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Barth U, Tautenhahn J, Klinsmann P, Meyer F, Halloul Z. [Vascularsurgical Long-term Outcome - Comparison of Orthotopic and Extraanatomic Reconstructions in Unilateral Occlusions of Iliac Artery over 10 Years]. Zentralbl Chir 2024. [PMID: 38885663 DOI: 10.1055/a-2324-1692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
In PAOD, several vascular regions are usually affected, the pelvic axis in 35% of cases. Interventional-radiological/endovascular or hybrid interventions have been established for recanalization, so that bypass procedures are increasingly taking a back seat, but are not losing their importance.To study unilateral iliac artery occlusions (inclusion criterion) that were repaired either by implantation of an orthotopic or extraanatomic bypass (oBP/eaBP).Over a defined period of time, the rate of open vessel, complications (frequency, type, severity) to characterize morbidity and mortality as well as the extent of clinical improvement after BP implantation were analyzed in a clinical-systematic, single-center observational study (for vascular surgical quality assurance and contribution to vascular medical-clinical health care research). The study method was not explicitly based on the STROBE criteria, but essentially corresponds to them.Over 10 years, 122 PAOD patients (50% in stage IIb-stage III and IV equally distributed; mean age: 63 [range, 44-87] years; majority ASA III) were included with the same number of reconstructions: 71 patients received an eaBP ("crossover"), 51 patients an iliacofemoral (orthotopic - oBP) bypass (neither significant difference regarding frequency nor number of risk factors per patient).The oBP is not superior to eaBP with regard to the analysis parameters of openness, complication rate and mortality. Furthermore, extraanatomic revascularization does not have to be reserved for polymorbid patients only.
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Affiliation(s)
- Udo Barth
- Arbeitsbereich Gefäßchirurgie, Klinik für Allgemein-, Viszeral-, Gefäß- und Transplantationschirurgie, Otto-von-Guericke-Universität mit Universitätsklinikum Magdeburg A.ö.R., Magdeburg, Deutschland
| | - Jörg Tautenhahn
- Klinik für Gefäßchirurgie, Klinikum Magdeburg gGmbH, Magdeburg, Deutschland
| | - Philipp Klinsmann
- Klinik für Anästhesiologie und Intensivtherapie, Pfeiffersche Stiftungen e.V., Magdeburg, Deutschland
| | - Frank Meyer
- Arbeitsbereich Gefäßchirurgie, Klinik für Allgemein-, Viszeral-, Gefäß- und Transplantationschirurgie, Otto-von-Guericke-Universität mit Universitätsklinikum Magdeburg A.ö.R., Magdeburg, Deutschland
| | - Zuhir Halloul
- Arbeitsbereich Gefäßchirurgie, Klinik für Allgemein-, Viszeral-, Gefäß- und Transplantationschirurgie, Otto-von-Guericke-Universität mit Universitätsklinikum Magdeburg A.ö.R., Magdeburg, Deutschland
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Fransson T, Sturedahl AD, Resch T, Björn E, Gottsäter A. Nationwide Study of the Outcome of Treatment of Lower Extremity Atherosclerotic Lesions With Endovascular Surgery With or Without Drug Eluting Methods in Patients With Diabetes. J Endovasc Ther 2024:15266028241241967. [PMID: 38577781 DOI: 10.1177/15266028241241967] [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: 04/06/2024]
Abstract
CLINICAL IMPACT This retrospective observational registry trial combines national registries for vascular surgical procedures and diabetes mellitus to clarify results of drug eluting technology in treating diabetic subjects with intermittent claudication or chronic limb threatening ischemia compared to treatment of non-diabetic subjects. As earlier proposed and showed in this trial, there may be an implication for a beneficial treatment efficacy with drug eluting therapy in the diabetic population with PAD compared to the non-diabetic population. A finding worth further exploration.
