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Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024:ehae179. [PMID: 39210722 DOI: 10.1093/eurheartj/ehae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Kobayashi T, Hamamoto M, Okazaki T, Okusako R, Hasegawa M, Takahashi S. Risk Analysis and Clinical Outcomes in Chronic Limb-threatening Ischemia Patients with Surgical Site Infection after Distal Bypass. Ann Vasc Surg 2024; 99:33-40. [PMID: 37926138 DOI: 10.1016/j.avsg.2023.09.091] [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: 06/30/2023] [Revised: 08/23/2023] [Accepted: 09/18/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND A recent randomized control study showed that long-term outcomes after surgical revascularization were superior to those after endovascular treatment for cases with chronic limb-threatening ischemia (CLTI) with an appropriate single-segment great saphenous vein. However, surgical site infection (SSI) in CLTI cases after infrapoplital bypass also resulted in a prolonged hospital stay and poor outcomes, including graft disruption. The aim of the current study was to analyze risk factors for SSI in CLTI patients after distal bypass and to compare outcomes in patients with and without SSI. METHODS A total of 515 cases that underwent distal bypass at a single center between 2009 and 2022 were analyzed retrospectively. Comparisons were made between patients with and without SSI after distal bypass. The primary end point was limb salvage after distal bypass. RESULTS Of the 515 cases that underwent distal bypass, 79 (15%) had SSI. The risk factors for SSI were preoperative antibacterial drug use (P = 0.001), pedal bypass (P = 0.001), and prolonged operation time (≥150 min) (P = 0.010). The median hospital stay in SSI cases was longer than that in non-SSI cases (P < 0.001). Of 515 distal bypasses, 7 (1.3%) bypass grafts ruptured postoperatively due to SSI, and of these 7 cases, 6 ruptured during the day, 5 cases occurred within 1 month postoperatively, and 2 patients (29%) are alive without amputation. The mean follow-up period was 34 ± 30 months. During follow-up, 62 limbs (SSI cases, 19; non-SSI cases, 43) required major amputation and there were 234 deaths (SSI cases, 46; non-SSI cases, 188). The 1-, 3-, and 5-year limb salvage rates of 82%, 71%, and 62%, respectively, in SSI cases were significantly lower than those in non-SSI cases (P < 0.001). The 5-year survival rate of 29% in SSI cases showed a tendency to be lower than that in non-SSI cases (P = 0.058). CONCLUSIONS The limb salvage rate in SSI cases was lower than in non-SSI cases after distal bypass. Graft rupture due to SSI occurred at a rate of 1.3% and resulted in poor outcomes in most cases. SSIs adversely affect outcomes and further study is needed to identify methods to avoid SSI following distal bypass.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan.
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Ryo Okusako
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Misa Hasegawa
- Department of Reconstructive and Plastic Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Minami-ku, Hiroshima, Japan
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Kobayashi T, Hamamoto M, Okazaki T, Tomota M, Fujiwara T, Hasegawa M, Takahashi S. Effectiveness of the Vascular Quality Initiative Chronic Limb-Threatening Ischemia Mortality Prediction Model in Patents with Distal Bypass. Ann Vasc Surg 2023; 90:188-196. [PMID: 36442707 DOI: 10.1016/j.avsg.2022.10.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/12/2022] [Accepted: 10/27/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The purpose of this study is to evaluate the effectiveness of mortality prediction using the Vascular Quality Initiative (VQI) chronic limb-threatening ischemia (CLTI) model in patients with distal bypass. METHODS Patients who underwent distal bypass for CLTI from 2009 to 2020 at a single center were retrospectively reviewed. Distal bypass was defined as any bypass with a distal anastomosis to the posterior tibial, anterior tibial, dorsalis pedis, plantar, or peroneal artery. Baseline characteristics, operative details, hospital outcomes, and medium-term outcomes were compared among patients with a low-, medium-, and high-risk of mortality based on a VQI CLTI calculation. The primary endpoints were survival and limb salvage. RESULTS A total of 287 distal bypasses were performed in 230 patients (153 males; median age, 74 years; diabetes mellitus, 70%; end-stage renal disease [ESRD] with hemodialysis, 38%). These patients were stratified into 153 (66%) low-, 35 (15%) medium-, and 42 (18%) high-risk cases based on the VQI CLTI model. There were two hospital deaths (1%) within 30 days. During a mean follow-up period of 33 ± 29 months, 105 patients died and 26 limbs (9%) required major amputation. The 2-year survival rate of 81% in the low-risk group was significantly higher than those of 41% in the medium-risk group and 46% in the high-risk group (both P < 0.001). The 2-year survival rates did not differ significantly between the medium- and high-risk groups (P = 0.81). The 2-year limb salvage rate of 93% in the low-risk group was significantly higher than those of 81% in the medium-risk (P = 0.023) and those of 87% in the high-risk (P = 0.039) groups. There were no significant differences in graft patency and wound healing among the three groups. CONCLUSIONS These results suggest that distal bypass is optimal treatment for patients with a low VQI-predicted risk of mortality. However, the lower limb salvage and higher mortality rates at 2 years suggest that the decision-making for VQI medium- and high-risk patients may be carefully considered.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan.
