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Mustapha JA, Igyarto Z, O'Connor D, Armstrong EJ, Iorio AR, Driver VR, Saab F, Behrens AN, Martinsen BJ, Adams GL. One-Year Outcomes of Peripheral Endovascular Device Intervention in Critical Limb Ischemia Patients: Sub-Analysis of the LIBERTY 360 Study. Vasc Health Risk Manag 2020; 16:57-66. [PMID: 32103970 PMCID: PMC7020930 DOI: 10.2147/vhrm.s230934] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/30/2019] [Indexed: 12/21/2022] Open
Abstract
Background High-risk patients with advanced peripheral artery disease (PAD), including critical limb ischemia (CLI), are often excluded from peripheral endovascular device intervention clinical trials, leading to difficulty in translating trial results into real-world practice. There is a need for prospectively assessed studies to evaluate peripheral endovascular device intervention outcomes in CLI patients. Methods LIBERTY 360 is a prospective, observational, multi-center study designed to evaluate the procedural and long-term clinical outcomes of peripheral endovascular device intervention in real-world patients with symptomatic lower-extremity PAD. One thousand two hundred and four patients were enrolled and stratified based on Rutherford Classification (RC): RC2-3 (N=501), RC4-5 (N=603), and RC6 (N=100). For this sub-analysis, RC5 and RC6 patients (RC5-6; N=404) were pooled and 1-year outcomes were assessed. Results Procedural complications rarely (1.7%) resulted in post-procedural hospitalization and 89.1% of RC5-6 patients were discharged to home. Considering the advanced disease state in RC5-6 patients, there was a high freedom from 1-year major adverse event rate of 65.5% (defined as target vessel revascularization, death to 30 days, and major target limb amputation). At 1 year, freedom from major amputation was 89.6%. Wounds identified at baseline on the target limb had completely healed in 172/243 (70.8%) of the RC5-6 subjects by 1 year. Additionally, the overall quality of life, as measured by VascuQoL, improved from baseline to 1 year. Conclusion LIBERTY investigated real-world PAD patients with independent oversight of outcomes. This analysis of LIBERTY RC5-6 patients demonstrates that peripheral endovascular device intervention can be successful in CLI patients, with low rates of major amputation and improvement in wound healing and quality of life through 1-year follow-up. LIBERTY 360, https://clinicaltrials.gov/ct2/show/NCT01855412, ClinicalTrials.gov Identifier: NCT01855412.
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Affiliation(s)
- Jihad A Mustapha
- College of Osteopathic Medicine, Michigan State University, E. Lansing, MI, USA.,Advanced Cardiac & Vascular Amputation Prevention Centers, Grand Rapids, MI, USA
| | | | - David O'Connor
- Hackensack University Medical Center, Hackensack, NJ, USA
| | - Ehrin J Armstrong
- Denver VA Medical Center, Denver, CO, USA.,Anschutz Medical Campus, University of Colorado, Denver, CO, USA
| | - Anthony R Iorio
- Foot Center of New York, New York College of Podiatric Medicine, New York, NY, USA
| | - Vickie R Driver
- Department of Orthopedics, Brown University School of Medicine, Providence, RI, USA
| | - Fadi Saab
- Advanced Cardiac & Vascular Amputation Prevention Centers, Grand Rapids, MI, USA
| | | | | | - George L Adams
- North Carolina Heart and Vascular, Rex Hospital, UNC School of Medicine, Raleigh, NC, USA
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Ghoneim B, Younis S, Elmahdy H, Elwan H, Khairy H. Endovascular intervention in flush superficial femoral artery occlusive disease: challenges and outcome. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2019. [DOI: 10.23736/s1824-4777.18.01368-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kishimoto S, Inoue KI, Nakamura S, Hattori H, Ishihara M, Sakuma M, Toyoda S, Iwaguro H, Taguchi I, Inoue T, Yoshida KI. Low-molecular weight heparin protamine complex augmented the potential of adipose-derived stromal cells to ameliorate limb ischemia. Atherosclerosis 2016; 249:132-9. [PMID: 27100923 DOI: 10.1016/j.atherosclerosis.2016.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 03/16/2016] [Accepted: 04/05/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS Heparin/protamine micro/nanoparticles (LH/P-MPs) were recently developed as low-molecular weight, biodegradable carriers for adipose-derived stromal cells (ADSCs). These particles can be used for a locally delivered stem cell therapy that promotes angiogenesis. LH/P-MPs bind to the cell surface of ADSCs and promote cell-to-cell interaction and aggregation of ADSCs. Cultured ADSC/LH/P-MP aggregates remain viable. Here, we examined the ability of these aggregates to rescue limb loss in a mouse model of hindlimb ischemia. METHODS Unilateral hindlimb ischemia was induced in adult male BALB/c mice by ligation of the iliac artery and hindlimb vein. For allotransplantation of ADSCs from the same inbred strain, we injected ADSC alone or ADSC/LH/P-MP aggregates or control medium (sham-treated) directly into the ischemic muscles. Ischemic limb blood perfusion, vessel density, and vessel area were recorded. The extent of ischemic limb necrosis or limb loss was assessed on postoperative days 2, 7, and 14. RESULTS Compared with the sham-treatment control, treatment with ADSCs alone showed modest effects on blood perfusion recovery and increased the number of α-SMA-positive vessels. Response to ADSC/LH/P-MP aggregates was significantly greater than ADSCs alone for every endpoint. ADSC/LH/P-MP aggregates more effectively prevented the loss of ischemic hindlimbs than ADSCs alone or the sham-treatment. CONCLUSION The LH/P-MPs augmented the effects of ADSCs on angiogenesis and reversal of limb ischemia. Use of ADSC/LH/P-MP aggregates offers a novel and convenient treatment method and potentially represents a promising new therapeutic approach to inducing angiogenesis in ischemic diseases.