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Affiliation(s)
- Torbjörn Fransson
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Andrea Dahl Sturedahl
- National Diabetes Register, Department of Data Management and Analysis, Region Västra Götaland, Gothenburg, Sweden
| | - Timothy Resch
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Vascular Surgery, Copenhagen University Hospital, Copenhagen, Denmark
- Faculty of Health Sciences, Copenhagen University, Copenhagen, Denmark
| | - Eliasson Björn
- National Diabetes Register, Department of Data Management and Analysis, Region Västra Götaland, Gothenburg, Sweden
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Gottsäter
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Medicine, Skåne University Hospital, Malmö, Sweden
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Dogbe L, Zil-E-Ali A, Krause KJ, So K, Aziz F. Preoperative Chronic Steroid Use is Associated with Increased Incidence of Postoperative Mortality and Limb Loss following Peripheral Arterial Bypass Surgery for Chronic Limb Threatening Ischemia. Ann Vasc Surg 2024; 101:95-104. [PMID: 38154493 DOI: 10.1016/j.avsg.2023.11.022] [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: 08/26/2023] [Revised: 10/27/2023] [Accepted: 11/10/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Steroids are a commonly prescribed medication in the United States and have been associated with poor surgical and treatment outcomes. The objective of this study is to assess the relationship between chronic steroid use and surgical outcomes of femoropopliteal and femoral-distal bypasses in patients suffering from chronic limb threatening ischemia (CLTI). METHODS All adult patients undergoing femoropopliteal and femoral-distal bypasses with single segment autologous vein with an indication of CLTI in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2012 and 2021 were stratified between chronic preoperative steroid use (Group I) and no preoperative use (Group II). Primary outcomes of the study included 30-day mortality, amputation, and combined outcome of mortality and/or limb loss. Secondary outcomes included specific bypass related, cardiovascular, respiratory and renal outcomes. RESULTS A total of 8,324 patients (66.8% Male, 33.2% Females) underwent peripheral arterial bypass operations for the indication of chronic limb threatening ischemia. The median age was 68 years. Group I included 408 patients (4.9%) and Group II included 7,916 patients (95.1%). As compared to patients in Group II, those in Group I were more likely to be females (Group I: 42.2% vs. Group II: 32.8%), more likely to have co-existing chronic obstructive pulmonary disease (Group I: 20.6% vs. Group II: 11.8%), less likely to be diabetic (Group I: 45.9% vs. Group II: 48%), less likely to be smokers (Group I: 30.6% vs. Group II: 45.4%) and more likely to be in American Society of Anesthesiologists III or IV Classes (Group I: 98% vs. Group II: 96.5%) (all P < 0.05). Primary outcomes were as follows: 30-day mortality (Group I: 3.3% vs. Group II: 1.7%), amputation (Group I: 5.9% vs. Group II: 2.8%), 30-day mortality and/or amputation (Group I: 9.1% vs. Group II: 4.5%) (all P < 0.05). Among secondary outcomes, the following were found to be statistically significant: untreated loss of patency (Group I: 4.2% vs. Group II: 1.7%), significant bleeding (Group I: 26.2% vs. Group II: 16.5%), wound infection/complication (Group I: 18.6% vs. Group II: 15%), and return to operating room (Group I: 21.8% vs. Group II: 16.7%) (all P < 0.05). As compared to patients with an indication of tissue loss (Rutherford's class V and VI), patients in Group I with an indication of rest pain (Rutherford's class IV) were more likely to experience 30-day mortality, major amputation and a composite of mortality and amputation. Risk adjusted analysis showed that chronic steroid use has a statistically significant effect on 30-day mortality (adjusted odds ratio [AOR] 1.7, P = 0.05), amputation (AOR 2.05, P < 0.001), composite outcomes of mortality and amputation (AOR 1.959, P < 0.001), untreated loss of patency (AOR 2.31, P = 0.002), bleeding (AOR 1.33, P < 0.011) and unplanned return to the operating room (AOR 1.36, P = 0.014). CONCLUSIONS Chronic steroid use in patients undergoing femoropopliteal or femoral-distal bypass is associated with a higher risk of 30-day mortality, major amputation, readmission, bleeding, return to operating room, and untreated loss of patency. No significant difference in outcomes were appreciated in patients with chronic steroid use and with Rutherford class V or VI disease (tissue loss), suggesting that the effects of steroids may be less prominent in those with the most advanced peripheral arterial disease. These findings may aid physicians with risk stratification and preoperative discussions regarding open revascularization in patients receiving chronic steroid therapy. More studies including randomized trials are needed to guide perioperative management of steroids in this cohort.
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Affiliation(s)
- Leana Dogbe
- Office of Medical Education, Penn State University College of Medicine, Hershey, PA
| | - Ahsan Zil-E-Ali
- Division of Vascular Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Kayla J Krause
- Office of Medical Education, Penn State University College of Medicine, Hershey, PA
| | - Kristine So
- Division of Vascular Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Faisal Aziz
- Division of Vascular Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA.