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mayu Tomota
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Takashi Fujiwara
- Department of Cardiology, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Misa Hasegawa
- Department of Reconstructive and Plastic Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University, Hiroshima, Japan
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Kobayashi T, Hamamoto M, Okazaki T, Tomota M, Fujiwara T, Yoshitomi Y, Hasegawa M, Takahashi S. Outcomes of a bypass-first strategy in chronic limb-threatening ischemia based on the Global Vascular Guidelines. J Vasc Surg 2023; 77:201-207. [PMID: 35934216 DOI: 10.1016/j.jvs.2022.06.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 06/20/2022] [Accepted: 06/28/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The Global Vascular Guidelines (GVGs) recommend initial revascularization (bypass or endovascular therapy) for chronic limb-threatening ischemia (CLTI) based on anatomical complexity and limb severity. This decision is made based on a prediction of the outcomes after endovascular intervention. This study was performed to evaluate outcomes after distal bypass in cases recommended for GVG bypass. METHODS A total of 239 distal bypasses for CLTI were evaluated in 195 patients with a GVG bypass recommendation treated between 2009 and 2020 at a single center in Japan. Comparisons were made between crural and pedal bypass cases. RESULTS The 195 patients (median age, 77 years; 67% male) underwent 133 crural bypasses (106 patients; 54%) and 106 pedal bypasses (89 patients; 46%). Hemodialysis was more common in pedal cases than in crural cases (P = .03). Hospital deaths occurred in two cases (1%) within 30 days. The whole cohort has a follow-up rate of 96% over a mean of 28 ± 26 months, with 3-year limb salvage rates of 87% and 3-year primary, assisted primary, and secondary patency rates of 40%, 65%, and 67%, all without significant differences between crural and pedal cases. The 1-year wound healing rate was 88% and tended to be higher in crural cases than in pedal cases (P = .068). The 3-year survival rate was 52% in the cohort and did not differ significantly between crural and pedal cases. CONCLUSIONS Patients with CLTI with a GVG bypass recommendation had acceptable limb salvage, graft patency, wound healing, and survival after distal bypass, regardless of the bypass method. These findings indicate that a GVG bypass recommendation as an initial revascularization method is valid in the real world.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan.
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mayu Tomota
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Takashi Fujiwara
- Department of Cardiology, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Yuki Yoshitomi
- Department of Cardiology, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Misa Hasegawa
- Department of Reconstructive and Plastic Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University, Hiroshima, Japan
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Krishnan P, Tarricone A, Chen S, Sharma S. The role of directional atherectomy in critical-limb ischemia. Ther Adv Cardiovasc Dis 2021; 135:17539447211046953. [PMID: 34796770 PMCID: PMC8606915 DOI: 10.1177/17539447211046953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Our aim was to review the current literature of the use of directional
atherectomy (DA) in the treatment of lower extremity critical-limb
ischemia. Methods: A search for relevant literature was performed in PubMed and PubMed Central
on 16 April 2020, sorted by best match. Three searches across two databases
were performed. Articles were included that contained clinical and
procedural data of DA interventions in lower extremity critical-limb
ischemia patients. All studies that were systematic reviews were
excluded. Results: Eleven papers were included in this review. Papers were examined under
several parameters: primary patency and secondary patency, limb
salvage/amputation, technical/procedural success,
complications/periprocedural events, and mean lesion length. Primary and
secondary patency rates ranged from 56.3% to 95.0% and 76.4% to 100%,
respectively. Limb salvage rates ranged from 69% to 100%. Lesion lengths
were highly varied, representing a broad population, ranging from 30 ± 33 mm
to 142.4 ± 107.9 mm. Conclusions: DA may be a useful tool in the treatment of lower extremity critical-limb
ischemia.
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Affiliation(s)
- Prakash Krishnan
- The Zena and Michael A. Weiner Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Cardiovascular Health Center, Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Arthur Tarricone
- The Zena and Michael A. Weiner Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Simon Chen
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Samin Sharma
- The Zena and Michael A. Weiner Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Krishnan P, Tarricone A, Gee A, Farhan S, Kamran H, Kapur V, Gujja K, Kini A, Sharma S. Analysis of Interwoven Nitinol Stenting for the Treatment of Critical Limb Ischemia: Outcomes From an Average 3-Year Follow-up Period. Angiology 2021; 73:407-412. [PMID: 34617824 DOI: 10.1177/00033197211043406] [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: 11/17/2022]
Abstract
We assessed the clinical outcomes of patients with critical limb-threatening ischemia (CLTI) who underwent interwoven nitinol stent (Supera) implantation for significant stenoses of the femoropopliteal segment. In this retrospective cohort study, 116 consecutive patients with CLTI who were treated with Supera stents between September 2015 and March 2020 were included in this analysis. Primary endpoint analysis was completed for amputation-free survival, target lesion revascularization (TLR), and mortality. After a mean follow-up time of 3.4 years, 21 (18%) patients had undergone amputations, 3 (2.6%) died, and, overall, the amputation-free survival rate was 81%. TLR occurred in 21 (18%) patients, resulting in the freedom from target lesion revascularization of 82%. The average Wagner score for all patients was 2.8 ± 1.1. A subgroup analysis of 57 patients revealed a median ulcer size of 3.0 cm2 [1.65, 9.0], with complete healing for 45 patients by 20 months. The Wagner score of this subgroup decreased by an average of 3.4 ± .9 points. Supera stents can be used together with other endovascular therapies and are a safe and effective treatment modality for CLTI.
