERIALS AND METHODS This is a prospective monocentric study on 18 no-option CLTI limbs treated with an IVUS-guided p-DVA. The primary outcome measures are: the freedom from major adverse events (MAEs) and survival at 30 days; limb salvage and amputation free survival (AFS) at 30 days, 6 months, 12 months and 24 months. The secondary outcome measures are: procedural success, survival, patency and wound healing. RESULTS We treated 14 patients with no-option CLTI, carrying out 18 p-DVA. Median age was 74,4 years (60-87). All these patients had a previous failed angioplasty of the tibial and foot arteries. Procedural success rate, defined as the establishment of arterial flow into the venous system of the foot, was 100%. No deaths and MAEs recorded at 30 days. Survival was 100%, 83.4% and 77.8%; limb salvage was 88.9%, 77.8% and 77.8%; AFS was 88.9%, 61.1% and 55.6% at 6, 12 and 24 months. Complete wound healing was 18.7% at 6 months, 80.0% at 12 months and 100% at 24 months. CONCLUSION Based on these results, the IVUS-guided p-DVA seems to be safe and effective for no-option CLTI patients, with no mortality related to the intervention, an acceptable limb salvage rate and amputation free survival.
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Affiliation(s)
- Bruno Migliara
- Vascular and Endovascular Unit, Department of Surgery, Pederzoli Hospital, Ospedale Pederzoli, Via Monte Baldo, 26, 37019, Peschiera del Garda, Verona, Italy.
| | - Giovanni Feriani
- Vascular and Endovascular Unit, Department of Surgery, Pederzoli Hospital, Ospedale Pederzoli, Via Monte Baldo, 26, 37019, Peschiera del Garda, Verona, Italy
| | - Mattia Mirandola
- Vascular and Endovascular Unit, Department of Surgery, Pederzoli Hospital, Ospedale Pederzoli, Via Monte Baldo, 26, 37019, Peschiera del Garda, Verona, Italy
| | - Andrea Griso
- Vascular and Endovascular Unit, Department of Surgery, Pederzoli Hospital, Ospedale Pederzoli, Via Monte Baldo, 26, 37019, Peschiera del Garda, Verona, Italy
| | - Tania Francesca Cappellari
- Vascular and Endovascular Unit, Department of Surgery, Pederzoli Hospital, Ospedale Pederzoli, Via Monte Baldo, 26, 37019, Peschiera del Garda, Verona, Italy
| | - Cristian Nicoletti
- Diabetic Foot Unit, Department of Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
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Muraishi M, Nakama T, Obunai K, Watanabe H. Infected subcutaneous hematoma in percutaneous deep venous arterialization with an off-the shelf device and venous arterialization simplified technique. J Cardiol Cases 2024; 30:47-50. [PMID: 39170921 PMCID: PMC11337033 DOI: 10.1016/j.jccase.2024.04.004] [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: 09/13/2023] [Revised: 04/12/2024] [Accepted: 04/19/2024] [Indexed: 08/23/2024] Open
Abstract
A 65-year-old man with no-option chronic limb-threatening ischemia underwent percutaneous deep venous arterialization (pDVA). An arteriovenous fistula (AVF) was created using a modified venous arterialization simplified technique. During the balloon dilation of the AVF site, the venous puncture site was accidentally also dilated, resulting in massive bleeding. The angiographic bleeding was controlled by stent graft deployment, and the final angiography revealed good DVA flow. Two weeks post-pDVA, the patient developed right shin pain. Suspecting a subcutaneous hematoma and infection, extensive debridement was performed. The patient's wounds completely healed approximately 7 months after the pDVA. Learning Objective Modified venous arterialization simplified technique (m-VAST) is a feasible technique for percutaneous deep venous arterialization; however, it may lead to unexpected complications. When performing m-VAST, the possibility of puncture site complications should be carefully considered.
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Affiliation(s)
- Makio Muraishi
- Department of Cardiology, Tokyo Bay Medical Center, Urayasu, Japan
| | - Tatsuya Nakama
- Department of Cardiology, Tokyo Bay Medical Center, Urayasu, Japan
- Division of Vascular Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kotaro Obunai
- Department of Cardiology, Tokyo Bay Medical Center, Urayasu, Japan
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So SE, Chan YC, Cheng SW. Efficacy and Durability of Percutaneous Deep Vein Arterialization: A Systematic Review. Ann Vasc Surg 2024; 105:89-98. [PMID: 38579910 DOI: 10.1016/j.avsg.2024.01.008] [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: 09/18/2023] [Revised: 12/07/2023] [Accepted: 01/06/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Endovascular deep vein arteriaization (DVA) is a novel technique aimed at salvaging peripheral arterial disease unamenable to conventional surgical intervention. This study aims to review contemporary literature on the efficacy, safety, and durability of DVA on patients with no-option critical limb ischemia (NO-CLI). METHODS The study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, using predefined search terms of "percutaneous deep vein arterialization" or "percutaneous deep venous arterialization" in PubMed, Web of Sciences, OvidSP, and Embase. Only studies with 5 or more patients were included, and studies involving open or hybrid DVA were excluded. The primary outcomes included technical success and primary amputation rates. Secondary outcomes included rates of wound healing, complication, reintervention, and all-cause mortality. RESULTS Ten studies encompassing a total of 233 patients were included. Patients were primarily those deemed to have NO-CLI. The median follow-up period was 12 months (range 1-63 months). The technical success rate was 97% (95% confidence interval [CI] 96.2%-97.9%) and the major amputation rate was 21.8% (95% 21.1%-22.4%). The wound healing rate was 69.5% (95% CI 67.9-71.0%), complication rate was 13.8% (95% CI 11.7%-15.9%), reintervention rate was 37.4% (95% CI 34.9%-39.9%), and all-cause mortality rate was 15.7% (95% CI 14.1%-17.2%). CONCLUSIONS Our study showed that endovascular DVA is safe for patients with NO-CLI. Nonetheless, studies were small with follow-up period of less than 1 year. There is currently lack of level 1 evidence to recommend routine use in patients with NO-CLI.
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Affiliation(s)
- Samuel E So
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong SAR, China
| | - Yiu Che Chan
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong SAR, China.
| | - Stephen W Cheng
- Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong SAR, China
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Lepow BD, Zulbaran-Rojas A, Park C, Chowdhary S, Najafi B, Chung J, Ross JA, Mills JL, Montero-Baker M. Guillotine Transmetatarsal Amputations With Staged Closure Promote Early Ambulation and Limb Salvage in Patients With Advanced Chronic Limb-Threatening Ischemia. J Endovasc Ther 2024; 31:687-696. [PMID: 36565249 DOI: 10.1177/15266028221144587] [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] [Indexed: 12/25/2022]
Abstract
PURPOSE Transmetatarsal amputation (TMA) with primary closure has long been an option for limb salvage in patients with advanced chronic limb-threatening ischemia (CLTI) with extensive tissue loss of the forefoot. However, TMA healing and closure techniques are challenging, specifically in high-risk patients. Guillotine transmetatarsal amputations (gTMA) with staged closure may provide an alternative treatment in this population. We report long-term outcomes of such technique. MATERIALS AND METHODS A single-center retrospective cohort study of CLTI patients undergoing gTMA between 2017 and 2020 was performed. Limb salvage, wound healing, and survival rates were quantified using Kaplan-Meier (KM) analysis. Multivariate regression was used to identify the effect of patient characteristics on the outcomes. RESULTS Forty-four gTMA procedures were reviewed. Median follow-up was 381 (interquartile range [IQR], 212-539.75) days. After gTMA, 87.8% (n=36) of the patients were able to ambulate after a median interval of 2 (IQR, 1-3) days. Eventual coverage was achieved in a personalized and staged approach by using a combination of skin substitutes (88.6%, n=39) ± split thickness skin grafts (STSG, 61.4%, n=27). KM estimates for limb salvage, wound healing, and survival were 84.1%, 54.5%, and 88.6% at 1 year and 81.8%, 63.8%, and 84.1% at 2 years. Wound healing was significantly associated with STSG application (p=0.002, OR=16.5, 95% CI 2.87-94.81). CONCLUSION gTMA resulted in high limb salvage rates during long-term follow-up in CLTI patients. Adjunctive STSG placement may enhance wound healing at the gTMA site, thus leading to expedited wound closure. Surgeons may consider gTMA as an alternative to reduce limb loss in CLTI patients at high risk of major amputation. CLINICAL IMPACT Currently, the clinical presentation of CLTI is becoming more complex to deal with due to the increasing comorbidities as the society becomes older. The data shown in this article means for clinicians that when facing diffused forefoot gangrene and extensive tissue loss, limb preservation could still be considered instead of major amputation. Guillotine transmetatarsal amputations in the setting of an aggressive multidisciplinary group, can be healed by the responsibly utilization of dermal substitutes and skin grafts leading to the preservation of the extremity, allowing mobility, avoiding of sarcopenia, and decreasing frailty. This will equate to maintenance of independent living and preservation of lifespan.
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Affiliation(s)
- Brian D Lepow
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Alejandro Zulbaran-Rojas
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Catherine Park
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Michael E. DeBakey VA Medical Center, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, VA Health Services Research & Development, Houston, TX, USA
- The Big Data Scientist Training Enhancement Program, VA Office of Research & Development, Washington, DC, USA
| | - Saakshi Chowdhary
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Bijan Najafi
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jayer Chung
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jeffrey A Ross
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Miguel Montero-Baker
- Vascular Surgery, Houston Methodist Cardiovascular Surgery Associates, Houston, TX, USA
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Tan M, Ueshima D, Iida O, Soga Y, Tobita K, Hayakawa N, Fujihara M, Mori S, Tsubakimoto Y, Nakao S, Tokuda T, Horie K, Kato T, Kaneko N, Ando H, Iwata S, Nakagawa Y, Sunaga D, Urasawa K. Clinical validity of the Japanese below-the-knee chronic total occlusion scoring system for the prediction of successful guidewire crossing. J Vasc Surg 2024:S0741-5214(24)01528-3. [PMID: 39029811 DOI: 10.1016/j.jvs.2024.07.025] [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: 04/24/2024] [Revised: 06/06/2024] [Accepted: 07/11/2024] [Indexed: 07/21/2024]
Abstract
OBJECTIVE To validate the Japanese below-the-knee (J-BTK) chronic total occlusion (CTO) score for the prediction of successful guidewire crossing (S-GC) in angiographic evaluation. METHODS A prospective, multicenter, nonrandomized study examined 751 consecutive BTK CTOs in 497 patients treated with endovascular therapy in 16 Japanese medical centers from April 2021 to March 2022. The cohort was classified into 2 groups: an S-GC group and a failed guidewire crossing group. RESULTS The J-BTK CTO score, which assigned one point to "Blunt type at the proximal entry point," one point to "Calcification at the proximal entry point," one point to "Reference vessel diameter <2.0 mm," one point to "CTO length ≥200 mm," and two points to "No outflow of the target vessel," was used to categorize BTK CTOs into 4 grades with varying probabilities of S-GC: grade A (J-BTK CTO score of 0 and 1), grade B (score of 2 and 3), grade C (score of 4 and 5), and grade D (score of 6). Rates of S-GC in each grade (grades A, B, C, and D) were 97.5%, 89.1%, 62.5%, and 27.3%, respectively. The area under the receiver-operating characteristic curve for S-GC was 0.8304. Although the previous J-BTK CTO study enrolled only de novo lesions, both de novo and restenotic lesions were evaluated in this study. De novo lesions have a lower chance of S-GC (odds ratio: 0.24, 95% confidence interval: 0.09-0.67) in the multivariate analysis, and the area under the receiver-operating characteristic curve of the modified J-BTK CTO score, which additionally assigned two points to "De novo lesion," was 0.846. The modified J-BTK CTO score showed an appropriate calibration (Hosmer-Lemeshow P = .957). CONCLUSIONS The J-BTK CTO score and the modified J-BTK CTO score predict the probability of an S-GC of BTK CTOs and stratify the difficulty of endovascular therapy for BTK CTOs in angiographic evaluation.