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Zhong T, Gao N, Guan Y, Liu Z, Guan J. Co-Delivery of Bioengineered Exosomes and Oxygen for Treating Critical Limb Ischemia in Diabetic Mice. ACS NANO 2023; 17:25157-25174. [PMID: 38063490 PMCID: PMC10790628 DOI: 10.1021/acsnano.3c08088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
Abstract
Diabetic patients with critical limb ischemia face a high rate of limb amputation. Regeneration of the vasculature and skeletal muscles can salvage diseased limbs. Therapy using stem cell-derived exosomes that contain multiple proangiogenic and promyogenic factors represents a promising strategy. Yet the therapeutic efficacy is not optimal because exosomes alone cannot efficiently rescue and recruit endothelial and skeletal muscle cells and restore their functions under hyperglycemic and ischemic conditions. To address these limitations, we fabricated ischemic-limb-targeting stem cell-derived exosomes and oxygen-releasing nanoparticles and codelivered them in order to recruit endothelial and skeletal muscle cells, improve cell survival under ischemia before vasculature is established, and restore cell morphogenic function under high glucose and ischemic conditions. The exosomes and oxygen-releasing nanoparticles, delivered by intravenous injection, specifically accumulated in the ischemic limbs. Following 4 weeks of delivery, the exosomes and released oxygen synergistically stimulated angiogenesis and muscle regeneration without inducing substantial inflammation and reactive oxygen species overproduction. Our work demonstrates that codelivery of exosomes and oxygen is a promising treatment solution for saving diabetic ischemic limbs.
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Affiliation(s)
- Ting Zhong
- Department of Mechanical Engineering & Materials Science, McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri 63130, United States
| | - Ning Gao
- Institute of Materials Science and Engineering, McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri 63130, United States
| | - Ya Guan
- Institute of Materials Science and Engineering, McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri 63130, United States
| | - Zhongting Liu
- Institute of Materials Science and Engineering, McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri 63130, United States
| | - Jianjun Guan
- Department of Mechanical Engineering & Materials Science, McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri 63130, United States
- Institute of Materials Science and Engineering, McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri 63130, United States
- Department of Biomedical Engineering, McKelvey School of Engineering, Washington University in St. Louis, St. Louis, Missouri 63130, United States
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Reijnen MMPJ, van Wijck I, Brodmann M, Micari A, Torsello G, Rha SW, Menk J, Zeller T. Five-Year Outcomes after Paclitaxel Drug-Coated Balloon Treatment of Femoropopliteal Lesions in Diabetic and Chronic Limb-Threatening Ischemia Cohorts: IN.PACT Global Study Post Hoc Analysis. Cardiovasc Intervent Radiol 2023; 46:1329-1345. [PMID: 37526706 PMCID: PMC10547845 DOI: 10.1007/s00270-023-03478-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/24/2023] [Indexed: 08/02/2023]
Abstract
PURPOSE To summarize the 5-year outcomes of drug-coated balloon (DCB) for the treatment of femoropopliteal lesions in patients with diabetes mellitus (DM) or chronic limb-threatening ischemia (CLTI) compared to non-DM and intermittent claudication (IC). METHODS The IN.PACT Global study was a real-world prospective, multicenter, international, single-arm study that enrolled 1535 participants. Post hoc analyses were conducted for participants with DM (n = 560) versus non-DM (n = 842) and CLTI (n = 156) versus IC (n = 1246). Assessments included freedom from clinically driven target lesion revascularization (CD-TLR) through 60 months, a composite safety outcome (freedom from device- and procedure-related death through 30 days, and freedom from major target limb amputation and freedom from CD-target vessel revascularization within 60 months), and major adverse events (MAEs). RESULTS Kaplan-Meier estimates of 60-month freedom from CD-TLR were 67.7% and 70.5% (p = 0.25) in the DM and non-DM cohorts; and 60.7% and 70.5% (p = 0.006) in the CLTI and IC cohorts. The Kaplan-Meier 60-month composite safety outcomes were 65.1% DM versus 68.9% non-DM (p = 0.12); 53.2% CLTI versus 69.1% IC (p < 0.001). Between DM and non-DM, MAE rates were not significantly different through 60 months except for all-cause mortality which was higher in DM (23.8% versus 16.6%; p < 0.001). Participants with CLTI had a higher cumulative incidence of major target limb amputation (6.8% versus 1.1%; p < 0.001) and all-cause mortality (37.4% versus 17.4%; p < 0.001) through 60 months compared to IC. CONCLUSIONS In this real-world study, 5-year reintervention rates following DCB angioplasty were similar between DM and non-DM, but mortality rates were expectedly higher in patients with DM. Reintervention, mortality, and amputation rates were all higher in CLTI patients compared to IC, which is consistent with the known frailty of this patient population. LEVEL OF EVIDENCE Level 3, Non-randomized controlled cohort/follow-up study.
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Affiliation(s)
- Michel M P J Reijnen
- Department of Vascular Surgery, Rijnstate, Arnhem, The Netherlands.