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Affiliation(s)
- Prakash Krishnan
- Icahn School of Medicine at the Mount Sinai Hospital, The Zena and Michael A. Weiner Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Cardiovascular Health Center, Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Arthur Tarricone
- Icahn School of Medicine at the Mount Sinai Hospital, The Zena and Michael A. Weiner Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Cardiovascular Health Center, Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Allen Gee
- Icahn School of Medicine at the Mount Sinai Hospital, The Zena and Michael A. Weiner Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Cardiovascular Health Center, Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Serdar Farhan
- Icahn School of Medicine at the Mount Sinai Hospital, The Zena and Michael A. Weiner Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Cardiovascular Health Center, Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Haroon Kamran
- Icahn School of Medicine at the Mount Sinai Hospital, The Zena and Michael A. Weiner Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Cardiovascular Health Center, Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vishal Kapur
- Icahn School of Medicine at the Mount Sinai Hospital, The Zena and Michael A. Weiner Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Cardiovascular Health Center, Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Karthik Gujja
- Icahn School of Medicine at the Mount Sinai Hospital, The Zena and Michael A. Weiner Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Cardiovascular Health Center, Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Annapoorna Kini
- Icahn School of Medicine at the Mount Sinai Hospital, The Zena and Michael A. Weiner Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Cardiovascular Health Center, Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samin Sharma
- Icahn School of Medicine at the Mount Sinai Hospital, The Zena and Michael A. Weiner Cardiovascular Institute and the Marie-Josée and Henry R. Kravis Cardiovascular Health Center, Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Kobayashi T, Hamamoto M, Okazaki T, Hasegawa M, Takahashi S. Does the Global Limb Anatomic Staging System Inframalleolar Modifier Influence Long Term Outcomes of Chronic Limb Threatening Ischaemia after Distal Bypass? Eur J Vasc Endovasc Surg 2021; 62:590-596. [PMID: 34465536 DOI: 10.1016/j.ejvs.2021.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 07/01/2021] [Accepted: 07/11/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the influence of inframalleolar disease (Global Limb Anatomic Staging System Inframalleolar [GLASS IM] modifier) on long term outcomes of patients with chronic limb threatening ischaemia (CLTI) after distal bypass. METHODS Patients who underwent distal bypass for CLTI from January 2012 to December 2019 at a single centre were reviewed retrospectively. Comparisons including baseline characteristics, procedural details, and long term outcomes were made between patients with an intact pedal arch (GLASS IM modifier P0), an absent or severely diseased pedal arch (P1), and no target artery crossing the ankle into the foot (P2), diagnosed by pre- and intra-operative high quality angiography. The primary endpoint was limb salvage. The secondary endpoints were graft patency and wound healing. RESULTS A total of 254 distal bypasses were performed in 206 patients (139 males; median age, 76 years). The GLASS IM modifier was P0 in 80 (32%) limbs, P1 in 127 (50%), and P2 in 47 (18%). During the follow up period, 22 limbs (9%) required major amputation. The limb salvage rates at three years in P0, P1, and P2 cases were 94%, 89%, and 93%, respectively, with no significant differences among the modifiers. The primary patencies at three years in P0, P1, and P2 cases were 49%, 38% and 24%, respectively. The primary patency in P2 cases was significantly lower than that in P0 cases (p < .050). The respective wound healing rates at 12 months were 97%, 93%, and 79%, and again the wound healing rate in P2 cases was significantly lower than those in other cases (p < .050). CONCLUSION Long term outcomes including patency, limb salvage, and wound healing after distal bypass for CLTI patients with an infrapopliteal lesion were acceptable in cases in each GLASS IM modifier.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Japan.
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Japan
| | - Misa Hasegawa
- Department of Reconstructive and Plastic Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University, Minami-ku, Japan
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Technical Success and Mid-Term Outcomes of Endovascular Revascularization of Tibio-Peroneal Trunk Lesions. J Clin Med 2021; 10:jcm10163610. [PMID: 34441909 PMCID: PMC8396830 DOI: 10.3390/jcm10163610] [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: 06/29/2021] [Revised: 08/07/2021] [Accepted: 08/12/2021] [Indexed: 11/16/2022] Open
Abstract
Tibio-peroneal trunk (TPT) lesions are usually categorized as ‘complex’ in anatomical classifications, which leads to the perception that endovascular therapy (EVT) will be challenging and the outcome most likely poor. This multicenter, retrospective cohort study investigates the efficacy of the EVT of TPT lesions in patients with chronic limb threatening ischemia (CLTI) or an infrapopliteal bypass at risk. The primary endpoint was limb-salvage. The secondary outcomes were technical success, freedom from clinically driven target lesion revascularization (CD-TLR), overall survival, and amputation-free survival. A total of 107 TPT lesions were treated in 101 patients. At 3 years, the limb-salvage rate was 76.4% (95% CI 66.0–86.8%). Technical success was achieved in 96.3% of cases. The freedom from CD-TLR, amputation-free survival, and overall survival at 3 years were 53.0% (95% CI 38.1–67.9%), 33.6% (95% CI 23.0–44.2%), and 47.7% (95% CI 36.1–59.3%), respectively. Reintervention significantly increased the hazard ratio for amputation by 7.65 (95% CI 2.50–23.44, p < 0.001). Our results show that the EVT of both isolated and complex TPT lesions is associated with high technical success and acceptable limb-salvage rates, with reintervention being a major risk factor for amputation. Moreover, mid-term mortality rate was relatively high. In future revisions of the anatomical grading scales, the classification of TPT lesions as highly complex should be reconsidered.