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Affiliation(s)
- Michinao Tan
- Department of Cardiology, Tokeidai Memorial Hospital, Sapporo, Japan.
| | - Daisuke Ueshima
- Department of Cardiology, Kameda Medical Center, Chiba, Japan
| | - Osamu Iida
- Osaka Police Hospital Cardiovascular Division, Osaka, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Kazuki Tobita
- Department of Cardiology, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Naoki Hayakawa
- Department of Cardiology, Asahi General Hospital, Chiba, Japan
| | - Masahiko Fujihara
- Department of Cardiology, Kishiwada Tokushukai Hospital, Kishiwada, Japan
| | - Shinsuke Mori
- Department of Cardiology, Saiseikai Yokohama City Eastern Hospital, Kanagawa, Japan
| | | | - Sho Nakao
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Takahiro Tokuda
- Department of Cardiology, Nagoya Heart Center, Nagoya, Japan
| | - Kazunori Horie
- Department of Cardiovascular Medicine, Sendai Kousei Hospital, Sendai, Japan
| | - Taku Kato
- Department of Cardiology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan; Department of Cardiology, Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Nobuhito Kaneko
- Heart Center, Kasukabe Chuo General Hospital, Saitama, Japan
| | - Hiroshi Ando
- Heart Center, Kasukabe Chuo General Hospital, Saitama, Japan
| | - Shuko Iwata
- Department of Cardiology, Tokeidai Memorial Hospital, Sapporo, Japan
| | - Yuya Nakagawa
- Department of Cardiology, Hakodate Medical Association Hospital, Hakodate, Japan
| | - Daisuke Sunaga
- Department of Cardiology, Hokkaido Cardiovascular Hospital, Sapporo, Japan
| | - Kazushi Urasawa
- Department of Cardiology, Tokeidai Memorial Hospital, Sapporo, Japan
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Saini N, Marrone L, Desai S, Herman KC, Rundback JH. Comparison of outcomes of percutaneous deep venous arterialization in multiple practice settings. J Vasc Surg 2024:S0741-5214(24)01230-8. [PMID: 38830436 DOI: 10.1016/j.jvs.2024.05.051] [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: 02/19/2024] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVE We compared the efficacy of percutaneous deep venous arterialization (pDVA) in patients with no-option chronic limb-threatening ischemia in the hospital vs in office-based laboratory (OBL) settings. METHODS A retrospective chart review was performed of all patients who underwent pDVA using off-the-shelf devices from January 2018 to March 2023 in a hospital and an OBL. We identified 73 eligible patients, 41 from a hospital setting (59% male; median age, 72 years; interquartile range, 18 years) and 32 from an OBL setting (59% males; 67 years; interquartile range, 16 years). All eligible patients were deemed to have no-option critical limb ischemia, had at least one patent proximal tibial artery available for the creation of an arteriovenous anastomosis, and were classified as having Rutherford classification IV or higher peripheral arterial disease. Patients were ineligible if classified as Rutherford classification III or lower, had active infection, did not have at least one appropriate venous target, and/or had rapidly progressing wounds requiring immediate major amputation. The primary outcome was major amputation-free survival (AFS). Secondary outcomes included technical success, limb salvage, survival, primary patency, reintervention rate, adverse events, and partial and complete wound healing. Outcomes were evaluated using Kaplan-Meier method, log-rank, and two-stage procedure tests. RESULTS Technical success was achieved in 70 patients (96%) with 1 hospital (2.4%) and 2 OBL (6.3%) patients lost to follow-up. Major AFS estimates at 6 months, 1 year, and 2 years were 51.4%, 40.4%, and 30.2% in the hospital group and 69.4%, 54.0%, and 49.5% in the OBL group, respectively. Partial wound healing estimates at 6 months, 1 year, and 2 years were 27.5%, 71.7%, and 81.2% in the hospital group and 62.7% at all time points in the OBL group. Complete wound healing estimates at 6 months, 1 year, and 2 years were 6.7%, 33.3%, and 33.3% in the hospital group and 5.3%, 37.7%, and 41.6% in the OBL group, respectively. There was no significant difference in major AFS (P = .13), limb salvage (P = .07), survival (P = .69), primary patency (P = .53), partial (P = .08), or complete wound healing (P = .79) between groups. Reintervention was performed in 8 hospital (20.5%) and 14 OBL (45.2%) patients. CONCLUSIONS pDVA is a feasible and safe procedure for no-option critical limb ischemia in the hospital and OBL setting without significant differences in outcomes at ≤2 years.
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Affiliation(s)
- Neginder Saini
- Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, NY
| | | | - Sanket Desai
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY
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Huang I, Nakama T, Ichihashi S, Pua U. Technical Aspects of Percutaneous Deep Venous Arterialization Using Off-the-Shelf Devices. J Endovasc Ther 2024; 31:350-359. [PMID: 36168745 DOI: 10.1177/15266028221127850] [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] [Indexed: 11/16/2022]
Abstract
PURPOSE Chronic limb-threatening ischemia (CLTI) represents the clinical end stage of lower extremity peripheral arterial disease (PAD). Although conventional open and endovascular revascularization options are available, some CLTI patients do not respond to these treatments, generally due to small vessel occlusive disease, with only limited or no clinical improvement achieved. This article aims to provide insights related to pertinent venous anatomy of the leg and below the ankle and a technical review of percutaneous deep venous arterialization (pDVA) creation using commonly-available devices. TECHNIQUE For patients with "no-option" CLTI, the risk of major amputation and mortality remains high. Although arterial revascularization remains the optimal treatment of CLTI, some patients with severely-diseased or gracile distal arteries have poor outcome. Deep venous arterialization (DVA), in a subset of patients with tibial anatomy amenable to DVA creation, represents the last-ditch attempt before these patients are deemed to have "no-hope" at limb salvage, and major amputation becomes necessary. Refinement in technique and advancement in device development have been shown to allow pDVA to be created with respectable outcomes for the "no-option" CLTI patient population. CONCLUSION The pDVA has garnered increasing interest among endovascular specialists to further understand the anatomical and technical key points of this procedure, and it may yet prove to be a useful addition in the armamentarium in our battle against CLTI. CLINICAL IMPACT Percutaneous deep venous arterialisation provides another option in the treatment of challenging "no-option" CLTI patients, and off-the-shelf devices will allow this procedure to be performed in centers where dedicated devices are not available.
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Affiliation(s)
- Ivan Huang
- Department of Radiology, Tan Tock Seng Hospital, Singapore
| | | | | | - Uei Pua
- Department of Radiology, Tan Tock Seng Hospital, Singapore
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Kapetanios D, Czihal M, Tsilimparis N, Torsello G, Rieck J, Stavroulakis K. Intravascular lithotripsy-assisted percutaneous deep vein arterialization for no-option chronic limb-threatening patients and heavily calcified tibial occlusive disease. Vascular 2024:17085381241257736. [PMID: 38807487 DOI: 10.1177/17085381241257736] [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: 05/30/2024]
Abstract
PURPOSE To report the first chronic limb-threatening ischemia (CLTI) patients who underwent an intravascular lithotripsy (IVL)-assisted percutaneous deep vein arterialization (pDVA). CASE REPORT 1 An 81-year-old patient presented with CLTI and a heavily calcified lesion of the popliteal artery and tibioperoneal trunk (TPT), with a distal tibial and foot arch occlusion. The patient underwent IVL and drug-coated balloon angioplasty for the distal popliteal artery and of the TPT to improve the inflow prior to pDVA. The wound situation remained stable without secondary procedure until the patient`s deaths due to complications of urosepsis 3 months later. CASE REPORT 2 A 64-year-old patient with rest pain of the left limb with a single-vessel tibial run-off (peroneal artery) and occluded pedal arch was treated with 3.5 mm IVL followed by a successful pDVA as mentioned above. IVL performed in the proximal posterior tibial artery to optimize the inflow to the circuit and change the compliance of the crossing point from the arterial to the vein system. The patient underwent repeat angioplasty of the plantar vein arch 5 months after the index procedure and thereafter remained asymptomatic during 2 years of follow-up. CONCLUSION The combined use of IVL and pDVA could improve the patency of the reconstruction with clinical benefits in no-option CTLI patients.
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Affiliation(s)
- Dimitrios Kapetanios
- Department of Vascular Surgery, Ludwig-Maximillians-University Hospital Munich, Munich, Germany
| | - Michael Czihal
- Division of Vascular Medicine, Medical Clinic and Policlinic IV, Hospital of the Ludwig-Maximillians-University, Munich, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximillians-University Hospital Munich, Munich, Germany
| | - Giovanni Torsello
- Department of Vascular and endovascular Surgery, St Franziskus Hospital Muenster, Munster, Germany
| | - Julian Rieck
- Clinical Consultant and therapy development Limflow medical, Paris, France
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Janda L, Clair D. Transcatheter Arterialization of the Deep Veins for Limb Salvage. Ann Vasc Surg 2024:S0890-5096(24)00158-4. [PMID: 38583763 DOI: 10.1016/j.avsg.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/03/2024] [Indexed: 04/09/2024]
Abstract
Critical limb-threatening ischemia is the most advanced stage of peripheral arterial disease, and patients with this problem represent a group at very high risk of limb loss. Until recently, patients with severe disease in the foot that was unreconstructable through the arterial system were relegated to treatment with wound care, pain management, and ultimately often faced major amputation. In recent investigations into the use of a percutaneous approach to venous arterialization, transcatheter arterialization of the deep veins has been evaluated as a mechanism to improve oxygen delivery to the foot in patients faced with the prospect of limb loss. Identifying patients who would benefit from this approach and a critical evaluation of the technique are provided along with expected outcomes. While the procedure remains in its infancy, early outcomes are promising, and continued advancement and improvement will further enhance options for these patients.
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Affiliation(s)
- Layne Janda
- Department of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Daniel Clair
- Department of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN.
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Li J, Varcoe R, Manzi M, Kum S, Iida O, Schmidt A, Shishehbor MH. Below-the-Knee Endovascular Revascularization: A Position Statement. JACC Cardiovasc Interv 2024; 17:589-607. [PMID: 38244007 DOI: 10.1016/j.jcin.2023.11.040] [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: 10/24/2022] [Revised: 10/30/2023] [Accepted: 11/28/2023] [Indexed: 01/22/2024]
Abstract
Patients with chronic limb-threatening ischemia, the terminal stage of peripheral artery disease, are frequently afflicted by below-the-knee disease. Although all patients should receive guideline-directed medical therapy, restoration of inline flow is oftentimes necessary to avoid limb loss. Proper patient selection and proficiency in endovascular techniques for below-the-knee revascularization are intended to prevent major amputation and promote wound healing. This review, a consensus among an international panel of experienced operators, provides guidance on these challenges from an endovascular perspective and offers techniques to navigate this complex disease process.
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Affiliation(s)
- Jun Li
- University Hospitals Harrington Heart and Vascular Institute, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ramon Varcoe
- Prince of Wales Hospital, Sydney, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Marco Manzi
- Interventional Radiology Unit, Foot and Ankle Clinic, Policlinico Abano Terme, Abano Terme, Italy
| | - Steven Kum
- Department of Surgery, Changi General Hospital, Singapore
| | - Osamu Iida
- Kasai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Andrej Schmidt
- Division of Angiology, Department of Internal Medicine, Neurology and Dermatology, University Hospital Leipzig, Leipzig, Germany
| | - Mehdi H Shishehbor
- University Hospitals Harrington Heart and Vascular Institute, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
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Shanmugasundaram S, Herman K, Rundback JH. Percutaneous Deep Venous Arterialization in Patients with No-Option Critical Limb Ischemia Performed in an Office-Based Laboratory Setting. J Vasc Interv Radiol 2024; 35:278-284. [PMID: 37839526 DOI: 10.1016/j.jvir.2023.10.003] [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: 04/23/2023] [Revised: 09/24/2023] [Accepted: 10/08/2023] [Indexed: 10/17/2023] Open
Abstract
PURPOSE To evaluate the feasibility and safety of percutaneous deep venous arterialization (pDVA) performed in an office-based laboratory (OBL) for patients with no-option critical limb ischemia (CLI). MATERIALS AND METHODS A retrospective chart review was performed of all patients who underwent pDVA using commercially available devices from January 2018 to November 2021 in a single OBL. In total, 22 patients (10 males and 12 females; Rutherford 4, 5, and 6: n = 1, 8, and 13, respectively) were identified with a median follow-up of 140 days. Amputation-free survival, wound healing, pDVA patency, and overall survival were evaluated at 30 days, 6 months, and throughout the remaining follow-up period. RESULTS All patients had undergone failed previous attempts at endovascular arterial reconstruction. At 6 months after procedure, 6.4% of arteriovenous conduits remained patent; 83.3% (10/12) of patients experienced complete or partial wound healing. In addition, 78.6% of patients avoided an above-ankle amputation, and overall survival was 83.6%. Nine patients underwent endovascular reinterventions at 6 months. One mild adverse event and 4 moderate adverse events occurred after procedure, and 1 cardiac death occurred 5 days after procedure. CONCLUSIONS pDVA is safe and feasible in the OBL for patients with no-option CLI. Many patients avoided an above-ankle amputation during the study period despite low overall pDVA patency.