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, The Netherlands.
| | - Iris van Wijck
- Department of Vascular Surgery, Rijnstate, Arnhem, The Netherlands
| | - Marianne Brodmann
- Department of Internal Medicine, Division of Angiology, Medical University, Graz, Austria
| | | | - Giovanni Torsello
- Institute for Vascular Research, St Franziskus-Hospital, Münster, Germany
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | | | - Thomas Zeller
- Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
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Rontoyanni VG, Blears E, Nunez Lopez O, Ogunbileje J, Moro T, Bhattarai N, Randolph AC, Fry CS, Fankhauser GT, Cheema ZF, Murton AJ, Volpi E, Rasmussen BB, Porter C. Skeletal Muscle Bioenergetics in Critical Limb Ischemia and Diabetes. J Surg Res 2023; 288:108-117. [PMID: 36963297 PMCID: PMC10192034 DOI: 10.1016/j.jss.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 02/06/2023] [Accepted: 02/19/2023] [Indexed: 03/26/2023]
Abstract
INTRODUCTION Mitochondrial dysfunction is implicated in the metabolic myopathy accompanying peripheral artery disease (PAD) and critical limb ischemia (CLI). Type-2 diabetes mellitus (T2DM) is a major risk factor for PAD development and progression to CLI and may also independently be related to mitochondrial dysfunction. We set out to determine the effect of T2DM in the relationship between CLI and muscle mitochondrial respiratory capacity and coupling control. METHODS We studied CLI patients undergoing revascularization procedures or amputation, and non-CLI patients with or without T2DM of similar age. Mitochondrial respiratory capacity and function were determined in lower limb permeabilized myofibers by high-resolution respirometry. RESULTS Fourteen CLI patients (65 ± 10y) were stratified into CLI patients with (n = 8) or without (n = 6) T2DM and were compared to non-CLI patients with (n = 18; 69 ± 5y) or without (n = 19; 71 ± 6y) T2DM. Presence of CLI but not T2DM had a marked impact on all mitochondrial respiratory states in skeletal muscle, adjusted for the effects of sex. Leak respiration (State 2, P < 0.025 and State 4o, P < 0.01), phosphorylating respiration (P < 0.001), and maximal respiration in the uncoupled state (P < 0.001), were all suppressed in CLI patients, independent of T2DM. T2DM had no significant effect on mitochondrial respiratory capacity and function in adults without CLI. CONCLUSIONS Skeletal muscle mitochondrial respiratory capacity was blunted by ∼35% in patients with CLI. T2DM was not associated with muscle oxidative capacity and did not moderate the relationship between muscle mitochondrial respiratory capacity and CLI.
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Affiliation(s)
| | - Elizabeth Blears
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Omar Nunez Lopez
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - John Ogunbileje
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Tatiana Moro
- Department of Nutrition and Metabolism, University of Texas Medical Branch, Galveston, Texas
| | - Nisha Bhattarai
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas; Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, Texas
| | - Amanda C Randolph
- Department of Nutrition and Metabolism, University of Texas Medical Branch, Galveston, Texas
| | - Christopher S Fry
- Department of Nutrition and Metabolism, University of Texas Medical Branch, Galveston, Texas; Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Grant T Fankhauser
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Zulfiqar F Cheema
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Andrew J Murton
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Elena Volpi
- Department of Nutrition and Metabolism, University of Texas Medical Branch, Galveston, Texas; Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Blake B Rasmussen
- Department of Nutrition and Metabolism, University of Texas Medical Branch, Galveston, Texas; Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Craig Porter
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas; Department of Pediatrics, University of Arkansas for Medical Sciences & Arkansas Children's Research Institute, Little Rock, Arkansas.
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McNeil S, Waller K, Poy Lorenzo YS, Mateevici OC, Telianidis S, Qi S, Churilov I, MacIsaac RJ, Galligan A. Detection, management, and prevention of diabetes-related foot disease in the Australian context. World J Diabetes 2023; 14:942-957. [PMID: 37547594 PMCID: PMC10401446 DOI: 10.4239/wjd.v14.i7.942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/06/2023] [Accepted: 05/23/2023] [Indexed: 07/12/2023] Open
Abstract
Diabetes-related foot disease (DFD) is a widely feared complication among people who live with diabetes. In Australia and globally, rates of disability, cardio-vascular disease, lower extremity amputation, and mortality are significantly increased in patients with DFD. In order to understand and prevent these outcomes, we analyse the common pathogenetic processes of neuropathy, arterial disease, and infection. The review then summarises important management considerations through the interdisciplinary lens. Using Australian and international guidelines, we offer a stepwise, evidence-based practical approach to the care of patients with DFD.
