TASC II Section E3 on the Treatment of Acute Limb Ischemia:Commentary From European Interventionists

Endovascular approach for acute limb ischemia without thrombolytic therapy

Background:

Endovascular therapy for acute lower limb ischemia (ALLI) has developed and demonstrated safety and efficacy. The purpose of this study was to assess clinical outcomes in patients treated for ALLI with conventional endovascular or surgical revascularization.

Method:

This study was a retrospective single-center review. Consecutive patients with ALLI treated with conventional endovascular revascularization (ER) without thrombolytic agent or surgical revascularization (SR) between 2008 and 2014 were investigated. The 1 year and 3 year amputation rate and mortality rate were assessed by time-to-event methods, including Kaplan–Meier estimation.

Result:

A total of 64 limbs in 62 patients with ALLI due to thromboembolism or thrombosis of a native artery, bypass graft, or previous stented vessel were included. The majority of limbs (90.9%) presented with Rutherford clinical categories 1 to 2 ischemia. Technical success rate was 95.5% in ER and 92.9% in SR group (p = 0.547). Overall amputation rates were 9.1% in ER versus 9.5% in SR after 1 year (p = 0.971) and 9.1% in ER versus 11.9% in SR after 3 year (p = 0.742). Overall mortality rates were 15% in ER versus 7.1% in SR after 1 year (p = 0.491) and 15% in ER versus 11.2% in SR after 3 year (p = 0.878).

Conclusion:

Endovascular or surgical revascularization of ALLI resulted in comparable outcomes in limb salvage and mortality rate at 1 year and 3 year. Conventional endovascular therapy without thrombolytic agent such as stenting, balloon angioplasty, or catheter-directed thrombosuction may be considered as a treatment option for ALLI.

Voluntary running protects against neuromuscular dysfunction following hindlimb ischemia-reperfusion in mice

Ischemia-reperfusion (IR) due to temporary restriction of blood flow causes tissue/organ damages under various disease conditions, including stroke, myocardial infarction, trauma, and orthopedic surgery. In the limbs, IR injury to motor nerves and muscle fibers causes reduced mobility and quality of life. Endurance exercise training has been shown to increase tissue resistance to numerous pathological insults. To elucidate the impact of endurance exercise training on IR injury in skeletal muscle, sedentary and exercise-trained mice (5 wk of voluntary running) were subjected to ischemia by unilateral application of a rubber band tourniquet above the femur for 1 h, followed by reperfusion. IR caused significant muscle injury and denervation at neuromuscular junction (NMJ) as early as 3 h after tourniquet release as well as depressed muscle strength and neuromuscular transmission in sedentary mice. Despite similar degrees of muscle atrophy and oxidative stress, exercise-trained mice had significantly reduced muscle injury and denervation at NMJ with improved regeneration and functional recovery following IR. Together, these data suggest that endurance exercise training preserves motor nerve and myofiber structure and function from IR injury and promote functional regeneration. NEW & NOTEWORTHY This work provides the first evidence that preemptive voluntary wheel running reduces neuromuscular dysfunction following ischemia-reperfusion injury in skeletal muscle. These findings may alter clinical practices in which a tourniquet is used to modulate blood flow.

An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries: A Supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II): The TASC Steering Comittee(.)

The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were last updated in 2007 (TASC II) and represented the collaboration of international vascular specialties involved in the management of patients with peripheral arterial disease (PAD). Since the publication of TASC II, there have been innovations in endovascular revascularization strategies for patients with PAD. The intent of this publication is to provide a complete anatomic lower limb TASC lesion classification, including the infrapopliteal segment, and an updated literature review of new endovascular techniques and practice patterns employed by vascular specialists today.

An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries: A Supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II)

The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were last updated in 2007 (TASC II) and represented the collaboration of international vascular specialties involved in the management of patients with peripheral arterial disease (PAD). Since the publication of TASC II, there have been innovations in endovascular revascularization strategies for patients with PAD. The intent of this publication is to provide a complete anatomic lower limb TASC lesion classification, including the infrapopliteal segment, and an updated literature review of new endovascular techniques and practice patterns employed by vascular specialists today.