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Affiliation(s)
| | - Kevin Herman
- NJ Endovascular & Amputation Prevention, West Orange, New Jersey
| | - John H Rundback
- NJ Endovascular & Amputation Prevention, West Orange, New Jersey.
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Roustazadeh R, Gombert A, Krabbe J, Jacobs M, Doukas P. Short-Term Outcomes and Efficacy of Percutaneous Deep Vein Arterialization for No-Option Critical Limb Ischemia: A Systematic Review and Meta-Analysis. Biomedicines 2024; 12:318. [PMID: 38397920 PMCID: PMC10886738 DOI: 10.3390/biomedicines12020318] [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: 12/20/2023] [Revised: 01/13/2024] [Accepted: 01/15/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Percutaneous deep vein arterialization (pDVA) is considered a treatment modality in patients with no-option critical limb ischemia. However, there is still a paucity of evidence regarding its safety and efficacy. DATA SOURCES MEDLINE (via PubMed), Embase and Web of Science databases as well as the CENTRAL registry up to the end of June 2023. METHODS This review adhered to the PRISMA guidelines (PROSPERO registration no. CRD42023445171). The risk of bias was assessed using the methodological index for non-randomized studies (MINORS). Primary endpoints included technical success, overall survival and limb salvage during the follow-up. Amputation-free survival at 30 days, 6 months and 1 year as well as complete wound healing, major adverse limb events and reintervention were investigated as secondary outcomes. RESULTS Five observational studies, comprising 208 patients (142 Rutherford class 5/77 Rutherford class 6), were included. MINORS revealed a low risk of bias. The meta-analysis reached a pooled technical success rate of 96.2% (95% CI: 91.5-98.4), an overall survival of 82.8% (95% CI: 70.5-95.2) and a limb salvage rate of 77.2% (95% CI: 65.2-89.1) during the follow-up. The amputation-free survival at 30 days, 6 months and 1 year was 87.8%, 68.7% and 65.6%, respectively. Furthermore, pDVA resulted in a complete wound healing rate of 53.4% (95% CI: 30.3-76.5). The pooled reintervention rate was as high as 46.7% (37.1-56.3%). CONCLUSIONS PDVA seems a feasible bail-out strategy for patients with no option for routine treatment of CLTI. However, due to the small number of studies, the strength of the evidence is low.
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Affiliation(s)
- Roshanak Roustazadeh
- European Vascular Centre Aachen-Maastricht, Department of Vascular Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany; (A.G.); (M.J.); (P.D.)
| | - Alexander Gombert
- European Vascular Centre Aachen-Maastricht, Department of Vascular Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany; (A.G.); (M.J.); (P.D.)
| | - Julia Krabbe
- Institute of Occupational, Social and Environmental Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Michael Jacobs
- European Vascular Centre Aachen-Maastricht, Department of Vascular Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany; (A.G.); (M.J.); (P.D.)
| | - Panagiotis Doukas
- European Vascular Centre Aachen-Maastricht, Department of Vascular Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany; (A.G.); (M.J.); (P.D.)
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13
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Ucci A, Perini P, Freyrie A, Schreve MA, Ünlü Ç, Huizing E, van den Heuvel DA, Kum S, Shishehbor MH, Ferraresi R. Endovascular and Surgical Venous Arterialization for No-Option Patients With Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis. J Endovasc Ther 2023:15266028231210220. [PMID: 38009322 DOI: 10.1177/15266028231210220] [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: 11/28/2023]
Abstract
BACKGROUND Chronic limb-threatening ischemia (CLTI) is known for its high rates of major amputation and mortality. Conventional revascularization techniques often fail in CLTI patients due to the heavily diseased arteries. Foot vein arterialization (FVA) has been proposed as an alternative technique to provide arterial blood to the foot by using the disease-free venous bed. OBJECTIVES This systematic review and meta-analysis aimed to determine outcomes of surgical FVA (sFVA) and percutaneous FVA (pFVA) at 6 and 12 months post-procedure. DATA SOURCES PubMed, Scopus, Web of Science, and the Cochrane Library databases were searched to identify papers reporting clinical outcomes of sFVA and pFVA published between January 1966 and March 2023. METHODS Databases were searched for eligible studies. A meta-analysis was performed to evaluate the limb salvage rate, overall survival rate, and wound healing rate at 6 and 12 months. RESULTS A total of 27 studies were included, with 753 patients and 793 limbs. Of the included studies, 16 analyzed the sFVA technique and 11 the pFVA technique. Of the included patients, 86.3% were Rutherford 5/6 in the sFVA group versus 98.4% in the pFVA group. The pooled limb salvage rate at 6 and 12 months was 78.1% and 74.1% in the sFVA group and 81.7% and 78.6% in the pFVA group, respectively. Wound healing rates were not reported in the sFVA group. In the pFVA group, the pooled wound healing rates were 48.1% and 64.5% at 6 and 12 months, respectively. CONCLUSION This study showed promising results after FVA among a large population of CLTI patients. In high-risk patients, pFVA is a feasible option with favorable limb salvage and wound healing rates.
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Affiliation(s)
- Alessandro Ucci
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Paolo Perini
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Antonio Freyrie
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Michiel A Schreve
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Çağdaş Ünlü
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Eline Huizing
- Department of Radiology, Spaarne Hospital, Haarlem, the Netherlands
| | | | - Steven Kum
- Vascular Service, Department of Surgery, Changi General Hospital, Singapore
| | - Mehdi H Shishehbor
- University Hospitals Harrington Heart and Vascular Institute, Cleveland, OH, USA
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14
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Watson NW, Mosarla RC, Secemsky EA. Endovascular Interventions for Peripheral Artery Disease: A Contemporary Review. Curr Cardiol Rep 2023; 25:1611-1622. [PMID: 37804391 DOI: 10.1007/s11886-023-01973-9] [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] [Accepted: 09/26/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE OF REVIEW Peripheral artery disease (PAD) is an increasingly prevalent but frequently underdiagnosed condition that can be associated with high rates of morbidity and mortality. While an initial noninvasive approach is the cornerstone of management, revascularization is often pursued for patients with treatment-refractory claudication or chronic limb-threatening ischemia (CLTI). In this review, we discuss the current state of endovascular interventions for PAD and explore the many new emerging technologies. RECENT FINDINGS The last decade has resulted in numerous advances in PAD interventions including the ongoing evolution of drug-coated devices, novel approaches to complex lesions, and contemporary evidence from large clinical trials for CLTI. Advances in endovascular management have allowed for increasingly complex lesions to be tackled percutaneously. Future directions for the field include the continued evolution in device technology, continued development of state-of-the-art techniques to revascularization of complex lesions, and increased collaboration between a largely multidisciplinary field.
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Affiliation(s)
- Nathan W Watson
- Harvard Medical School, Boston, MA, USA
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ramya C Mosarla
- Division of Cardiology, Department of Medicine, New York University Medical Center, New York, NY, USA
| | - Eric A Secemsky
- Harvard Medical School, Boston, MA, USA.
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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15
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Smith JA, Kandala J, Turner JT, Cho JS, Shishehbor MH. Off-the-shelf percutaneous deep vein arterialization for no-option chronic limb-threatening ischemia related to Buerger disease. J Vasc Surg Cases Innov Tech 2023; 9:101211. [PMID: 37388665 PMCID: PMC10300406 DOI: 10.1016/j.jvscit.2023.101211] [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] [Received: 03/02/2023] [Accepted: 04/05/2023] [Indexed: 07/01/2023] Open
Abstract
Percutaneous deep venous arterialization (pDVA) is an important technique in the pursuit of limb salvage for a certain high-risk subset of patients with chronic limb-threatening ischemia (CLTI) considered to have "no option" owing to the lack of tibial or pedal targets for revascularization. pDVA seeks to establish an arteriovenous connection at the level of the tibial vessels, in addition to tibial and/or pedal venoplasty, to provide a pathway for arterial perfusion via the tibial and/or plantar venous system. A commercial system for pDVA exists; however, it is not yet approved by the U.S. Food and Drug Administration. In the present report, we detail a method of pDVA that uses commercially available devices for a patient with no-option CLTI related to Buerger disease.
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Affiliation(s)
- Justin A. Smith
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jagdesh Kandala
- Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jason Ty Turner
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jae S. Cho
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Mehdi H. Shishehbor
- Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
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16
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Ong DY, Yong E, Pua U. Utility of BeBack crossing catheter in fistula creation during percutaneous deep vein arterialization. J Vasc Surg Cases Innov Tech 2023; 9:101201. [PMID: 37799848 PMCID: PMC10547733 DOI: 10.1016/j.jvscit.2023.101201] [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: 01/25/2023] [Accepted: 04/06/2023] [Indexed: 10/07/2023] Open
Abstract
For patients with "no-option" chronic limb-threatening ischemia, a final attempt can be made for limb salvage in the form of percutaneous deep vein arterialization (pDVA). In the present study, we describe five cases of pDVA using a BeBack crossing catheter (Bentley InnoMed GmbH; previously, the GoBack crossing catheter; Upstream Peripheral Technologies). From November 2021 to July 2022, five patients underwent pDVA using the BeBack crossing catheter. The demographic data, procedural details, and patient outcomes were recorded. Successful vascular crossing was achieved in all five cases using the BeBack device. No surgical complications were encountered. The limb salvage rate was 60%, and the wound closure rate was 40%. No mortalities occurred during the follow-up period. The findings from the present study demonstrate that the use of the BeBack crossing catheter for pDVA is safe and feasible.
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Affiliation(s)
- Daniel Yuxuan Ong
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore
| | - Enming Yong
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Uei Pua
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore
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17
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Montero-Baker M, Sommerset J, Miranda JA. Hybrid superficial venous arterialization and endovascular deep venous arterialization. J Vasc Surg Cases Innov Tech 2023; 9:101160. [PMID: 37404577 PMCID: PMC10315921 DOI: 10.1016/j.jvscit.2023.101160] [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] [Received: 01/25/2023] [Accepted: 02/24/2023] [Indexed: 07/06/2023] Open
Abstract
We report on two venous arterialization (VA) techniques for treatment of CLTI in patients traditionally considered as having no treatment options for standard arterial endovascular or surgical bypass procedures. Screening and the preprocedural workup findings are outlined as deciding factors in determining a patient's fitness for the two techniques, with a focus on careful preprocedure arterial duplex ultrasound and assessment for vein suitability. Cardiac and infection screening are also factors in determining patient suitability for VA. In addition, radiographic assessment for the presence of medial artery calcification, which is used as a marker of technical difficulty and is a predictor of poor outcomes, is required. Ultimately, anatomic factors are used to determine the decision between hybrid superficial VA and or endovascular deep VA. Those with an occluded anterior tibial artery and suitable great saphenous vein are prioritized to hybrid superficial VA, and those with an occluded posterior tibial artery to endovascular deep VA. Both procedures are described in detail in this report of vascular and surgical techniques.