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Affiliation(s)
- Scott McNeil
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Kate Waller
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Podiatry, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Yves S Poy Lorenzo
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Infectious Diseases Unit, Department of Medicine, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Pharmacy, St Vincent’s Hospital Melbourne, Fitzroy 3065, Australia
- Department of Medicine, St Vincent’s Hospital Melbourne, University of Melbourne, Fitzroy 3065, Victoria, Australia
| | - Olimpia C Mateevici
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Infectious Diseases Unit, Department of Medicine, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Stacey Telianidis
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Vascular Surgery, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Sara Qi
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Vascular Surgery, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Irina Churilov
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Medicine, St Vincent’s Hospital Melbourne, University of Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Rehabilitation Medicine, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Richard J MacIsaac
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Medicine, St Vincent’s Hospital Melbourne, University of Melbourne, Fitzroy 3065, Victoria, Australia
- the Australian Centre for Accelerating Diabetes Innovations, School of Medicine, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Anna Galligan
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
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Piñar-Gutiérrez A, Gros-Herguido N, Losada-Viñau F, Farfán-Díaz F, Enríquez-Macías M, Pérez-Morales A, González-Navarro I, Acosta-Delgado D, Guerrero-Vázquez R, Martínez-Ortega AJ, Pumar-López A, Mangas-Cruz MÁ, Bataller-de Juan E, Tallón-Aguilar L, Soto-Moreno A. Outcomes of a multidisciplinary Diabetic Foot Day Unit. ENDOCRINOL DIAB NUTR 2023; 70:381-388. [PMID: 37356875 DOI: 10.1016/j.endien.2022.11.023] [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: 07/30/2021] [Accepted: 12/29/2021] [Indexed: 06/27/2023]
Abstract
OBJECTIVE To analyse the main characteristics of patients and the health outcomes obtained and to evaluate the impact of peripheral artery disease (PAD) in patients treated in our multidisciplinary Diabetic Foot Unit. RESEARCH DESIGN AND METHODS Observational prospective study. 273 patients from two different populations (with and without PAD - classified according to the presence of distal pulses) treated over a 14-month period in the multidisciplinary Diabetic Foot Unit were included. The data on patient characteristics and outcomes were analysed for the purpose of comparison. For the inference study, a comparison of medians with the non-parametric test for independent samples for the quantitative variables and a χ2 test for the comparison of proportions in qualitative variables were performed. RESULTS Patients with PAD ulcers were older (60 (54-67) vs. 64 (75-81), p=0.000) and had a higher macrovascular burden (8.1% vs. 29% for ischaemic heart disease history, p=0.000; 6.7% vs. 18.1% for cerebrovascular disease history, p=0.004). Their Texas Score was higher (p=0.000) and their major amputation rate was higher (1.4% vs. 12.3%, p=0.001). They had less background of previous ulcers (52.6% vs. 26.8%, p=0.000), their episode duration was shorter (4 (0-10) vs. 0 (0-3) weeks, p=0.000), and their proportional need for antibiotic therapy was lower (64.4% vs. 51.4%, p=0.03). CONCLUSIONS The differences found between ulcers with and without vascular involvement support the need for a different approach and for the inclusion of vascular surgeons on the team. The multidisciplinary care model for diabetic foot patients could be effective and improve health outcomes.
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Affiliation(s)
- Ana Piñar-Gutiérrez
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
| | - Noelia Gros-Herguido
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Fernando Losada-Viñau
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Fátima Farfán-Díaz
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Ana Pérez-Morales
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | | | | | | | - Alfonso Pumar-López
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | | | - Luis Tallón-Aguilar
- UGC Cirugía General, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Alfonso Soto-Moreno
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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9
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Vansteenland I, Forss R. What are the current diabetic foot assessment methods in private podiatry practices in Flanders, Belgium: an exploratory mixed method study. J Foot Ankle Res 2023; 16:17. [PMID: 36973800 PMCID: PMC10041772 DOI: 10.1186/s13047-023-00615-1] [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: 09/29/2022] [Accepted: 03/16/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Diabetic foot assessments detect patients at risk for developing a diabetes-related foot ulceration and can significantly reduce the risk of amputation. In order to organize this assessment effectively, diabetic foot assessment guidelines are required according to the International Working Group of the Diabetic Foot. However, these international guidelines have not been adapted into a national guideline for podiatrists in Flanders, Belgium. This study aims to identify the methods and guidelines currently used to assess the diabetic foot in private podiatry practices in Flanders, Belgium and to explore the podiatrists' opinions on developing a national diabetic foot assessment guideline. METHODS This exploratory mixed method study was composed of an anonymous online survey comprising of open- and closed-ended questions followed by 1:1 online semi-structured interviews. Participants were recruited via e-mail and a closed private Facebook group of podiatry alumni. Data was analyzed using SPSS statistics and thematic analysis described by Braun and Clarke. RESULTS This study showed that the vascular assessment of the diabetic foot exists solely of a medical history and palpation of the pedal pulses. Non-invasive tests such as doppler, toe brachial pressure index or ankle brachial pressure index are seldom used. Only 66% reported to use a guideline for the diabetic foot assessment. There was a variety of reported guidelines and risk stratification systems in use in private podiatry practices in Flanders, Belgium. CONCLUSION Non-invasive tests such as the doppler, ankle brachial pressure index or toe brachial pressure index are rarely used for the vascular assessment of the diabetic foot. Diabetic foot assessment guidelines and risk stratification systems to identify patients at risk for developing a diabetic foot ulcer were not frequently used. International guidelines of the International Working Group of the Diabetic Foot have not yet been implemented in private podiatry practices in Flanders, Belgium. This exploratory research has provided useful information for future research studies.