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Sigala F, Galyfos G, Stavridis K, Tigkiropoulos K, Lazaridis I, Karamanos D, Mpontinis V, Melas N, Zournatzi I, Filis K, Saratzis N. Prognostic Factors in Patients Treated with Drug-Coated Balloon Angioplasty for Symptomatic Peripheral Artery Disease. Vasc Specialist Int 2019; 34:94-102. [PMID: 30671418 PMCID: PMC6340698 DOI: 10.5758/vsi.2018.34.4.94] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/13/2018] [Accepted: 09/23/2018] [Indexed: 11/20/2022] Open
Abstract
Purpose Aim of this study is to report real-life experience on the treatment of peripheral artery disease (PAD) with a specific drug-coated balloon (DCB), and to evaluate potential prognostic factors for outcomes. Materials and Methods This is a retrospective study reporting outcomes in patients with PAD who were treated with the Lutonix DCB during a four-year period. Major outcomes included: all-cause mortality, amputation, clinical improvement, wound healing and target lesion revascularization (TLR). Mean follow-up was 24.2±2.3 months. Results Overall, 149 patients (mean age: 68.6±8.3 years; 113 males) were treated, either for intermittent claudication (IC) (n=86) or critical limb ischemia (CLI) (n=63). More than half the target lesions (n=206 in total) were located in the superficial femoral artery and 18.0% were below-the-knee lesions. CLI patients presented more frequently with infrapopliteal (P=0.002) or multilevel disease (P=0.0004). Overall, all-cause mortality during follow-up was 10.7%, amputation-free survival was 81.2% and TLR-free survival was 96.6%. CLI patients showed higher all-cause mortality (P=0.007) and total amputation (P=0.0001) rates as well as lower clinical improvement (P=0.0002), compared to IC patients. Coronary artery disease (CAD), gangrene and infrapopliteal disease were found to be predictors for death whereas CLI and gangrene were found to be predictors for amputation, during follow-up. Conclusion PAD treatment with Lutonix DCBs seems to be an efficient and safe endovascular strategy yielding promising results. However, CAD, gangrene, CLI and infrapopliteal lesions were found to be independent predictors for adverse outcomes. Larger series are needed to identify additional prognostic factors.
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Affiliation(s)
- Fragiska Sigala
- First Department of Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece.,First Department of Propaedeutic Surgery, Ethnikon and Kapodistriakon University of Athens, Hippocration Hospital, Athens, Greece
| | - George Galyfos
- First Department of Propaedeutic Surgery, Ethnikon and Kapodistriakon University of Athens, Hippocration Hospital, Athens, Greece
| | - Kyriakos Stavridis
- First Department of Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Konstantinos Tigkiropoulos
- First Department of Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Ioannis Lazaridis
- First Department of Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Dimitrios Karamanos
- First Department of Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Vangelis Mpontinis
- First Department of Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Nikolaos Melas
- First Department of Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Ioulia Zournatzi
- First Department of Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Konstantinos Filis
- First Department of Propaedeutic Surgery, Ethnikon and Kapodistriakon University of Athens, Hippocration Hospital, Athens, Greece
| | - Nikolaos Saratzis
- First Department of Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
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10
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Matsushita K, Kwak L, Yang C, Pang Y, Ballew SH, Sang Y, Hoogeveen RC, Jaar BG, Selvin E, Ballantyne CM, Sharrett AR, Folsom AR, Heiss G, Coresh J, Hirsch AT. High-sensitivity cardiac troponin and natriuretic peptide with risk of lower-extremity peripheral artery disease: the Atherosclerosis Risk in Communities (ARIC) Study. Eur Heart J 2018; 39:2412-2419. [PMID: 29579246 PMCID: PMC6031056 DOI: 10.1093/eurheartj/ehy106] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/30/2017] [Accepted: 03/13/2018] [Indexed: 01/08/2023] Open
Abstract
Aims Cardiac troponin T (cTnT) is suggested as a predictor of amputation in patients with peripheral artery disease (PAD). However, cTnT-PAD association has not been systematically studied in a large study. This study evaluated the association of high-sensitivity cTnT (hs-cTnT) with PAD incidence and also explored whether natriuretic peptide (NT-proBNP), another representative cardiac marker, predicts PAD risk. Methods and results Among 12 288 middle-aged adults, the associations of hs-cTnT and NT-proBNP with incident PAD (hospitalizations with PAD diagnosis or leg revascularization [cases with rest pain or tissue loss considered as critical limb ischaemia (CLI)]) were quantified with multivariable Cox regression models. The risk discrimination was assessed by c-statistic. During a follow-up over 22 years, 454 participants developed PAD (164 CLI cases). In demographically adjusted models, the highest category of hs-cTnT (≥14 vs. <3 ng/L) and NT-proBNP (≥258.3 vs. <51.5 pg/mL) showed ∼8- and 10-20-fold higher risk of PAD and CLI, respectively. Even after adjusting for potential confounders and each other, hazard ratios were greater for CLI than for PAD (7.74 95% confidence interval [95% CI 4.43-13.55] vs. 2.84 [2.02-4.00] for the highest vs. reference hs-cTnT category and 4.63 [2.61-8.23] vs. 3.16 [2.23-4.49] for the highest vs. reference NT-proBNP category). The addition of these cardiac markers improved c-statistics for CLI. Conclusion High-sensitivity cTnT and NT-proBNP were independently associated with incident PAD, particularly its severe form, CLI. Although future studies are warranted to investigate pathophysiological mechanisms behind these associations, our study suggests the usefulness of cardiac markers to identify individuals at high risk of CLI.