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Affiliation(s)
- Satoko Kishimoto
- Research Support Center, Dokkyo Medical University, Mibu, Tochigi, Japan; Center for Regenerative Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan.
| | - Ken-Ichi Inoue
- Research Support Center, Dokkyo Medical University, Mibu, Tochigi, Japan; Center for Regenerative Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Shingo Nakamura
- Division of Biomedical Engineering, Research Institute, National Defense Medical College, Saitama, Japan
| | - Hidemi Hattori
- Division of Biomedical Engineering, Research Institute, National Defense Medical College, Saitama, Japan
| | - Masayuki Ishihara
- Division of Biomedical Engineering, Research Institute, National Defense Medical College, Saitama, Japan
| | - Masashi Sakuma
- Center for Regenerative Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan; Department of Cardiovascular Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Shigeru Toyoda
- Center for Regenerative Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan; Department of Cardiovascular Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Hideki Iwaguro
- Center for Regenerative Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan; Department of Cardiovascular Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Isao Taguchi
- Center for Regenerative Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan; Department of Cardiology, Koshigaya Hospital, Dokkyo Medical University, Koshigaya, Saitama, Japan
| | - Teruo Inoue
- Research Support Center, Dokkyo Medical University, Mibu, Tochigi, Japan; Center for Regenerative Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan; Department of Cardiovascular Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Ken-Ichiro Yoshida
- Center for Regenerative Medicine, Dokkyo Medical University, Mibu, Tochigi, Japan
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Naoum JJ, Arbid EJ. Endovascular techniques in limb salvage: infrapopliteal angioplasty. Methodist Debakey Cardiovasc J 2014; 9:103-7. [PMID: 23805344 DOI: 10.14797/mdcj-9-2-103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Critical limb ischemia (CLI) results from inadequate blood flow to supply and sustain the metabolic needs of resting muscle and tissue. Infragenicular atherosclerosis is the most common cause of CLI, and it is more likely to develop when multilevel or diffuse arterial disease coincides with compromised run-off to the foot. Reports of good technical and clinical outcomes have advanced the endovascular treatment options, which have gained a growing acceptance as the primary therapeutic strategy for CLI, especially in patients with significant risk factors for open surgical bypass. In fact, endovascular recanalization of below-the-knee arteries has proven to be feasible and safe, reduce the need for amputation, and improve wound healing. The distribution of various vascular territories or angiosomes in the foot has been recognized, and it appears advantageous to revascularize the artery supplying the territory directly associated with tissue loss. In addition, the targeted application and local delivery of drugs using drug-coated balloons (DCB) during angioplasty has the potential to improve patency rates compared to balloon angioplasty alone.
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Bunte MC, Shishehbor MH. Treatment of infrapopliteal critical limb ischemia in 2013: the wound perfusion approach. Curr Cardiol Rep 2013; 15:363. [PMID: 23605465 DOI: 10.1007/s11886-013-0363-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The primary goals of treatment for critical limb ischemia (CLI) are alleviation of ischemic rest pain, healing of arterial insufficiency ulcers, and improving quality of life. These goals are directed toward preventing limb loss and CLI-related mortality. Arterial revascularization serves as the foundation of a contemporary approach to promote amputation-free survival. Mounting evidence supports a wound-directed angiosome revascularization approach, increasingly achieved with endovascular techniques. Innovations in technology and wound-perfusion strategy have advanced patient care and are accelerating the pace of CLI treatment. The evolving angiosome revascularization approach has been augmented with a multidisciplinary wound care strategy that deserves particular emphasis. These state-of-the-art advances in CLI management are reported herein with considerations for the future treatment of CLI.
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Affiliation(s)
- Matthew C Bunte
- Robert & Suzanne Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Mail code J3-5, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Abstract
The prevalence of peripheral arterial disease and both traditional and nontraditional vascular risk factors are more common in patients with end-stage renal disease who are undergoing hemodialysis than the general population. Patients undergoing hemodialysis may also be at risk for peripheral arterial disease via nonvascular risk factors and the hemodialysis treatment itself. Unfortunately, because peripheral arterial disease and its risk factors in hemodialysis patients have not been thoroughly ascertained, evaluation of potential treatments has been limited. Given the high potential of morbidity and impaired quality-of-life related to peripheral arterial disease in patients with end-stage renal disease, additional studies are needed to evaluate both quality of life and potential screening for peripheral arterial disease, its risk factors, and treatments to identify areas for improvement in this vulnerable population.
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Affiliation(s)
- Houssam K Younes
- Methodist DeBakey Heart & Vascular Center, The Methodist Hospital, Houston, Texas, USA
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