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Affiliation(s)
- Irene Vansteenland
- School of Sport & Health Sciences, University of Brighton, 49 Darley Road, Eastbourne, BN20 7UR, UK.
- Podoconsult Vansteenland Irene BV, Hendrik Consciencelaan 54, 9950, Lievegem, Belgium.
| | - Rachel Forss
- Centre for Regenerative Medicine and Devices, University of Brighton, Brighton, UK
- School of Sport and Health Sciences, University of Brighton, 49 Darley Road, Eastbourne, BN20 7UR, UK
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10
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Meloni M, Bellia A, Giurato L, Lauro D, Uccioli L. Below-the-ankle arterial disease: a new marker of coronary artery disease in patients with diabetes and foot ulcers. Acta Diabetol 2022; 59:1331-1338. [PMID: 35864261 DOI: 10.1007/s00592-022-01932-w] [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: 04/30/2022] [Accepted: 06/29/2022] [Indexed: 11/01/2022]
Abstract
AIM The aim of the current study is to evaluate the association between below-the-ankle (BTA) arterial disease and coronary artery disease (CAD) in patients with diabetic foot ulcers (DFUs). METHODS The study group was composed of patients with an active neuro-ischaemic DFUs managed in a tertiary care diabetic foot clinic. All patients received a pre-set limb salvage protocol including lower limb revascularization. By a retrospective analysis of individual angiograms, patients were divided in two groups: below-the-ankle (BTA) and above-the-ankle (ATA) arterial disease groups. The rate of CAD at baseline assessment and the new events of acute myocardial ischaemia (AMI) during 1-year of follow-up were evaluated and compared between the two groups. RESULTS Two hundreds seventy-two (272) patients were included, 120 (44.1%) showed BTA arterial disease while 152 (55.9%) ATA arterial disease. The mean age was 68.9 ± 9.6 years, 198 (72.8%) were male, 246 (90.4%) had type 2 diabetes, the mean diabetes duration was 20.7 ± 11.6 years, the mean HbA1c was 7.8 ± 4.2% (62 ± 22 mmmol/mol). The whole population reported CAD in 172 cases (63.4%), and the rate in the BTA group was significantly higher than in ATA group, respectively, 90 (75.4%) vs 82 (54.1%), p < 0.0001. During the follow-up, BTA group had 5% of new cases of AMI in comparison to 1.3% in ATA group (p < 0.001). At the multivariate analysis BTA resulted an independent marker of CAD [OR 1.9 CI 9 5% (1.3-4.5) p = 0.0001]. CONCLUSION The current study shows a significant association between BTA arterial disease and CAD. A close cardiovascular screen should be required in patients with DFUs.
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Affiliation(s)
- Marco Meloni
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy.