An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries

The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were last updated in 2007 (TASC II) and represented the collaboration of international vascular specialties involved in the management of patients with peripheral arterial disease (PAD). Since the publication of TASC II, there have been innovations in endovascular revascularization strategies for patients with PAD. The intent of this publication is to provide a complete anatomic lower limb TASC lesion classification, including the infrapopliteal segment, and an updated literature review of new endovascular techniques and practice patterns employed by vascular specialists today.

[Management of peripheral vascular disease based on current guidelines. Peripheral artery occlusive disease of the iliac and femoral arteries and carotid artery stenosis]

The article summarizes the recommendations of current European and American guidelines concerning the diagnosis and treatment of peripheral arterial occlusive disease and carotid artery stenosis. In comparison to older recommendations, current guidelines concerning endovascular treatment and concomitant medical therapy have been changed in recent years. With the exception of very complex and long lesions, endovascular methods are seen as the therapy of choice for revascularization of the iliac and femoral arteries. For cardiovascular risk reduction, patients with symptomatic peripheral arterial disease and stenosis of the carotid arteries should receive antiplatelet as well as statin therapy and should not be treated different from patients with coronary artery disease.

Assessment of effectiveness of endovascular treatment of common and external iliac artery stenosis/occlusion using self-expanding Jaguar SM stents

The goal of this work was to assess the effectiveness of endovascular treatment of common and external iliac artery stenosis/occlusion classified according to TASC using a self-expanding stent Jaguar SM. The study group included 95 patients (61 men and 34 women) who underwent treatment for stenosis or occlusion of lower limb arteries at the Department of Radiology of the University Hospital in Bialystok and the Diagnostic Radiology Department of the Central Clinical Hospital of the Ministry of Interior (MSWiA) in Warsaw between 2005 and 2007. All arterial lesions were of atherosclerotic etiology. The shortest stenotic fragment was 10 mm long and the longest occluded arterial fragment did not exceed 90 mm. Morphological classification of iliac artery lesions in treated patients was performed according to TASC II classification and included 10 patients with type A, 39 cases of type B, 36 with type C and 10 patients with type D lesions. Endovascular procedure failed to restore flow in five patients with TASC type D lesions, who were later referred for surgery. One patient suffered a complication – vessel perforation during predilatation, and had a stentgraft implanted. In 95% of patients stents were expanded using a balloon after implantation. Good results were achieved in practically all patients who underwent stent implantation. Patients were subjected to follow-up clinical and imaging evaluation during next 1–24 months. Success rate of the performed procedures as well as in a 30-day observation period was 100% in case of stenosis and 80% in case of vessel occlusion. A follow-up after 12 and 24 months showed patency of treated vessels in 84% and 76% of patients, respectively.

[Arterial occlusive disease. Catheter-directed thrombolytic therapy]

Local catheter-directed thrombolysis of extremity artery or bypass thromboembolic occlusions is a promising therapeutic option with comparatively low complication rates, if the severity of the ischemia does not require urgent surgical revascularization. This therapeutic decision has to be made by a vascular team taking individual circumstances and contraindications into consideration. Apart from an adequate dosage, a strict intrathrombotic administration of the fibrinolytic agent and careful clinical monitoring including surveillance of the coagulation system is necessary and intensive care unit resources should be used. If necessary the thrombolysis therapy can be combined with mechanical thrombaspiration and balloon dilatation or surgical correction of an underlying lesion.

[Peripheral arterial disease. Diagnosis and therapy according to current guidelines]

Guidelines conduce to establish consistent standards of therapy and contribute to the orientation and safeguard of the attending physician. Peripheral arterial disease (PAD) may be classified according to its stage as intermittent claudication, chronic critical limb ischemia or acute limb ischemia. Since these diseases are common and life-threatening, current guidelines are of major interest for the attending physician, not least because of forensic reasons. This overview describes the current principles of diagnosis and therapy as well as recent developments in peripheral endovascular intervention. Current national and international guidelines, particularly the Transatlantic Intersociety Consensus (TASC), were taken into account.