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Affiliation(s)
- Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Lucia Kwak
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Chao Yang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Yuanjie Pang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Ron C Hoogeveen
- Department of Medicine, Section of Atherosclerosis and Vascular Medicine, Baylor College of Medicine, 6565 Fannin Street, Houston, TX, USA
| | - Bernard G Jaar
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, 1830 East Monument St., Baltimore, MD, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Christie M Ballantyne
- Department of Medicine, Section of Atherosclerosis and Vascular Medicine, Baylor College of Medicine, 6565 Fannin Street, Houston, TX, USA
| | - A Richey Sharrett
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Aaron R Folsom
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, West Bank Office Building, 1300 South Second Street, Minneapolis, MN, USA
| | - Gerardo Heiss
- University of North Carolina at Chapel Hill Gillings School of Global Public Health, 123 W. Franklin Street, Chapel Hill, NC, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Alan T Hirsch
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, 1830 East Monument St., Baltimore, MD, USA
- University of Minnesota Medical School, Mayo Building, 420 Delaware Street SE, Minneapolis, MN, USA
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11
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The Relationship between Hospital or Surgeon Volume and Outcomes in Lower Limb Vascular Surgery in the United Kingdom and Europe. Ann Vasc Surg 2017; 45:271-286. [DOI: 10.1016/j.avsg.2017.04.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 04/25/2017] [Indexed: 11/22/2022]
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12
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Karles-Ernotte AJ, Bermúdez-Posada A, Rincón-Sánchez HM, Padilla-Castro AT, Drews-Elger K, Novoa-Leal M, Hiller-Correa HG. Efecto terapéutico del alprostadil en pacientes con isquemia crítica terminal de los miembros inferiores. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2016.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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13
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Single-Center Experience With Lutonix Drug-Coated Balloons in Infrapopliteal Arteries. J Endovasc Ther 2016; 23:417-23. [DOI: 10.1177/1526602816645080] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To examine patient outcomes following the use of the Lutonix drug-coated balloon (DCB) in patients undergoing endovascular intervention in below-the-knee (BTK) arteries. Methods: A retrospective chart review identified 248 patients who were treated for symptomatic peripheral artery disease with the Lutonix DCB between May 2013 and October 2014. Forty patients were lost to follow-up, leaving 208 patients (mean age 74.1±9.7 years; 138 men) with evaluable data for outcome analysis. The patient cohort suffered from either severe claudication (38.6%) or critical limb ischemia (CLI; 61.4%) in 220 limbs. Almost two-thirds (140, 63.6%) of the 220 target lesions were total occlusions, and 37 (17.8%) of all patients had occlusion of all 3 BTK vessels before intervention. Results: Over a median 9-month follow-up, target lesion revascularization occurred in 15.9% of patients with an average time to first reintervention of 8 months. In total, 39 amputations were performed in 31 limbs. However, 17 of these amputations were preplanned minor amputations below the ankle; only 9 (4.1%) major amputations occurred corresponding to 6.6% of the CLI cohort. Freedom from the composite of death or major amputation was estimated as 92% and 85% at 6 and 12 months, respectively, by Kaplan-Meier analysis. In the full cohort, improvement of at least 1 Rutherford category was seen in 130 (59.1%) limbs after 1 year or at the last follow-up, with 104 (80.0%) of those limbs showing an improvement of ≥2 categories. Conclusion: From this single-center experience, the Lutonix DCB shows therapeutic promise in a disease state where new treatment options are needed.
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Shimada Y. Commentary: Another back door to the endovascular future: an antegrade pedal approach for retrograde revascularization. J Endovasc Ther 2014; 21:779-82. [PMID: 25453878 DOI: 10.1583/14-4801c.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Yoshihisa Shimada
- Cardiovascular Center, Shiroyama Hospital, Habikino City, Osaka, Japan
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15
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16
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Smith L, Fox M, Seriki D. The role of the community clinician in early detection, referral and treatment of critical limb ischaemia. Br J Community Nurs 2014; 19:266-72. [PMID: 24902054 DOI: 10.12968/bjcn.2014.19.6.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Critical limb ischaemia (CLI) is a significant public health issue worldwide, with an ever-growing incidence among people over 65. Awareness of CLI is low, particularly among non-vascular clinicians, leading to underdiagnosis and undertreatment. A diagnosis of CLI is known to have a grave effect on a person's quality of life, with devastating outcomes for both their life and limb, often resulting in uncontrolled pain, amputation or early death from a cardiovascular event. Community nurses and podiatrists are key clinicians who can play a crucial and active role in earlier identification, rapid referral and ongoing non-surgical care for this overlooked population.
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Affiliation(s)
- Lisa Smith
- Vascular Nurse Specialist, Pennine Acute Hospitals NHS Trust
| | - Martin Fox
- Vascular Specialist Podiatrist, Pennine Acute Hospitals NHS Trust
| | - Dare Seriki
- Consultant Vascular Radiologist, University Hospital of South Manchester NHS Foundation Trust
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17
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Shammas NW. An overview of optimal endovascular strategy in treating the femoropopliteal artery: mechanical, biological, and procedural factors. Int J Angiol 2014; 22:1-8. [PMID: 24436577 DOI: 10.1055/s-0032-1331840] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Treatment of the femoropopliteal (FP) artery remains a challenge to the endovascular specialist. Long-term patency is low with a high rate of target lesion revascularization. The true patency rate varies considerably between studies partly because there is a lack of uniform performance criteria and reporting standards in peripheral arterial interventions. Literature review supports three principles that emerge as important components of an optimal strategy in treating the FP artery: (1) improving vessel compliance and subsequently less dissections and bailout stenting, (2) reducing smooth muscle cell proliferation, and (3) protecting outflow vessels from distal embolization. In this overview, we examine current data that support the validity of this strategy.