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Affiliation(s)
| | - Jill Sommerset
- Hope Vascular & Podiatry Clinical Innovation Center, Houston, TX
- Advanced Vascular Centers, Portland, OR
| | - Jorge A. Miranda
- Division of Vascular and Endovascular Surgery, Department of Surgery, Baylor College of Medicine, Houston, TX
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18
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Fang Y, Liu H, Pan T, Fang G, Fu W, Lin J, Liu J, Dong Z. Evaluation of the lower extremity blood supply in no-option critical limb ischemia patients with stem cell transplantation by time maximum intensity projection CT perfusion: A single-centre prospective study. Vascular 2023:17085381231192852. [PMID: 37523200 DOI: 10.1177/17085381231192852] [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: 08/01/2023]
Abstract
OBJECTIVES Cell therapy has had satisfactory safety and efficacy outcomes for no-option critical limb ischaemia (NO-CLI) patients. In the current study, we aimed to compare the image quality of ischaemic lower limb blood vessels shown on volumetric CT-based time maximum intensity projection CT perfusion (t-MIP CTP) versus single-phase CTA (sCTA). We also tried to quantify the blood flow of the ischaemic lower extremity based on the t-MIP technique, not only to precisely show the dynamic change in blood flow from before to after cell therapy but also to detect any relationship between this change and patient prognosis. METHODS A total of 31 patients with thromboangiitis obliterans (TAO)-induced NO-CLI who had been referred from the department of vascular surgery to undergo autologous stem cell transplantation into a single limb from January 2020 to March 2021 were prospectively enrolled in this study. Preoperative sCTA or t-MIP CTP and postoperative 1-month t-MIP CTP were performed in all patients. Clinical outcomes, including the 1-month ankle-brachial index (ABI) and 3-month CLI status, were also analysed. Image quality, including objective scores (attenuation, signal-to-noise ratio [SNR] and contrast-to-noise ratio [CNR]), subjective scores and collateral scores, was compared between preoperative sCTA and t-MIP CTP. Vascular volume was calculated as the total volume (mL) of lower limb arteries within the scanning range. All images and calculations were performed by 2 separate radiologists. Receiver operating characteristic curves were drawn to reveal the sensitivity and specificity of vascular volume and ABI in predicting prognosis. RESULTS Both sCTA and t-MIP CTP images exhibited good quality for diagnosis. t-MIP CTP images showed significantly higher attenuation, SNR and CNR in all arterial segments (popliteal artery, anterior tibial artery, posterior tibial artery and peroneal artery). In subjective and collateral score evaluations, t-MIP CTP images were also significantly better than sCTA images (both p < .05). At 1 month after transplantation, both vascular volume and ABI showed significant improvement (both p < .01). At 3 months after transplantation, 38.71% of patients (12/31) achieved CLI relief (Rutherford class < 4). Through the receiver operating characteristic (ROC) curve, the 1-month vascular volume increase ratio showed better ability to predict the 3-month prognosis (radiologist 1: AUC, 0.757; sensitivity, 0.750; specificity, 0.840; radiologist 2: AUC, 0.803; sensitivity, 0.500; specificity, 1.000) than the 1-month ABI increase ratio (AUC, 0.607; sensitivity, 0.230; specificity, 0.820) or 1-month ABI (AUC, 0.410; sensitivity, 0.080; specificity, 0.580). CONCLUSION t-MIP CTP showed significantly higher-quality images of ischaemic limb vascularity than sCTA. t-MIP CTP can reveal the anatomical information of collaterals more accurately, which is of great importance for NO-CLI patients undergoing cell transplantation. The 1-month vascular volume increase ratio can predict the 3-month prognosis more precisely on this basis.
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Affiliation(s)
- Yuan Fang
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Hao Liu
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Tianyue Pan
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Gang Fang
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Weiguo Fu
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Jiang Lin
- Departments of Medical Imaging of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Junzhen Liu
- Departments of Medical Imaging of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhihui Dong
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
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19
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Zaman N, Rundback J. Deep Venous Arterialization: Background, Patient Selection, Technique, Outcomes and Follow-up, and Future Implementation. Semin Intervent Radiol 2023; 40:183-192. [PMID: 37333738 PMCID: PMC10275674 DOI: 10.1055/s-0043-57264] [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: 06/20/2023]
Abstract
Critical limb-threatening ischemia (CLTI) is a severe manifestation of peripheral arterial disease with a highly increased risk for morbidity and mortality that has limited and suboptimal opportunities for treatment, ultimately resulting in major amputation for patients. Deep venous arterialization (DVA) provides a suitable limb salvage option for "no-option" patients facing amputation by introducing an artificial anastomosis between a site of proximal arterial inflow and retrograde venous outflow to deliver tissue perfusion to lower extremity wounds. Because DVAs are employed as a last-resort effort in CLTI patients, it is important to provide updated information on indications for usage, strategies in creating DVA conduits, and discussion of outcomes and expectations for patients undergoing this procedure. Additionally, variations in method, including use of various techniques and devices, are explored. The authors provide an up-to-date review of the literature and discuss pertinent procedural and technical considerations for utilizing DVAs in CLTI patients.
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Affiliation(s)
- Naveed Zaman
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - John Rundback
- Advanced Interventional and Vascular Services, LLP, Teaneck, New Jersey
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20
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Shishehbor MH, Powell RJ, Montero-Baker MF, Dua A, Martínez-Trabal JL, Bunte MC, Lee AC, Mugglin AS, Mills JL, Farber A, Clair DG. Transcatheter Arterialization of Deep Veins in Chronic Limb-Threatening Ischemia. N Engl J Med 2023; 388:1171-1180. [PMID: 36988592 DOI: 10.1056/nejmoa2212754] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND Approximately 20% of patients with chronic limb-threatening ischemia have no revascularization options, leading to above-ankle amputation. Transcatheter arterialization of the deep veins is a percutaneous approach that creates an artery-to-vein connection for delivery of oxygenated blood by means of the venous system to the ischemic foot to prevent amputation. METHODS We conducted a prospective, single-group, multicenter study to evaluate the effect of transcatheter arterialization of the deep veins in patients with nonhealing ulcers and no surgical or endovascular revascularization treatment options. The composite primary end point was amputation-free survival (defined as freedom from above-ankle amputation or death from any cause) at 6 months, as compared with a performance goal of 54%. Secondary end points included limb salvage, wound healing, and technical success of the procedure. RESULTS We enrolled 105 patients who had chronic limb-threatening ischemia and were of a median age of 70 years (interquartile range, 38 to 89). Of the patients enrolled, 33 (31.4%) were women and 45 (42.8%) were Black, Hispanic, or Latino. Transcatheter arterialization of the deep veins was performed successfully in 104 patients (99.0%). At 6 months, 66.1% of the patients had amputation-free survival. According to Bayesian analysis, the posterior probability that amputation-free survival at 6 months exceeded a performance goal of 54% was 0.993, which exceeded the prespecified threshold of 0.977. Limb salvage (avoidance of above-ankle amputation) was attained in 67 patients (76.0% by Kaplan-Meier analysis). Wounds were completely healed in 16 of 63 patients (25%) and were in the process of healing in 32 of 63 patients (51%). No unanticipated device-related adverse events were reported. CONCLUSIONS We found that transcatheter arterialization of the deep veins was safe and could be performed successfully in patients with chronic limb-threatening ischemia and no conventional surgical or endovascular revascularization treatment options. (Funded by LimFlow; PROMISE II study ClinicalTrials.gov number, NCT03970538.).
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Affiliation(s)
- Mehdi H Shishehbor
- From University Hospitals Harrington Heart and Vascular Institute, Cleveland (M.H.S.); the Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (R.J.P.); the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston (M.F.M.-B., J.L.M.); the Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School (A.D.), and the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine (A.F.) - both in Boston; the Division of Vascular Surgery, Ponce Health Sciences University, St. Luke's Episcopal Hospital, Ponce, Puerto Rico (J.L.M.-T.); Saint Luke's Mid America Heart Institute, Kansas City, MO (M.C.B.); HCA Florida North Florida Hospital, the Cardiac and Vascular Institute, Gainesville (A.C.L.); Paradigm Biostatistics, Anoka, MN (A.S.M.); and the Department of Vascular Surgery, Vanderbilt School of Medicine, Nashville (D.G.C.)
| | - Richard J Powell
- From University Hospitals Harrington Heart and Vascular Institute, Cleveland (M.H.S.); the Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (R.J.P.); the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston (M.F.M.-B., J.L.M.); the Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School (A.D.), and the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine (A.F.) - both in Boston; the Division of Vascular Surgery, Ponce Health Sciences University, St. Luke's Episcopal Hospital, Ponce, Puerto Rico (J.L.M.-T.); Saint Luke's Mid America Heart Institute, Kansas City, MO (M.C.B.); HCA Florida North Florida Hospital, the Cardiac and Vascular Institute, Gainesville (A.C.L.); Paradigm Biostatistics, Anoka, MN (A.S.M.); and the Department of Vascular Surgery, Vanderbilt School of Medicine, Nashville (D.G.C.)
| | - Miguel F Montero-Baker
- From University Hospitals Harrington Heart and Vascular Institute, Cleveland (M.H.S.); the Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (R.J.P.); the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston (M.F.M.-B., J.L.M.); the Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School (A.D.), and the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine (A.F.) - both in Boston; the Division of Vascular Surgery, Ponce Health Sciences University, St. Luke's Episcopal Hospital, Ponce, Puerto Rico (J.L.M.-T.); Saint Luke's Mid America Heart Institute, Kansas City, MO (M.C.B.); HCA Florida North Florida Hospital, the Cardiac and Vascular Institute, Gainesville (A.C.L.); Paradigm Biostatistics, Anoka, MN (A.S.M.); and the Department of Vascular Surgery, Vanderbilt School of Medicine, Nashville (D.G.C.)
| | - Anahita Dua
- From University Hospitals Harrington Heart and Vascular Institute, Cleveland (M.H.S.); the Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (R.J.P.); the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston (M.F.M.-B., J.L.M.); the Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School (A.D.), and the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine (A.F.) - both in Boston; the Division of Vascular Surgery, Ponce Health Sciences University, St. Luke's Episcopal Hospital, Ponce, Puerto Rico (J.L.M.-T.); Saint Luke's Mid America Heart Institute, Kansas City, MO (M.C.B.); HCA Florida North Florida Hospital, the Cardiac and Vascular Institute, Gainesville (A.C.L.); Paradigm Biostatistics, Anoka, MN (A.S.M.); and the Department of Vascular Surgery, Vanderbilt School of Medicine, Nashville (D.G.C.)
| | - Jorge L Martínez-Trabal
- From University Hospitals Harrington Heart and Vascular Institute, Cleveland (M.H.S.); the Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (R.J.P.); the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston (M.F.M.-B., J.L.M.); the Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School (A.D.), and the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine (A.F.) - both in Boston; the Division of Vascular Surgery, Ponce Health Sciences University, St. Luke's Episcopal Hospital, Ponce, Puerto Rico (J.L.M.-T.); Saint Luke's Mid America Heart Institute, Kansas City, MO (M.C.B.); HCA Florida North Florida Hospital, the Cardiac and Vascular Institute, Gainesville (A.C.L.); Paradigm Biostatistics, Anoka, MN (A.S.M.); and the Department of Vascular Surgery, Vanderbilt School of Medicine, Nashville (D.G.C.)
| | - Matthew C Bunte
- From University Hospitals Harrington Heart and Vascular Institute, Cleveland (M.H.S.); the Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (R.J.P.); the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston (M.F.M.-B., J.L.M.); the Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School (A.D.), and the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine (A.F.) - both in Boston; the Division of Vascular Surgery, Ponce Health Sciences University, St. Luke's Episcopal Hospital, Ponce, Puerto Rico (J.L.M.-T.); Saint Luke's Mid America Heart Institute, Kansas City, MO (M.C.B.); HCA Florida North Florida Hospital, the Cardiac and Vascular Institute, Gainesville (A.C.L.); Paradigm Biostatistics, Anoka, MN (A.S.M.); and the Department of Vascular Surgery, Vanderbilt School of Medicine, Nashville (D.G.C.)
| | - Arthur C Lee
- From University Hospitals Harrington Heart and Vascular Institute, Cleveland (M.H.S.); the Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (R.J.P.); the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston (M.F.M.-B., J.L.M.); the Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School (A.D.), and the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine (A.F.) - both in Boston; the Division of Vascular Surgery, Ponce Health Sciences University, St. Luke's Episcopal Hospital, Ponce, Puerto Rico (J.L.M.-T.); Saint Luke's Mid America Heart Institute, Kansas City, MO (M.C.B.); HCA Florida North Florida Hospital, the Cardiac and Vascular Institute, Gainesville (A.C.L.); Paradigm Biostatistics, Anoka, MN (A.S.M.); and the Department of Vascular Surgery, Vanderbilt School of Medicine, Nashville (D.G.C.)
| | - Andrew S Mugglin
- From University Hospitals Harrington Heart and Vascular Institute, Cleveland (M.H.S.); the Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (R.J.P.); the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston (M.F.M.-B., J.L.M.); the Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School (A.D.), and the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine (A.F.) - both in Boston; the Division of Vascular Surgery, Ponce Health Sciences University, St. Luke's Episcopal Hospital, Ponce, Puerto Rico (J.L.M.-T.); Saint Luke's Mid America Heart Institute, Kansas City, MO (M.C.B.); HCA Florida North Florida Hospital, the Cardiac and Vascular Institute, Gainesville (A.C.L.); Paradigm Biostatistics, Anoka, MN (A.S.M.); and the Department of Vascular Surgery, Vanderbilt School of Medicine, Nashville (D.G.C.)