| | - Alfonso Bellia
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Laura Giurato
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Davide Lauro
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Luigi Uccioli
- CTO Andrea Alesini Hospital, Division of Endocrinology and Diabetes Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
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11
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Outcomes of a multidisciplinary Diabetic Foot Day Unit. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2021.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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12
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Hoogervorst R, van Overhagen H, de Jong PA, Spiering W, de Borst GJ, Veger HTC, Mairuhu ATA, Mali WPTM. Treatment of arterial calcification in patients with chronic limb threatening ischemia with etidronate: protocol of an investigator-initiated multicenter, double blind, placebo-controlled, randomized clinical trial. CVIR Endovasc 2022; 5:26. [PMID: 35666322 PMCID: PMC9170866 DOI: 10.1186/s42155-022-00298-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/08/2022] [Indexed: 11/29/2022] Open
Abstract
Background Pathologic studies have shown that in patients with critical limb threatening ischaemia (CLTI) medial arterial calcifications are frequently found and may be responsible for aggravating the disease. These extensive calcifitcations are found not only in arteries of the leg but also in the coronary arteries and the aorta. The progression of these calcifications is fast and they stiffen the vessel wall and may thus increase the cardiovascular risk. Reduction of progression of calcification may not only reduce the burden of CLTI but may also reduce the high residual cardiovascular risk. Medial calcifications have been halted by etidronate in other trials. Its potential to reduce the burden from peripheral vascular disease in CLTI and residual cardiovascular risk remains to be established. Methods This is an investigator-initiated multicenter, double blind, placebo-controlled, randomized trial comparing the effects of etidronate versus placebo in patients with CLTI. Subjects will be randomized to either treatment with etidronate for 12 months (cyclical 20 mg/kg for 2 weeks on and 10 weeks off) orally or placebo for 12 months (in a similar routine). The primary endpoint is the change in arterial calcification as quantified by CT-scan. Secondary endpoints are the number of amputations above and below the ankle, mortality, number of vascular interventions and quality of life. Discussion Up to now, the inert end stage of vascular disease in patients with CLTI, has been considered calcification of vessel walls. We believe there is reason to reverse causation and hypothesize that calcification causes vascular disease. This reversal can be proven in a clinical trial if halting the calcification process improves the outcome of the patient. Therefore we use etidronate, a bisphosphate that has proven to stop the calcification in several rare monogenetic calcifying diseases. We aim to perform this mechanistic proof-of-concept study hopefully leading to a clinical outcome study later on.
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Affiliation(s)
- R Hoogervorst
- Haga Hospital, HagaZiekenhuis, The Hague, The Netherlands.
| | | | - P A de Jong
- Haga Hospital, HagaZiekenhuis, The Hague, The Netherlands.,UMC Utrecht, The Hague, The Netherlands
| | - W Spiering
- Haga Hospital, HagaZiekenhuis, The Hague, The Netherlands.,UMC Utrecht, The Hague, The Netherlands
| | - G J de Borst
- Haga Hospital, HagaZiekenhuis, The Hague, The Netherlands.,UMC Utrecht, The Hague, The Netherlands
| | - H T C Veger
- Haga Hospital, HagaZiekenhuis, The Hague, The Netherlands
| | - A T A Mairuhu
- Haga Hospital, HagaZiekenhuis, The Hague, The Netherlands
| | - W P T M Mali
- Haga Hospital, HagaZiekenhuis, The Hague, The Netherlands.,UMC Utrecht, The Hague, The Netherlands
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13
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Rustagi Y, Abouhashem AS, Verma P, Verma SS, Hernandez E, Liu S, Kumar M, Guda PR, Srivastava R, Mohanty SK, Kacar S, Mahajan S, Wanczyk KE, Khanna S, Murphy MP, Gordillo GM, Roy S, Wan J, Sen CK, Singh K. Endothelial Phospholipase Cγ2 Improves Outcomes of Diabetic Ischemic Limb Rescue Following VEGF Therapy. Diabetes 2022; 71:1149-1165. [PMID: 35192691 PMCID: PMC9044136 DOI: 10.2337/db21-0830] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 02/15/2022] [Indexed: 11/13/2022]
Abstract
Therapeutic vascular endothelial growth factor (VEGF) replenishment has met with limited success for the management of critical limb-threatening ischemia. To improve outcomes of VEGF therapy, we applied single-cell RNA sequencing (scRNA-seq) technology to study the endothelial cells of the human diabetic skin. Single-cell suspensions were generated from the human skin followed by cDNA preparation using the Chromium Next GEM Single-cell 3' Kit v3.1. Using appropriate quality control measures, 36,487 cells were chosen for downstream analysis. scRNA-seq studies identified that although VEGF signaling was not significantly altered in diabetic versus nondiabetic skin, phospholipase Cγ2 (PLCγ2) was downregulated. The significance of PLCγ2 in VEGF-mediated increase in endothelial cell metabolism and function was assessed in cultured human microvascular endothelial cells. In these cells, VEGF enhanced mitochondrial function, as indicated by elevation in oxygen consumption rate and extracellular acidification rate. The VEGF-dependent increase in cell metabolism was blunted in response to PLCγ2 inhibition. Follow-up rescue studies therefore focused on understanding the significance of VEGF therapy in presence or absence of endothelial PLCγ2 in type 1 (streptozotocin-injected) and type 2 (db/db) diabetic ischemic tissue. Nonviral topical tissue nanotransfection technology (TNT) delivery of CDH5 promoter-driven PLCγ2 open reading frame promoted the rescue of hindlimb ischemia in diabetic mice. Improvement of blood flow was also associated with higher abundance of VWF+/CD31+ and VWF+/SMA+ immunohistochemical staining. TNT-based gene delivery was not associated with tissue edema, a commonly noted complication associated with proangiogenic gene therapies. Taken together, our study demonstrates that TNT-mediated delivery of endothelial PLCγ2, as part of combination gene therapy, is effective in diabetic ischemic limb rescue.