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18
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Goodney PP, Travis LL, Brooke BS, DeMartino RR, Goodman DC, Fisher ES, Birkmeyer JD. Relationship between regional spending on vascular care and amputation rate. JAMA Surg 2014; 149:34-42. [PMID: 24258010 DOI: 10.1001/jamasurg.2013.4277] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Although lower extremity revascularization is effective in preventing amputation, the relationship between spending on vascular care and regional amputation rates remains unclear. OBJECTIVE To test the hypothesis that higher regional spending on vascular care is associated with lower amputation rates for patients with severe peripheral arterial disease. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 18,463 US Medicare patients who underwent a major peripheral arterial disease-related amputation during the period between 2003 and 2010. EXPOSURE Price-adjusted Medicare spending on revascularization procedures and related vascular care in the year before lower extremity amputation, across hospital referral regions. MAIN OUTCOMES AND MEASURES Correlation coefficient between regional spending on vascular care and regional rates of peripheral arterial disease-related amputation. RESULTS Among patients who ultimately underwent an amputation, 64% were admitted to the hospital in the year prior to the amputation for revascularization, wound-related care, or both; 36% were admitted only for their amputation. The mean cost of inpatient care in the year before amputation, including costs related to the amputation procedure itself, was $22,405, but it varied from $11,077 (Bismarck, North Dakota) to $42,613 (Salinas, California) (P < .001). Patients in high-spending regions were more likely to undergo vascular procedures as determined by crude analyses (12.0 procedures per 10,000 patients in the lowest quintile of spending and 20.4 procedures per 10,000 patients in the highest quintile of spending; P < .001) and by risk-adjusted analyses (adjusted odds ratio for receiving a vascular procedure in highest quintile of spending, 3.5 [95% CI, 3.2-3.8]; P < .001). Although revascularization was associated with higher spending (R = 0.38, P < .001), higher spending was not associated with lower regional amputation rates (R = 0.10, P = .06). The regions that were most aggressive in the use of endovascular interventions were the regions that were most likely to have high spending (R = 0.42, P = .002) and high amputation rates (R = 0.40, P = .004). CONCLUSIONS AND RELEVANCE Regions that spend the most on vascular care perform the most procedures, especially endovascular interventions, in the year before amputation. However, there is little evidence that higher regional spending is associated with lower amputation rates. This suggests an opportunity to limit costs in vascular care without compromising quality.
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Affiliation(s)
- Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire2Dartmouth-Hitchcock Medical Center, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Lori L Travis
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland4Center for Health Outcomes and Policy, University of Michigan, Ann Arbor
| | - Benjamin S Brooke
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Randall R DeMartino
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - David C Goodman
- Dartmouth-Hitchcock Medical Center, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Elliott S Fisher
- Dartmouth-Hitchcock Medical Center, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - John D Birkmeyer
- Dartmouth-Hitchcock Medical Center, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
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19
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Baumann F, Fust J, Engelberger RP, Hügel U, Do DD, Willenberg T, Baumgartner I, Diehm N. Early Recoil After Balloon Angioplasty of Tibial Artery Obstructions in Patients With Critical Limb Ischemia. J Endovasc Ther 2014; 21:44-51. [DOI: 10.1583/13-4486mr.1] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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20
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Braune S, Grunze M, Straub A, Jung F. Are there sufficient standards for the in vitro hemocompatibility testing of biomaterials? Biointerphases 2013; 8:33. [PMID: 24706143 DOI: 10.1186/1559-4106-8-33] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 11/06/2013] [Indexed: 11/10/2022] Open
Affiliation(s)
- Steffen Braune
- Institute of Biomaterial Science and Berlin-Brandenburg Center for Regenerative Therapies, Helmholtz-Zentrum Geesthacht, Kantstrasse 55, Teltow, 14513, Germany,
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21
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Systematic Review on Health-Related Quality of Life After Revascularization and Primary Amputation in Patients With Critical Limb Ischemia. Ann Vasc Surg 2013; 27:1105-14. [DOI: 10.1016/j.avsg.2013.01.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 01/19/2013] [Accepted: 01/28/2013] [Indexed: 11/17/2022]
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22
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van Overhagen H, Spiliopoulos S, Tsetis D. Below-the-knee interventions. Cardiovasc Intervent Radiol 2013; 36:302-11. [PMID: 23354963 DOI: 10.1007/s00270-013-0550-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 12/13/2012] [Indexed: 02/05/2023]
Affiliation(s)
- H van Overhagen
- Department of Radiology, Hagaziekenhuis, Leyweg 275, 2545 CH, The Hague, The Netherlands.
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23
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Fossaceca R, Guzzardi G, Di Terlizzi M, Divenuto I, Malatesta E, Cerini P, Cusaro C, Carriero A. Comparison of cryoplasty and conventional angioplasty for treating stenotic-occlusive lesions of the femoropopliteal arteries in diabetic patients: immediate, mid-term and long-term results. Radiol Med 2012; 117:1176-89. [DOI: 10.1007/s11547-012-0793-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 05/25/2011] [Indexed: 11/25/2022]
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24
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Airoldi F, Faglia E, Losa S, Tavano D, Latib A, Lanza G, Clerici G. Antegrade approach for percutaneous interventions of ostial superficial femoral artery: outcomes from a prospective series of diabetic patients presenting with critical limb ischemia. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2012; 13:20-4. [DOI: 10.1016/j.carrev.2011.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 09/19/2011] [Accepted: 10/06/2011] [Indexed: 12/21/2022]
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25
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Baumann F, Willenberg T, Do DD, Keo HH, Baumgartner I, Diehm N. Endovascular Revascularization of Below-the-Knee Arteries: Prospective Short-Term Angiographic and Clinical Follow-Up. J Vasc Interv Radiol 2011; 22:1665-73. [DOI: 10.1016/j.jvir.2011.08.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 08/26/2011] [Accepted: 08/30/2011] [Indexed: 10/16/2022] Open
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26
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Casillas JM, Troisgros O, Hannequin A, Gremeaux V, Ader P, Rapin A, Laurent Y. Rehabilitation in patients with peripheral arterial disease. Ann Phys Rehabil Med 2011; 54:443-61. [DOI: 10.1016/j.rehab.2011.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 06/28/2011] [Accepted: 07/02/2011] [Indexed: 12/27/2022]