| | - Joseph L Mills
- From University Hospitals Harrington Heart and Vascular Institute, Cleveland (M.H.S.); the Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (R.J.P.); the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston (M.F.M.-B., J.L.M.); the Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School (A.D.), and the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine (A.F.) - both in Boston; the Division of Vascular Surgery, Ponce Health Sciences University, St. Luke's Episcopal Hospital, Ponce, Puerto Rico (J.L.M.-T.); Saint Luke's Mid America Heart Institute, Kansas City, MO (M.C.B.); HCA Florida North Florida Hospital, the Cardiac and Vascular Institute, Gainesville (A.C.L.); Paradigm Biostatistics, Anoka, MN (A.S.M.); and the Department of Vascular Surgery, Vanderbilt School of Medicine, Nashville (D.G.C.)
| | - Alik Farber
- From University Hospitals Harrington Heart and Vascular Institute, Cleveland (M.H.S.); the Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (R.J.P.); the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston (M.F.M.-B., J.L.M.); the Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School (A.D.), and the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine (A.F.) - both in Boston; the Division of Vascular Surgery, Ponce Health Sciences University, St. Luke's Episcopal Hospital, Ponce, Puerto Rico (J.L.M.-T.); Saint Luke's Mid America Heart Institute, Kansas City, MO (M.C.B.); HCA Florida North Florida Hospital, the Cardiac and Vascular Institute, Gainesville (A.C.L.); Paradigm Biostatistics, Anoka, MN (A.S.M.); and the Department of Vascular Surgery, Vanderbilt School of Medicine, Nashville (D.G.C.)
| | - Daniel G Clair
- From University Hospitals Harrington Heart and Vascular Institute, Cleveland (M.H.S.); the Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (R.J.P.); the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston (M.F.M.-B., J.L.M.); the Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School (A.D.), and the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine (A.F.) - both in Boston; the Division of Vascular Surgery, Ponce Health Sciences University, St. Luke's Episcopal Hospital, Ponce, Puerto Rico (J.L.M.-T.); Saint Luke's Mid America Heart Institute, Kansas City, MO (M.C.B.); HCA Florida North Florida Hospital, the Cardiac and Vascular Institute, Gainesville (A.C.L.); Paradigm Biostatistics, Anoka, MN (A.S.M.); and the Department of Vascular Surgery, Vanderbilt School of Medicine, Nashville (D.G.C.)
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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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22
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Wadowski PP, Piechota-Polańczyk A, Andreas M, Kopp CW. Cardiovascular Disease Management in the Context of Global Crisis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:689. [PMID: 36613012 PMCID: PMC9819164 DOI: 10.3390/ijerph20010689] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 12/28/2022] [Accepted: 12/20/2022] [Indexed: 06/17/2023]
Abstract
The outbreak of coronavirus disease 2019 (COVID-19) initiated a pandemic that has deteriorated health care access and thus disadvantaged vulnerable populations [...].
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Affiliation(s)
- Patricia P. Wadowski
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria
| | - Aleksandra Piechota-Polańczyk
- Department of Medical Biotechnology, Faculty of Biophysics, Biochemistry and Biotechnology, Jagiellonian University, 30-387 Cracow, Poland
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Christoph W. Kopp
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria
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Duplex and Angiographic-Assisted Evaluation of Outcomes of Endovascular Embolization after Surgical Deep Vein Arterialization for the Treatment No-Option Critical Limb Ischemia Patients. Diagnostics (Basel) 2022; 12:diagnostics12122986. [PMID: 36552992 PMCID: PMC9777475 DOI: 10.3390/diagnostics12122986] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 11/24/2022] [Accepted: 11/25/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To report early and mid-term outcomes of the arterialization of the deep venous system in no-option critical limb-threatening ischemia (CLTI) using duplex ultrasound and angiographic evaluation to improve limb perfusion. METHODS A single-center prospective study of patients with no-option CLTI treated with hybrid surgical arterialization of the deep venous circulation and staged endovascular embolization of the venous collateral. Embolization was performed using a controlled-release spiral, within two weeks after bypass surgery. Patients were assessed for clinical status, wound healing, median transcutaneous partial pressure of O2 (TcPO2), and post-operative duplex ultrasound evaluating peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) to assess foot perfusion and bypass features. Primary endpoint analysis was primary technical success, limb salvage, patency rates, and clinical improvement. Secondary endpoints were 30-day and long-term mortality, major cardiovascular events (MACE), including myocardial infarction or stroke, and serious adverse events (SAE). RESULTS Five patients with no-option CLTI were treated at our center using the hybrid deep vein arterialization technique. Clinical stage was grade 3 in one patient and grade 4 in the remaining four. Mean age was 65.8 years (range 49-76 years), and two patients were affected by Buerger's disease. Primary technical success was achieved in all patients, and all the bypasses were patent at the angiographic examination. At 30-day and at average follow-up of 9.8 months (range 2-24 months), mortality, major cardiovascular events (MACE), and serious adverse events (SAE) were not reported, with a primary patency and limb salvage rates of 100%. Three patients required minor amputation. Clinical improvement was demonstrated in all patients with granulation, resolution of rest pain, or both. Median TcPO2 values rose from 10 mm Hg (range 4-25) before the procedure to 35 (range 31-57) after surgery, and to 59 mm Hg (range 50-76) after the staged endovascular procedure. CONCLUSIONS In our initial experience, the arterialization of the deep venous circulation, with subsequent selective embolization of the venous escape routes from the foot, seems a feasible and effective solution for limb salvage in patients with no-option CLTI and those in the advanced wound, ischemia, and foot infection (WIfI) clinical stage.
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24
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Saab FA, Mustapha JA, Ansari M, Pupp G, Madassery K, N’Dandu Z, Wiechmann BN, Bernstein R, Mize A, Pliagas G. Percutaneous Deep Venous Arterialization: Treatment of Patients with End-Stage Plantar Disease. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100437. [PMID: 39132375 PMCID: PMC11308457 DOI: 10.1016/j.jscai.2022.100437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/12/2022] [Accepted: 07/26/2022] [Indexed: 08/13/2024]
Abstract
Background Percutaneous deep venous arterialization (pDVA) is a minimally invasive technique connecting the tibial arteries below the knee to the tibial venous system into plantar venous circulation to deliver oxygenated blood to otherwise nonperfused foot. This study demonstrated outcomes of pDVA with commercially available equipment and described single-center experience on pDVA for critical limb-threatening ischemia patients with small artery diseases and end-stage plantar disease (ESPD) who were deemed no-option cases. Methods A single-center retrospective review was performed on patients who underwent pDVA. Primary end points were successful establishment of tibial vein flow with venous pedal loop, rate of major amputation, and major adverse events over 6 months. Secondary end points were primary and secondary patency rates, minor amputation rates, and wound healing over 6 months. Results Forty-two patients with ESPD underwent pDVA. Risk factors identified were hypertension (92.8%), hyperlipidemia (85.7%), diabetes (78.6%), tobacco abuse (42.9%), and chronic kidney disease ≥ stage 3 (42.8%). Three patients were categorized as Rutherford Class 4, 14 patients Class 5, and 25 patients (59.5%) Class 6. Of 42 procedures, 33 (78.6%) were deemed successful. Amputation-free survival at 6 months was reported in 25 patients (60.9%); 16 patients (38.1%) reported minor amputations. Wound healing rate reported at 6 months was 23.8%. Conclusions This is one of the largest case series to date with real-world no-option patients undergoing pDVA. pDVA seems a reasonable option for limb salvage in patients with ESPD where traditional arterial revascularization is not feasible. Identifying criteria for patient selection and advanced wound care is important to ensure clinical success. Additional research is required to establish diagnostic guidelines for patients being evaluated for pDVA.
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Affiliation(s)
- Fadi A. Saab
- Advanced Cardiac and Vascular Centers for Amputation Prevention, Grand Rapids, Michigan
| | - Jihad A. Mustapha
- Advanced Cardiac and Vascular Centers for Amputation Prevention, Grand Rapids, Michigan
| | - Mohammad Ansari
- Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Guy Pupp
- Foot and Ankle Institute of Michigan, Southfield, Michigan
| | | | - Zola N’Dandu
- Ochsner Health System, Ochsner Medical Center – Kenner, Kenner, Louisiana
| | | | | | - Abigail Mize
- Advanced Cardiac and Vascular Centers for Amputation Prevention, Grand Rapids, Michigan
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Technical Approach to Percutaneous Femoropopliteal Bypass and Deep Vein Arterialization. Tech Vasc Interv Radiol 2022; 25:100843. [DOI: 10.1016/j.tvir.2022.100843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Liu H, Fang Y, Pan T, Fang G, Liu Y, Jiang X, Chen B, Gu S, Wei Z, Liu P, Fu W, Yang J, Dong Z. Autologous Stem Cells Transplantation for No-Option Angiitis-Induced Critical Limb Ischemia: Recurrence and New Lesion. Stem Cells Transl Med 2022; 11:504-512. [PMID: 35446404 PMCID: PMC9154329 DOI: 10.1093/stcltm/szac017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 02/25/2022] [Indexed: 11/25/2022] Open
Abstract
Although satisfying outcomes have been demonstrated in terms of autologous stem cell transplantation in the treatment of angiitis-induced critical limb ischemia (AICLI), few studies have systematically reported the recurrence conditions. In the current study, we aimed to investigate recurrence conditions of a relatively large AICLI cohort in our center during a long-term follow-up period. From May 2009 to August 2020, 181 patients with AICLI received peripheral blood mononuclear cells (PBMNCs) or purified CD34+ cells (PCCs) transplantation. The main outcomes included recurrence and new lesions. Patient demographic data, ischemic limb characteristics, interventional characteristics, etc., were identified and analyzed. A logistic multivariable regression was performed to identify the independent risk factors for recurrence by a stepwise selection of variables. One hundred forty-eight patients were enrolled in this study. The mean follow-up period was 62.3 ± 37.4 months (range 12-144 months). The 5- and 10-year recurrence-free rates were 88.5% (95% confidence interval [CI] 3.1%-82.6%) and 71.7% (95% CI 7.6%-58.2%), respectively. The 5- and 10-year new lesion-free rates were 93.2% (95% CI 2.2%-89.0%) and 91.7% (95% CI 2.7%-86.6%), respectively. The finding of multiple limbs involved (OR 1.322 95% CI 1.123-12.549, P = .036) and ischemia relief period ≥5 months (OR 3.367 95% CI 1.112-10.192, P = .032) were demonstrated to be independent risk factors for recurrence in patients with AICLI who underwent cell transplantation. For patients with AICLI who responded to cell transplantation, the durability of this therapy was satisfactory, with 5- and 10-year recurrence-free rates of 88.5% and 71.7%, respectively. Multiple limbs involved at admission and ischemia relief period ≥5 months were demonstrated to be independent risk factors for recurrence after transplantation.