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27
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Joviliano EE, Piccinato CE, Dellalibera-Joviliano R, Moriya T, Évora PR. Inflammatory Markers and Restenosis in Peripheral Percutaneous Angioplasty With Intravascular Stenting: Current Concepts. Ann Vasc Surg 2011; 25:846-55. [DOI: 10.1016/j.avsg.2011.02.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 12/16/2010] [Accepted: 02/21/2011] [Indexed: 11/25/2022]
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Segers VFM, Revin V, Wu W, Qiu H, Yan Z, Lee RT, Sandrasagra A. Protease-resistant stromal cell-derived factor-1 for the treatment of experimental peripheral artery disease. Circulation 2011; 123:1306-15. [PMID: 21403096 DOI: 10.1161/circulationaha.110.991786] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Peripheral artery disease is a potentially incapacitating disease for which pharmacological options are limited. Stromal cell-derived factor-1 (SDF-1) is a chemokine that attracts endothelial progenitor cells and promotes angiogenesis. Therapeutic use of SDF-1 in hindlimb ischemia may be challenged by proteolytic degradation. We hypothesized that protease-resistant variants of SDF-1 can increase blood flow in an experimental model of hindlimb ischemia. METHODS AND RESULTS We screened a peptide library for mutations in SDF-1 that provide resistance to matrix metalloproteinase cleavage. Recombinant SDF-1 proteins carrying the mutations were designed, expressed, and purified, and activity of mutant proteins was tested with receptor activation assays and in vivo Matrigel plug assays. SSDF-1(S4V), which is resistant to both dipeptidylpeptidase IV/CD26 and matrix metalloproteinase-2 cleavage, was active in vitro and induced angiogenesis in vivo. We then designed and purified fusion proteins of SSDF-1 and SSDF-1(S4V) with the sequence of self-assembling peptide nanofibers for incorporation into nanofibers. In a blinded and randomized hindlimb ischemia mouse study, SSDF-1(S4V) delivery by nanofibers improved blood flow as measured by laser Doppler from 23.1±1.9% (untreated control) to 55.1±5.7% 6 weeks after surgery (P<0.001). Nanofibers alone or SSDF-1 delivered by nanofibers did not improve blood flow. Furthermore, SSDF-1(S4V) delivered by nanofibers increased formation of new arterioles. In vitro, SSDF-1(S4V) attracts smooth muscle cells but does not induce mitosis. CONCLUSIONS SDF-1 engineered to be resistant to dipeptidylpeptidase IV/CD26 and matrix metalloproteinase-2 cleavage and delivered by nanofibers improves blood flow in a model of peripheral artery disease.
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Okada M, Yoshida M, Tsuji Y, Horii H. Clinical application of laser treatment for cardiovascular surgery. Laser Ther 2011; 20:217-32. [PMID: 24155531 PMCID: PMC3799031 DOI: 10.5978/islsm.20.217] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 07/29/2011] [Indexed: 11/06/2022]
Abstract
BACKGROUND Recently, several kinds of lasers have been widely employed in the field of medicine and surgery. However, laser applications are very rare in the field of cardiovascular surgery throughout the world. So, we have experimentally tried to use lasers in the field of cardiovascular surgery. There were three categories: 1) Transmyocardial laser revascularization (TMLR), 2) Laser vascular anastomosis, and 3) Laser angioplasty in the peripheral arterial diseases. By the way, surgery for ischemic heart disease has been widely performed in Japan. Especially coronary artery bypass grafting (CABG) for these patients has been done as a popular surgical method. Among these patients there are a few cases for whom CABG and percutaneous coronary intervention (PCI) could not be carried out, because of diffuse stenosis and small caliber of coronary arteries. Materials and methods of TMLR: A new method of tranasmyocardial revascularization by CO2 laser (output 100 W, irradiation time 0.2 sec) was experimentally performed to save severely ill patients. In this study, a feasibility of transmyocardial laser revascularization from left ventricular cavity through artificially created channels by laser was precisely evaluated. RESULTS In trials on dogs laser holes 0.2mm in diameter have been shown microscopically to be patent even 3 years after their creation, thus this procedure could be used as a new method of transmyocardial laser revascularization. Clinical application of TMLR: Subsequently, transmyocardial laser revascularization was employed in a 55-year-old male patient with severe angina pectoris who had undergone pericardiectomy 7 years before. He was completely recovered from severe chest pain. Conclusions of TMLR: This patient was the first successful case in the world with TMLR alone. This method might be done for the patients who percutaneous coronary intervention and coronary artery bypass grafting could be carried out. Laser vascular anastomosis: At present time, in vascular surgery there are some problems to keep long-term patency after anastomosis of the conventional suture method, especially for small-caliber vessels. Materials and methods of Laser vascular anastomosis: From these standpoints, a low energy CO2 laser was employed experimentally in vascular anastomosis for small-caliber vessels. Resullts of Laser vascular anastomosis: From preliminary experiments it could be concluded that the optimal laser output was 20-40 mW and irradiation time was 6-12 sec/mm for vascular anastomosis of small-caliber vessels in the extremities. And then, histologic findings and intensity of the laser anastomotic sites were investigated thereafter. Subseqently, good enough intensity and good healing of laser anastomotic sites as well as the conventional suture method could be observed. There were no statistic differences between laser and suture methods. A feasibility of laser anastomosis could be considered and clinical application could be recognized. Clinical applications of Laser vascular anastomosis: On February 21, 1985, arterio-venous laser anastomosis for the patient with renal failure was smoothly done and she could accept hemodialysis. Conclusions of Laser vascular anastomosis: This patient was the first clinical successful case in the world. Thereafter, Laser vascular anastomosis were in 111 patients with intermittent claudication, refractory crural ulcer, and coronary disorders. Thereafter, they are going well. Laser angioplasty: Laser angioplasty for peripheral arterial diseases. There are many methods to treat peripheral arterial diseases such as balloon method, atherectomy, laser technique and stenting graft in the field of endovascular treatment. Recent years, minimal invasive treatment should be employed even in the surgical treatment. However, there are different images between these methods. Materials and methods of Laser angioplasty: We have chosen to use laser for endovascular treatment for peripheral arterial diseases. We have tried to check between laser energy and vessel wall. Results of Laser angioplasty: Subsequently, it could be concluded that optimal conditions for laser angioplasty were 6 W in output and irradiation time was 5 sec. And with another method of feedback control system, temperature of metal tip probe was 200°C and irradiation time was 5 sec for each shot. And histological study and feasibility of angioscopic guidance could be done and clinical application was started. Until now, 115 patients were successfully treated with their life longevity. Conclusions of Laser angioplasty: Thus, laser applications were useful methods to treat a lot of patients with some ischemic problems.
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Abstract
The 1- to 2-year primary patency rates associated with self-expanding nitinol stents for the treatment of symptomatic femoropopliteal disease are superior to those for percutaneous transluminal angioplasty (PTA) and the first-generation stainless steel balloon-expandable stents. The advantages of nitinol stents include improved radial strength and flexibility, the ability to recover from being crushed, reduced foreshortening, and (importantly) deployability without balloon dilation of the stent edge (which may decrease the incidence of the edge stenosis, or "candy-wrap" effect, often observed with balloon-expandable stents). The technical success rate associated with primary deployment of nitinol stents is very high, and acute to 6-month patency results are predictably excellent. Prior to the introduction of nitinol stents, the original guidelines (2000) of the multidisciplinary TransAtlantic Inter-Society Consensus (TASC I) recommended only an adjunctive role for femoropopliteal stents following suboptimal PTA. The abbreviated 2007 TASC II report essentially extended this recommendation to nitinol stents. Here, current trials of nitinol stenting in the femoropopliteal segment are discussed, with emphasis on the advantages of primary (and often direct) deployment in selected circumstances dependent on factors including lesion length, lesion location, indication for treatment (critical limb ischemia or claudication, in-stent restenosis, stent-graft restenosis), and the relative appropriateness of other modalities (e.g., covered stents). Technical considerations in primary nitinol stenting are briefly reviewed. Open questions regarding the factors involved in nitinol stent fracture and the possible association of fracture and restenosis are examined in the context of current clinical trials. A new generation of femoropopliteal nitinol stents combining superior durability and flexibility is expected soon. Development and implementation of uniform reporting and surveillance standards is important for optimizing current and future research.
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Affiliation(s)
- Mark W Mewissen
- Vascular Center, St. Luke's Medical Center, 2801 W. Kinnickinnic River Parkway, Suite 514, Milwaukee, WI 53215, USA.
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31
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Ansel GM, Lumsden AB. Evolving modalities for femoropopliteal interventions. J Endovasc Ther 2009; 16:II82-97. [PMID: 19624076 DOI: 10.1583/08-2654.1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Despite technical advances in balloon design and technique, there has been little improvement of primary patency rates after balloon-based endovascular interventions for all but focal femoropopliteal lesions. Improving on stainless steel models, nitinol stents have been associated with favorable short- and midterm primary patency rates; studies with longer-term follow-up will be required to learn whether restenosis is ongoing, with continued loss of primary patency. Studies in recent years have shown varying incidences of mechanical fatigue leading to nitinol stent fracture. Covered stents are designed to prevent the tissue infiltration and intimal hyperplasia that can lead to bare metal in-stent restenosis. Several clinical studies, mainly single-center registries, have demonstrated a general effectiveness of the Hemobahn/Viabahn polytetrafluoroethylene-covered stent-grafts, approved for femoral arterial occlusive disease, and have helped to distinguish indications for use and to delineate possible failure modes. A multicenter randomized trial, which has completed enrollment, will compare the Viabahn with self-expanding bare nitinol stents. The primary use of drug-eluting stents (DES) has become routine clinical practice for coronary artery disease. The 2-phase multicenter randomized double-blind SIROCCO trials have been completed, with results published through 24 months. Follow-up demonstrated the feasibility and safety of deploying sirolimus-eluting stents in the femoropopliteal segment but failed to show superior efficacy for DES versus bare nitinol stents. However, the restenosis rates with bare metal stents were unexpectedly low. A paclitaxel-eluting stent without a polymer coating is currently being evaluated in the recently enrolled Zilver PTX randomized trial and international registry. A polymer-based everolimus-eluting stent is being evaluated for femoropopliteal use in the nonrandomized European STRIDES trial. Balloons coated with paclitaxel have recently been evaluated for simple femoropopliteal disease with encouraging results through 2 years of follow-up. The bioabsorbable stent concept emerged in response to the potential issues with metal stents, but to date no investigational device has successfully overcome issues such as relatively low radial force and variable degradation rates.
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Affiliation(s)
- Gary M Ansel
- MidOhio Cardiology and Vascular Consultants, Midwest Cardiology Research Foundation, Riverside Methodist Hospital, Columbus, Ohio 43214, USA.
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Lumsden AB, Das TS. Second Symposium on Endovascular Management of Infrainguinal Disease. J Endovasc Ther 2009; 16:II1-4. [PMID: 19624071 DOI: 10.1583/1545-1550-16.sp13.ii1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Alan B Lumsden
- Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, Texas, USA
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Lyden SP, Smouse HB. TASC II and the Endovascular Management of Infrainguinal Disease. J Endovasc Ther 2009; 16:II5-18. [DOI: 10.1583/08-2659.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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