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Affiliation(s)
- Hao Liu
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
- National Clinical Research Center for Interventional Medicine, Shanghai, People’s Republic of China
| | - Yuan Fang
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
- National Clinical Research Center for Interventional Medicine, Shanghai, People’s Republic of China
| | - Tianyue Pan
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
- National Clinical Research Center for Interventional Medicine, Shanghai, People’s Republic of China
| | - Gang Fang
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
- National Clinical Research Center for Interventional Medicine, Shanghai, People’s Republic of China
| | - Yifan Liu
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
- National Clinical Research Center for Interventional Medicine, Shanghai, People’s Republic of China
| | - Xiaolang Jiang
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
- National Clinical Research Center for Interventional Medicine, Shanghai, People’s Republic of China
| | - Bin Chen
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
- National Clinical Research Center for Interventional Medicine, Shanghai, People’s Republic of China
| | - Shiyang Gu
- Department of Hematology of Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Zheng Wei
- Department of Hematology of Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Peng Liu
- Department of Hematology of Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Weiguo Fu
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
- National Clinical Research Center for Interventional Medicine, Shanghai, People’s Republic of China
| | - Jue Yang
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
- National Clinical Research Center for Interventional Medicine, Shanghai, People’s Republic of China
| | - Zhihui Dong
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
- National Clinical Research Center for Interventional Medicine, Shanghai, People’s Republic of China
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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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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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Liu H, Liu Y, Pan T, Fang Y, Fang G, Jiang X, Chen B, Wei Z, Gu S, Liu P, Fu W, Dong Z. Return to work after cell transplantation in patients with angiitis-induced critical limb ischaemia and factors related: a single-centre retrospective cohort study. Stem Cell Res Ther 2022; 13:139. [PMID: 35365238 PMCID: PMC8972707 DOI: 10.1186/s13287-022-02807-1] [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] [Received: 08/30/2021] [Accepted: 12/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background Angiitis-induced critical limb ischaemia (AICLI) patients, who are usually young and have a high amputation rate, always lose their ability to return to the labour force. Return to work (RTW) not only indicates patients’ physical health, showing that they could undertake the work, but also demonstrates their psychological well-being. While cell transplantation showed satisfactory efficacy in limb salvage, few studies of AICLI patients’ RTW after transplantation have been reported. Methods From May 2009 to May 2021, AICLI patients who underwent cell transplantation and completed no less than 12 months of follow-up were retrospectively enrolled. The primary endpoint was RTW. Patient demographics and characteristics of the ischaemic limbs were reviewed to analyse independent risk factors for RTW. Results A total of 171 AICLI patients (170 males) were enrolled with a mean age of 41.9 ± 9.6 years (range: 20–57 years). The 12-month and 24-month RTW cumulative rates were 69.4% (95% confidence interval [CI] 61.6–75.6%) and 70.1% (95% CI 62.3–76.2%), respectively. Age < 40 years (odds ratio [OR] 2.659, 95% CI 1.138–6.719) and preoperative occupation as a mental worker (OR 8.930, 95% CI 2.665–42.847) were identified as independent protective factors for RTW. Perioperative limb infection with ulcer or gangrene (OR 0.250, 95% CI 0.075–0.779) was identified as an independent risk factor. Conclusion AICLI patients who underwent cell transplantation usually had a satisfactory midterm RTW cumulative rate. AICLI patients < 40 years old with preoperative occupation as mental workers were more likely to return to work. Prevention of limb infection during the perioperative period is of great significance to RTW.
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Affiliation(s)
- Hao Liu
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Yifan Liu
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Tianyue Pan
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Yuan Fang
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Gang Fang
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Xiaolang Jiang
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Bin Chen
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Zheng Wei
- Department of Hematology of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China
| | - Shiyang Gu
- Department of Hematology of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China
| | - Peng Liu
- Department of Hematology of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Zhihui Dong
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
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Liu H, Pan T, Liu Y, Fang Y, Fang G, Jiang X, Chen B, Wei Z, Gu S, Liu P, Fu W, Dong Z. The peripheral blood mononuclear cells versus purified CD34 + cells transplantation in patients with angiitis-induced critical limb ischemia trial: 5-year outcomes and return to work analysis-a randomized single-blinded non-inferiority trial. Stem Cell Res Ther 2022; 13:116. [PMID: 35313967 PMCID: PMC8935813 DOI: 10.1186/s13287-022-02804-4] [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] [Received: 02/07/2022] [Accepted: 02/27/2022] [Indexed: 11/24/2022] Open
Abstract
Backgrounds Patients with AICLI constitute a considerable proportion of NO-CLI patients and cannot be treated with surgical or endovascular treatment. Although cell therapy has shown satisfactory results in treating AICLI, research comparing the efficacy of treatment with the 2 kinds of cell products is rare. The aim of this study was to report the 5-year outcomes of a randomized single-blinded noninferiority trial (Number: NCT 02089828) on peripheral blood mononuclear cells (PBMNCs) and purified CD34+ cells (PCCs) transplantation for treating angiitis-induced critical limb ischemia (AICLI). Methods A randomized single-blinded non-inferiority trial (Number: NCT 02089828) was performed. Fifty patients were randomized 1:1 to the PBMNCs and PCCs groups. Efficacy outcomes, safety outcomes and patients’ work conditions were analyzed. The primary efficacy outcomes included major amputation and total amputation over 60 months. Results During the 60-month follow-up, 1 patient was lost to follow-up, 1 died, and 2 underwent major amputation. The major amputation-free survival rate (MAFS) was 92.0% (95% confidence interval [CI] 82.0%-100.0%) in the PBMNCs group and 91.7% (95% CI 81.3%-100.0%) in the PCCs group (P = 0.980). Compared with the PCCs group, the PBMNCs group had a significantly higher 5-year new lesion-free survival rate (100.0% vs. 83.3% [95% CI 69.7–99.7%], P = 0.039). All patients lost their ability to work before transplantation, and the 5-year cumulative return to work (RTW) rates were 88.0% in the PBMNCs group and 76.0% in the PCCs group (P = 0.085). Conclusion The long-term follow-up outcomes of this trial not only demonstrated similar efficacy and safety for the 2 types of autoimplants but also showed a satisfactory cumulative RTW rate in AICLI patients who underwent cell transplantation. Trial registration: ClinicalTrials.gov, number NCT 02089828. Registered 14 March 2014, https://clinicaltrials.gov/ct2/show/record/NCT02089828.
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Affiliation(s)
- Hao Liu
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Tianyue Pan
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yifan Liu
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yuan Fang
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Gang Fang
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xiaolang Jiang
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Bin Chen
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.,National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Zheng Wei
- Departments of Hematology of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shiyang Gu
- Departments of Hematology of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Peng Liu
- Departments of Hematology of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiguo Fu
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China. .,National Clinical Research Center for Interventional Medicine, Shanghai, China.
| | - Zhihui Dong
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China. .,National Clinical Research Center for Interventional Medicine, Shanghai, China.
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Twelve-Month Clinical Outcomes of Percutaneous Deep Venous Arterialization with Alternative Techniques and Ordinary Endovascular Therapy Devices for Patients with Chronic Limb-Threatening Ischemia: Results of the DEPARTURE Japan Study. Cardiovasc Intervent Radiol 2022; 45:622-632. [DOI: 10.1007/s00270-022-03095-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 02/06/2022] [Indexed: 01/24/2023]
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Argyriou A, Rantner B, Stana J, Tsilimparis N, Sensebat Ö, Torsello G, Stavroulakis K. Moderne endovaskuläre Therapieoptionen bei diabetischem Fußsyndrom. DIABETOLOGE 2022. [DOI: 10.1007/s11428-022-00869-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Comparison of clinical outcomes, including the wound healing rate, between inframalleolar bypass to the pedal artery and that to the pedal branch artery in the modern endovascular era. J Vasc Surg 2022; 75:2019-2029.e2. [PMID: 35182663 DOI: 10.1016/j.jvs.2022.01.138] [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: 11/16/2021] [Accepted: 01/30/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Inframalleolar (IM) bypass has been reported to demonstrate acceptable patency and limb salvage in chronic limb-threatening ischemia (CLTI) patients. However, wound healing after IM bypass and comparisons between pedal artery (PA) bypass and pedal branch artery (PBA) bypass are lacking. METHODS We reviewed prospectively collected data from 208 consecutive patients after IM bypass performed over a period of six years. Patients were divided into two groups based on the distal anastomotic artery: the PA group (dorsal pedis artery or common plantar artery) and the PBA group (medial tarsal, lateral tarsal, medial plantar, and lateral plantar artery). The primary outcome was wound healing, and secondary outcomes included loss of patency and limb and life prognosis. RESULTS Of the 208 patients, 174 (74%) had PA bypass, whereas 34 (16%) had PBA bypass. Patients in the PBA group were significantly younger than those in the PA group (69 ± 7 vs. 73 ± 9, P = .03). Although early (30-day) graft failure was more common in the PBA group, late clinical outcomes, including the wound healing rate (79% in the PA group and 84% in the PBA group, P=.74), were similar between the two groups. The Global Limb Anatomic Staging System (GLASS) IM grade (HR, 0.73; 95% confidence interval [CI], 0.58-0.93: P=.006); wound, ischemia, and foot infection (WIfI) wound grade (HR, 0.67; 95% CI, 0.51-0.89: P<.01); and WIfI foot infection grade (HR, 0.79; 95% CI, 0.65-0.96: P=.02) were independent predictors of wound healing. CONCLUSIONS The current study revealed that wound healing in patients following PBA bypass was acceptable and comparable to that following PA bypass. In the modern era, including high prevalence of infrapopliteal angioplasty, our results could provide useful information to clinicians in actual clinical settings. Moreover, PBA bypass may be an alternative revascularization procedure to avoid major amputation when the pedal artery is occluded, such as in the GVG IM P2 grade. Prospective multicenter larger studies are warranted to confirm the findings of this study and to compare PBA bypass and IM EVT in anatomical "no-option" CLTI.
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Clair D, Gibbons M. A review of percutaneous deep vein arterialization for the treatment of nonreconstructable chronic limb threatening ischemia. Semin Vasc Surg 2021; 34:188-194. [PMID: 34911624 DOI: 10.1053/j.semvascsurg.2021.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/11/2022]
Abstract
Peripheral arterial disease is estimated to affect more than 200 million people worldwide with some patients progressing to chronic limb threatening ischemia (CLTI). Patients with CLTI have extremely high rates of amputation and associated increases in morbidity and mortality. There is a subset of patients with CLTI that have no available options for revascularization due to factors such as the absence of distal target vessels or adequate conduit for surgical revascularization. Percutaneous deep vein arterialization can be used in patients with nonreconstructable CLTI. In this review article, we discuss patient selection, methods, and techniques of deep vein arterialization. In addition, results from studies evaluating the use of percutaneous deep vein arterialization, such as the Alkmaar (The Netherlands), Leipzig (Germany), Paris (France), and Singapore (ALPS) multicenter center study and the prospective, multicenter, single-arm, early feasibility (PROMISE I) trial, are highlighted. These results have been encouraging with improved rates of limb salvage and wound healing reported, suggesting percutaneous deep vein arterialization may be beneficial in treating patients with CLTI.
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Affiliation(s)
- Daniel Clair
- Department of Vascular Surgery, Section of Surgical Sciences, 1161 21st Avenue S, MCN D-4314, Vanderbilt University Medical Center, Nashville, TN, 37232-2730
| | - Michael Gibbons
- Department of General Surgery, Prisma Health/University of South Carolina School of Medicine Columbia, 2 Medical Park, Suite 306, Columbia, SC, 29203.
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35
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Yan Q, Prasla S, Carlisle DC, Rajesh A, Treffalls J, Davies MG. Deep Venous Arterialization for Chronic Limb Threatening Ischemia in Atherosclerosis Patients - A meta-analysis. Ann Vasc Surg 2021; 81:1-21. [PMID: 34883231 DOI: 10.1016/j.avsg.2021.10.059] [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: 05/25/2021] [Revised: 08/09/2021] [Accepted: 10/23/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Venous arterialization is an upcoming and novel alternative in chronic limb threatening ischemia (CLTI) patients in the absence of standard revascularization options. The aim of this study is to systematically review and analyze outcomes of venous arterialization. STUDY DESIGN A systematic literature search was performed in 5 databases using the PRISMA methodology. Inclusion criteria were English language original research papers on CLTI patients treated with venous arterialization. EXCLUSION CRITERIA absence of CLTI due to atherosclerosis, duplicate study or reporting of patients, meeting abstract only. Quality and risk of bias were evaluated. Meta-analysis was performed using random effects model on articles that have a sample size of equal or greater than 10. RESULTS Twelve studies included 442 patients that underwent treatment for 445 limbs (374 patients and 377 limbs underwent venous arterialization while remainder underwent traditional bypass and served as control subjects). Average age was 66 [18 studies, range 37-91 years], 68% were male [271/366, 15 studies] and 67% diabetic [271/406, 16 studies]). Most limbs (88%, 352/398, 16 studies) had tissue loss. Pooled 30-day mortality was 3.7% (95%-confidence interval [CI] 0.8-6.6%), 30-day morbidity was 15.5% (95%-CI 3.2-27.8%), 30-day major adverse cardiovascular event was 5.2% (95%-CI 1.7-8.6%) and 30-day major adverse limb event was 16.7% (95%-CI 1.5-31.9%). Pooled 1-year limb-salvage rate was 79.0% (95%-CI 68.7-90.7) and 1-year survival rate was 85.7% (95%-CI 76.2-96.4). Studies quality varied significantly across studies. CONCLUSION Venous arterialization has an acceptable a 1-year limb salvage rate of 79%, however, this is based on low levels of evidence. More randomized controlled trials or high-quality cohort studies are needed to further define the effectiveness of this procedure for CLTI.
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Affiliation(s)
- Qi Yan
- Division of Vascular and Endovascular Surgery, University of Texas Health at San Antonio, San Antonio, Texas; Department of Surgery, University of Texas Health at San Antonio, San Antonio, Texas.; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Texas
| | - Sanaa Prasla
- Department of Surgery, University of Texas Health at San Antonio, San Antonio, Texas
| | - Daniel C Carlisle
- Department of Surgery, University of Texas Health at San Antonio, San Antonio, Texas
| | - Aashish Rajesh
- Department of Surgery, University of Texas Health at San Antonio, San Antonio, Texas
| | - John Treffalls
- Department of Surgery, University of Texas Health at San Antonio, San Antonio, Texas
| | - Mark G Davies
- Center for Quality, Effectiveness and Outcomes in Cardiovascular Diseases, University of Texas Health at San Antonio, San Antonio, Texas; Division of Vascular and Endovascular Surgery, University of Texas Health at San Antonio, San Antonio, Texas; Department of Surgery, University of Texas Health at San Antonio, San Antonio, Texas.; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Texas..
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36
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Spiliopoulos S, Del Giudice C, Manzi M, Reppas L, Rodt T, Uberoi R. CIRSE Standards of Practice on Below-the-Knee Revascularisation. Cardiovasc Intervent Radiol 2021; 44:1309-1322. [PMID: 34173044 DOI: 10.1007/s00270-021-02891-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 06/01/2021] [Indexed: 02/05/2023]
Abstract
The CIRSE Standards of Practice Committee established a writing group that was tasked with producing up-to-date recommendations for performing below-the-knee revascularisation, taking into account data on novel techniques, devices, and long-term outcomes that have emerged over the last decade. CIRSE Standards of Practice documents are not clinical practice guidelines or systematic reviews of the literature. This document is not intended to impose a standard of clinical patient care but recommends a reasonable approach to and best practices for performing below-the-knee revascularisation.
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Affiliation(s)
- Stavros Spiliopoulos
- Interventional Radiology Unit, 2nd Department of Radiology, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece.
| | | | | | - Lazaros Reppas
- Interventional Radiology Unit, 2nd Department of Radiology, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Thomas Rodt
- Dept. of Diagnostic and Interventional Radiology, Lüneburg Hospital, Lüneburg, Germany
| | - Raman Uberoi
- John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
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Migliara B, Cappellari TF, Mirandola M, Griso A, Feriani G, Prosdocimi L, Nicoletti C. Percutaneous Saphenous Vein Arterialization. J Endovasc Ther 2021; 28:823-827. [PMID: 34229500 DOI: 10.1177/15266028211030530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE In patients with no-option critical limb-threatening ischemia, venous foot arterialization can be considered the last chance before major amputation. Up until now, a really significant limitation of endovascular arterialization compared with surgery was the possibility to obtain arterial flow into the foot only through the deep plantar network. TECHNIQUE Two 5-mm snares are placed: one in the proximal tibial artery and the other in the great saphenous vein. After passing through these snares with a needle and a guidewire and closing the snares, the guidewire is pulled through the proximal arterial sheath and the distal venous sheath. Thus, the arterial-venous connection is created. A covered stent is, then, placed between the artery and the vein to avoid leakage. CONCLUSIONS Based on our knowledge, this is the first described totally percutaneous arterialization of the superficial dorsal venous foot system, through reverse flow in the great saphenous vein.
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Affiliation(s)
- Bruno Migliara
- Vascular and Endovascular Unit, Department of Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
| | | | - Mattia Mirandola
- Vascular and Endovascular Unit, Department of Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Andrea Griso
- Vascular and Endovascular Unit, Department of Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Giovanni Feriani
- Vascular and Endovascular Unit, Department of Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Linda Prosdocimi
- Vascular and Endovascular Unit, Department of Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Cristian Nicoletti
- Diabetic Foot Unit, Department of Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
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Clair DG, Mustapha JA, Shishehbor MH, Schneider PA, Henao S, Bernardo NN, Deaton DH. PROMISE I early feasibility study of the LimFlow System for percutaneous deep vein arterialization in no-option chronic limb-threatening ischemia 12-month results. J Vasc Surg 2021; 74:1626-1635. [PMID: 34019990 DOI: 10.1016/j.jvs.2021.04.057] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/17/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We report the 6 and 12-month outcomes of the PROMISE I early feasibility study (EFS) after treatment of no-option chronic limb-threatening ischemia (CLTI) with percutaneous deep vein arterialization (pDVA) using the LimFlow System. METHODS Thirty-two no-option CLTI patients, previously offered major amputation, were enrolled in this single-arm EFS of the LimFlow pDVA System. No-option CLTI was defined as being ineligible for surgical or endovascular arterial revascularization. Patients were assessed for clinical status, pain, wound healing, and duplex ultrasound at 30 days, 6 months, and 12 months post-treatment. Primary endpoint analysis was amputation-free survival (AFS) at 30 days and 6 and 12 months. AFS was defined as freedom from above-ankle amputation of the index limb and freedom from all-cause mortality. Secondary endpoints evaluated included technical success of the procedure, and wound healing at 6 and 12 months. RESULTS Of 32 enrolled patients, 31 (97%) were successfully treated with the LimFlow System at the time of the procedure, and 2 (6.3%) were lost to follow-up. The 30-day, 6-month, and 12-month AFS rates were 91%, 74%, and 70% respectively. Wound healing status of fully healed or healing was 67% at 6-months, and 75% at 12-months. Reintervention was performed in 16 patients (52%) with 14 (88%) of the maintenance reinterventions occurring within the first three months. The majority of reinterventions, 12 (75%), involved the arterial inflow tract proximal to the stented LimFlow circuit, and no in-stent stenoses were determined to have been the cause of reintervention. CONCLUSIONS The LimFlow pDVA System was utilized in treating no-option patients with CLTI. High technical success rate was observed, with a significant percentage of patients surviving free of major amputation at 12 months. These results suggest early safety and provide an initial assessment of the efficacy of the LimFlow pDVA System which supports the expansion of carefully executed studies to determine whether this is a viable option that can be used in this critically disadvantaged and growing patient population.
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Affiliation(s)
- Daniel G Clair
- Department of Surgery, University of South Carolina, Columbia, SC.
| | - Jihad A Mustapha
- Advanced Cardiac and Vascular Amputation Prevention Centers, Grand Rapids, Mich
| | - Mehdi H Shishehbor
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, Calif
| | - Steve Henao
- Division of Vascular Surgery, New Mexico Heart Institute, Albuquerque, NM
| | | | - David H Deaton
- Division of Vascular Surgery, University of Pennsylvania, Philadelphia, Pa
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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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Liu H, Pan T, Fang Y, Fang G, Liu Y, Jiang X, Chen B, Wei Z, Gu S, Liu P, Fu W, Dong Z. Three-year outcomes of peripheral blood mononuclear cells vs purified CD34 + cells in the treatment of angiitis-induced no-option critical limb ischemia and a cost-effectiveness assessment: A randomized single-blinded noninferiority trial. Stem Cells Transl Med 2021; 10:647-659. [PMID: 33399273 PMCID: PMC8046046 DOI: 10.1002/sctm.20-0033] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 10/26/2020] [Accepted: 11/12/2020] [Indexed: 01/06/2023] Open
Abstract
For patients with angiitis-induced critical limb ischemia (AICLI), cell transplantation, such as purified CD34+ cells (PCCs) and peripheral blood mononuclear cells (PBMNCs), is gradually being used as a promising treatment. This was the first randomized single-blinded noninferiority trial (number: NCT02089828) specifically designed to evaluate the therapeutic efficacies of the transplantation of PCCs vs those of PBMNCs for the treatment of AICLI. We aimed to compare the mid-term safety and efficacy between the two groups and determine their respective advantages. From April 2014 to September 2019, 50 patients with AICLI were equally allocated to the two groups, except for 1 lost patient, 1 amputee, and 1 patient who died of heart disease. The other 47 patients completed the 36-month follow-up. The endpoints were as follows: major amputation-free survival and total amputation-free survival at 6 months, which were 96.0% and 84.0% in the PBMNCs group and 96.0% and 72.0% in the PCCs group, respectively. These rates remained stable at 12, 24, and 36 months. The PCCs group had a significant higher probability of rest pain relief than the PBMNCs group, whereas earlier significant improvements in the Rutherford classification were observed in the PBMNCs group. Accordingly, PCCs would be preferred for patients with significant pain, whereas PBMNCs may be a good option for patients with two or more critically ischemic limbs. Concerning cost-effectiveness, PCCs are not more cost-effective than PBMNCs. These outcomes require verification from long-term trials involving larger numbers of patients.
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Affiliation(s)
- Hao Liu
- Department of Vascular Surgery of Zhongshan HospitalFudan UniversityShanghaiPeople's Republic of China
| | - Tianyue Pan
- Department of Vascular Surgery of Zhongshan HospitalFudan UniversityShanghaiPeople's Republic of China
| | - Yuan Fang
- Department of Vascular Surgery of Zhongshan HospitalFudan UniversityShanghaiPeople's Republic of China
| | - Gang Fang
- Department of Vascular Surgery of Zhongshan HospitalFudan UniversityShanghaiPeople's Republic of China
| | - Yifan Liu
- Department of Vascular Surgery of Zhongshan HospitalFudan UniversityShanghaiPeople's Republic of China
| | - Xiaolang Jiang
- Department of Vascular Surgery of Zhongshan HospitalFudan UniversityShanghaiPeople's Republic of China
| | - Bin Chen
- Department of Vascular Surgery of Zhongshan HospitalFudan UniversityShanghaiPeople's Republic of China
| | - Zheng Wei
- Department of Hematology of Zhongshan HospitalFudan UniversityShanghaiPeople's Republic of China
| | - Shiyang Gu
- Department of Hematology of Zhongshan HospitalFudan UniversityShanghaiPeople's Republic of China
| | - Peng Liu
- Department of Hematology of Zhongshan HospitalFudan UniversityShanghaiPeople's Republic of China
| | - Weiguo Fu
- Department of Vascular Surgery of Zhongshan HospitalFudan UniversityShanghaiPeople's Republic of China
| | - Zhihui Dong
- Department of Vascular Surgery of Zhongshan HospitalFudan UniversityShanghaiPeople's Republic of China
- Department of Project Management, Fudan Zhangjiang InstituteShanghaiPeople's Republic of China
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Ichihashi S, Tamura Y, Maeda S, Kichikawa K. Percutaneous deep venous arterialization at femoropopliteal segment for unhealed amputated stump ulcer after below the knee amputation. Catheter Cardiovasc Interv 2021; 98:E124-E126. [PMID: 33825316 DOI: 10.1002/ccd.29693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/19/2021] [Accepted: 03/23/2021] [Indexed: 11/09/2022]
Abstract
Efficacy of percutaneous deep venous arterialization (pDVA) has been reported for patients with no-option chronic limb threatening ischemia. To date, the procedure has been limited for below the knee/below the ankle occlusive disease. The present report describes the pDVA performed at a femoropopliteal segment for a patient with a stump complication after below the knee amputation. The patient was a 70-year-old male who had a history of endovascular treatment in the right superficial femoral artery (SFA) and below knee amputation 6 years before. He had an unhealed ulcer at the amputated stump for 3 years. Computed tomography angiography demonstrated occluded right SFA, with a stenotic popliteal artery. Revascularization was considered unfeasible due to the absence of run off vessels. In order to improve the perfusion at the ulcer, pDVA was performed at the distal SFA level, bridging SFA and femoral vein using stent grafts. The final angiogram demonstrated the revascularized SFA connecting to popliteal vein with a brisk flow. After pDVA, the stump ulcer improved and the stent grafts were kept patent after 6 months of the procedure. pDVA at the SFA level was technically feasible and could be a useful approach for stump complication after below knee amputation.
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Affiliation(s)
- Shigeo Ichihashi
- Department of Radiology, Nara Medical University, Kashihara, Japan
| | - Yamato Tamura
- Department of Cardiovascular Surgery, Nara Prefecture Seiwa Medical Center, Ikomagun, Japan
| | - Shinsaku Maeda
- Department of Cardiovascular Surgery, Nara Prefecture Seiwa Medical Center, Ikomagun, Japan
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Tan M, Ueshima D, Urasawa K, Hayakawa N, Dannoura Y, Itoh T, Kozuki A, Shimooka Y, Hayashi T, Sato Y. Prediction of successful guidewire crossing of below-the-knee chronic total occlusions using a Japanese scoring system. J Vasc Surg 2021; 74:506-513.e2. [PMID: 33607205 DOI: 10.1016/j.jvs.2021.01.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/16/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To develop a scoring system that can adequately predict a successful guidewire crossing (S-GC) of below-the-knee (BTK) chronic total occlusions (CTOs) in angiographic evaluation. METHODS A retrospective, multicenter, nonrandomized study examined 448 consecutive BTK CTOs in 299 patients treated with endovascular therapy in seven Japanese medical centers from April 2012 to April 2020. The cohort was classified into two groups: an S-GC group and a failed guidewire crossing group. RESULTS The final logistic regression model created by a backward stepwise multivariate logistic regression model included five variables: "No outflow of the target vessel," "CTO length ≥200 mm," "Reference vessel diameter <2.0 mm," "Calcification at the proximal entry point," and "Blunt type at entry point." Optimisms were adjusted using 1000 bootstrap samples with replacement and candidate's risk score models developed according to optimism-adjusted correlation coefficients of risk factors. Choosing the best model as the Japanese-BTK (J-BTK) CTO score by comparing the optimism-adjusted area under receiver-operating characteristic curves it was decided to assign one point to "Blunt type at the proximal entry point," one point to "Calcification at the proximal entry point," one point to "Reference vessel diameter <2.0 mm," one point to "CTO length ≥200 mm," and two points to "No outflow of the target vessel." This rule was then used to categorize BTK CTOs into four grades with varying probabilities of S-GC: grade A (J-BTK CTO score of 0 and 1), grade B (score of 2 and 3), grade C (score of 4 and 5), and grade D (score of 6). Rates of S-GC in each grade (grades A, B, C, and D) were 97.3%, 76.8%, 19.3%, and 0%, respectively. Lesions categorized as grade C or D have a lower chance of S-GC. Internal validation was performed using the Hosmer-Lemeshow test (P = .99). CONCLUSIONS The J-BTK CTO score predicts the probability of an S-GC of BTK CTOs and stratifies the difficulty of endovascular therapy for BTK CTOs in angiographic evaluation.
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Affiliation(s)
- Michinao Tan
- Cardiovascular Center, Tokeidai Memorial Hospital, Sapporo, Japan.
| | - Daisuke Ueshima
- Department of Cardiology, Kameda Medical Center, Chiba, Japan
| | - Kazushi Urasawa
- Cardiovascular Center, Tokeidai Memorial Hospital, Sapporo, Japan
| | - Naoki Hayakawa
- Department of Cardiology, Asahi General Hospital, Chiba, Japan
| | - Yutaka Dannoura
- Department of Cardiology, Sapporo City General Hospital, Sapporo, Japan
| | - Takahito Itoh
- Department of Cardiology, Oji General Hospital, Tomakomai, Japan
| | - Amane Kozuki
- Department of Cardiology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | | | - Taichi Hayashi
- Cardiovascular Center, Tokeidai Memorial Hospital, Sapporo, Japan
| | - Yusuke Sato
- Cardiovascular Center, Tokeidai Memorial Hospital, Sapporo, Japan
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Cangiano G, Corvino F, Giurazza F, De Feo EM, Fico F, Palumbo V, Amodio F, Silvestre M, Corvino A, Niola R. Percutaneous Deep Foot Vein Arterialization IVUS-Guided in No-Option Critical Limb Ischemia Diabetic Patients. Vasc Endovascular Surg 2020; 55:58-63. [PMID: 33256561 DOI: 10.1177/1538574420965743] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To report our clinical experience with IVUS-guided percutaneous deep vein arterialization (pDVA) to treat chronic critical limb ischemia (cCLI) patients with no-endovascular or surgical options approach due to creation of an arteriovenous fistula (AVF). MATERIALS AND METHODS In a 2 years period, 14 no-option cCLI patients were treated with percutaneous deep vein arterialization (pDVA) by creating an AVF with a IVUS-guided system between posterior tibial artery and its satellite deep vein. Technical success was defined as successful AVF creation and venous perfusion of the wound site. Patients' characteristics, procedure details, mortality and wound outcomes were assessed prospectively. RESULTS Successful pDVA was successfully performed in all patients (mean age 82 years) without any procedural complications. Clinical improvement was achieved in all patients with resolution of rest pain, tissue formation of granulation tissue or both; only 3 major amputations were performed within the study period with a limb salvage rate of 78%. Median wound healing time was 4.8 months. CONCLUSION pDVA is a safe and feasible revascularization technique alternative in no-option cCLI patients.
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Affiliation(s)
- Gianluca Cangiano
- Interventional Radiology Department, 18617AORN "A. Cardarelli," Naples, Italy
| | - Fabio Corvino
- Interventional Radiology Department, 18617AORN "A. Cardarelli," Naples, Italy
| | - Francesco Giurazza
- Interventional Radiology Department, 18617AORN "A. Cardarelli," Naples, Italy
| | - Eugenio Maria De Feo
- Diabetic Foot Unit, Department of General and Specialist Medicine, 18617AORN "A. Cardarelli," Naples, Italy
| | - Francesca Fico
- Diabetic Foot Unit, Department of General and Specialist Medicine, 18617AORN "A. Cardarelli," Naples, Italy
| | - Vincenzo Palumbo
- Diabetic Foot Unit, Department of General and Specialist Medicine, 18617AORN "A. Cardarelli," Naples, Italy
| | - Francesco Amodio
- Interventional Radiology Department, 18617AORN "A. Cardarelli," Naples, Italy
| | - Mattia Silvestre
- Interventional Radiology Department, 18617AORN "A. Cardarelli," Naples, Italy
| | - Antonio Corvino
- Motor Science and Wellness Department, 18993University of Naples "Parthenope," Naples, Italy
| | - Raffaella Niola
- Interventional Radiology Department, 18617AORN "A. Cardarelli," Naples, Italy
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Kim TI, Vartanian SS, Schneider PA. A Review and Proposed Classification System for the No-Option Patient With Chronic Limb-Threatening Ischemia. J Endovasc Ther 2020; 28:183-193. [PMID: 33032494 DOI: 10.1177/1526602820963911] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A growing, but poorly defined subset of patients with chronic limb-threatening ischemia (CLTI) have "no option" for revascularization. One notable subgroup includes patients with severe ischemia and advanced pedal artery occlusive disease, termed "desert foot," who are at high risk for major amputation due to a lack of conventional revascularization options. Although new therapies are being developed for no-option patients with desert foot anatomy, this subgroup and the broader group of no-option patients are not well defined, limiting the ability to evaluate outcomes. Based on a systematic review, a classification of the no-option CLTI patient was constructed for use in clinical practice and studies. Several no-option conditions were identified, including type I-severe and pedal occlusive disease (desert foot anatomy) for which there is no accepted method of repair; type II-lack of suitable venous conduit for bypass in the setting of an acceptable target for bypass; type III-extensive tissue loss with exposure of vital structures that renders salvage impossible; type IV-advanced medical comorbidities for which available revascularization options would pose a prohibitive risk; and type V-presence of a nonfunctional limb. While type I and type II patients may have no option for revascularization, type III and type V patients have wounds, infection, comorbidities, or functional status that may leave them with few options for revascularization. As treatment strategies continue to evolve and novel methods of revascularization are developed, the ability to identify no-option patients in a standardized fashion will aid in treatment selection and assessment of outcomes.
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Affiliation(s)
- Tanner I Kim
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Shant S Vartanian
- Division of Vascular and Endovascular Surgery, University of California at San Francisco School of Medicine, San Francisco, CA, 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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Schreve MA, Huizing E, Kum S, de Vries JPPM, de Borst GJ, Ünlü Ç. Volume Flow and Peak Systolic Velocity of the Arteriovenous Circuit in Patients after Percutaneous Deep Venous Arterialization. Diagnostics (Basel) 2020; 10:diagnostics10100760. [PMID: 32998196 PMCID: PMC7601062 DOI: 10.3390/diagnostics10100760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/23/2020] [Accepted: 09/26/2020] [Indexed: 12/31/2022] Open
Abstract
Percutaneous deep venous arterialization (pDVA) is a developing technique for limb salvage in patients with chronic limb-threatening ischemia by creating an arteriovenous (AV) circuit. After pDVA, patency of the AV circuit is evaluated using duplex ultrasound (DUS) imaging. Peak systolic velocity (PSV) and volume flow (VF) values for maintaining a patent AV circuit are undefined; therefore, guidance about when a reintervention should be performed is lacking. The objective of this study was to interpret post-pDVA PSV and VF values in relation to AV circuit preservation. This was performed by analyzing DUS results of 22 post-pDVA patients. A total of 670 PSV and 623 VF measurements were collected. A PSV value of ≤55 cm/s and a VF value of ≤195 mL/min were found predictive for failure. The reliability of PSV and VF measurements in patent AV-circuits was good (intraclass correlation coefficient; PSV, 0.85; VF, 0.88). In conclusion, this study is the first to analyze DUS measurements in post-pDVA patients and showed that DUS can be used to anticipate for failure. The thresholds found can be used to help interpret DUS measurements in post-pDVA patients. More research in a larger patient population is needed to prospectively validate these thresholds.
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Affiliation(s)
- Michiel A. Schreve
- Department of Surgery, Northwest Clinics, 1815 JD Alkmaar, The Netherlands; (E.H.); (Ç.Ü.)
- Correspondence: ; Tel.: +31-(0)72-548-4444
| | - Eline Huizing
- Department of Surgery, Northwest Clinics, 1815 JD Alkmaar, The Netherlands; (E.H.); (Ç.Ü.)
| | - Steven Kum
- Vascular Service, Department of Surgery, Changi General Hospital, Singapore 529889, Singapore;
| | - Jean-Paul P. M. de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, 9713 GZ Groningen, The Netherlands;
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Çağdaş Ünlü
- Department of Surgery, Northwest Clinics, 1815 JD Alkmaar, The Netherlands; (E.H.); (Ç.Ü.)
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Armstrong EJ. Advances in the Treatment of Chronic Limb-Threatening Ischemia. J Endovasc Ther 2020; 27:521-523. [PMID: 32900276 DOI: 10.1177/1526602820942857] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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47
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Schmidt A, Schreve MA, Huizing E, Del Giudice C, Branzan D, Ünlü Ç, Varcoe RL, Ferraresi R, Kum S. Reply to "More Data Are Needed to Elucidate the Achilles' Heel of Percutaneous Deep Venous Arterialization". J Endovasc Ther 2020; 27:874-876. [PMID: 32869686 DOI: 10.1177/1526602820948157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andrej Schmidt
- Department of Interventional Angiology, University Hospital Leipzig, Germany
| | | | - Eline Huizing
- Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Costantino Del Giudice
- Department of Interventional Radiology, Hôpital Européen Georges Pompidou, Paris, France
| | - Daniela Branzan
- Department of Vascular Surgery, University Hospital, Leipzig, Germany
| | - Çağdaş Ünlü
- Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Ramon L Varcoe
- Department of Surgery, Prince of Wales Hospital and University of New South Wales, Randwick, Sydney, Australia
| | | | - Steven Kum
- Department of Surgery, Vascular Service, Changi General Hospital, Singapore
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48
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Migliara B, Mirandola M, Griso A, Feriani G, Nicoletti C, Lino M. Totally Percutaneous Deep Foot Vein Arterialization in a Patient with No-Option Critical Limb Ischemia, Scheduled for Bilateral Major Amputation. J Vasc Interv Radiol 2020; 31:1505-1507. [DOI: 10.1016/j.jvir.2020.04.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/23/2020] [Accepted: 04/28/2020] [Indexed: 11/17/2022] Open
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49
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Ryu SW, Tan GWL, Pua U. Percutaneous Deep Vein Arterialization in Buerger's Disease. J Vasc Interv Radiol 2020; 31:1897-1900.e1. [PMID: 32807614 DOI: 10.1016/j.jvir.2020.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/23/2020] [Accepted: 01/26/2020] [Indexed: 10/23/2022] Open
Affiliation(s)
- Seung Wook Ryu
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore
| | - Glenn Wei Leong Tan
- Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore
| | - Uei Pua
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore
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50
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Hines EM, Choy KT, Bhutia S. Deep venous arterialization for no-option critical limb-threatening ischaemia. ANZ J Surg 2020; 91:E63-E66. [PMID: 32621634 DOI: 10.1111/ans.16116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Elizabeth M Hines
- Department of Vascular Surgery, Cairns Base Hospital, Cairns, Queensland, Australia
| | - Kai Tai Choy
- Department of Vascular Surgery, Cairns Base Hospital, Cairns, Queensland, Australia
| | - Sherab Bhutia
- Department of Vascular Surgery, Cairns Base Hospital, Cairns, Queensland, Australia
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