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Affiliation(s)
- Yashika Rustagi
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Ahmed S. Abouhashem
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
- Sharkia Clinical Research Department, Ministry of Health and Population, Cairo, Egypt
| | - Priyanka Verma
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Sumit S. Verma
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Edward Hernandez
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Sheng Liu
- Center for Computational Biology and Bioinformatics, Indiana University School of Medicine, Indianapolis, IN
| | - Manishekhar Kumar
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Poornachander R. Guda
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Rajneesh Srivastava
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Sujit K. Mohanty
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Sedat Kacar
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Sanskruti Mahajan
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Kristen E. Wanczyk
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Savita Khanna
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Michael P. Murphy
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Gayle M. Gordillo
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Sashwati Roy
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Jun Wan
- Center for Computational Biology and Bioinformatics, Indiana University School of Medicine, Indianapolis, IN
| | - Chandan K. Sen
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
| | - Kanhaiya Singh
- Indiana Center for Regenerative Medicine and Engineering, Indiana University Health Comprehensive Wound Center, Indiana University School of Medicine, Indianapolis, IN
- Corresponding author: Kanhaiya Singh,
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14
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Clinical Effect of Revascularization Strategies and Pharmacologic Treatment on Long-Term Results in Patients with Advanced Peripheral Artery Disease with TASC C and D Femoropopliteal Lesions. J Interv Cardiol 2022; 2022:3741967. [PMID: 35317345 PMCID: PMC8916894 DOI: 10.1155/2022/3741967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/25/2021] [Accepted: 12/13/2021] [Indexed: 11/18/2022] Open
Abstract
Background This study was to assess the clinical outcome and associated parameters of endovascular therapy (EVT group) and bypass surgery (bypass group) in patients with long femoropopliteal TransAtlantic Inter-Society Consensus II (TASC II) C and D peripheral artery disease (PAD). Methods 187 patients who underwent successful EVT or bypass surgery were assessed. The endpoints included the events of cardiovascular disease (CVD) and lower-extremity amputation (LEA), 3-year primary patency, and 3-year amputation-free survival (AFS). Results The 3-year primary and secondary patency rates were better in the bypass group (P=0.007 and P=0.039, respectively), while the incidences of LEA, new CVD events, and mortality were comparable between groups. Weighted multivariate Cox analyses showed that cilostazol treatment (hazard ratio (HR): 0.46, 95% confidence interval (CI): 0.3–0.72, P=0.001), statin treatment (HR: 0.54, 95% CI: 0.33–0.9, P=0.014), and direct revascularization (DR) (HR: 0.47, 95% CI: 0.29–0.74, P=0.001) were predictive factors of 3-year primary patency. Kaplan–Meier curve analyses of time-to-primary cumulative AFS showed that nondiabetes mellitus, mild PAD, and cilostazol and statin treatment were correlated with a superior 3-year AFS (log rank test, P=0.001, P < 0.001, P=0.009, and P=0.044, respectively). Conclusions Endovascular stenting based on the angiosome concept and bypass surgery provide comparable benefits for the treatment of long, advanced femoropopliteal lesions after a short follow-up period, whereas cilostazol therapy for more than 3 months, aggressive treatment of dyslipidemia, and surgical revascularization were associated with higher primary patency.
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15
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Hou X, Guo P, Cai F, Lin Y, Zhang J. Angiosome-guided endovascular revascularization for treatment of diabetic foot ulcers with peripheral artery disease. Ann Vasc Surg 2022; 86:242-250. [PMID: 35257914 DOI: 10.1016/j.avsg.2022.02.012] [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: 11/13/2021] [Revised: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Because diabetic foot ulcers (DFUs) are difficult to heal and cause huge economic losses to society, accelerating their healing has become extremely important. The purpose of this study was to evaluate the effect of revascularization based on the angiosome concept on DFU. MATERIALS AND METHODS Between January 2018 and July 2020, 112 consecutive legs with DFUs in 111 patients who were discharged from the vascular surgery department of our hospital were retrospectively evaluated. The legs were assigned to two groups depending on whether direct arterial flow to the foot ulcer based on the angiosome concept was achieved. Comparisons of the ulcer healing rate, mean time to ulcer healing, major amputation rate, survival rate, and major amputation-free survival rate between the angiosome direct revascularization (DR) and angiosome indirect revascularization (IR) groups were performed. RESULTS DR was achieved in 71 legs (63%) compared with IR in 41 legs. The ulcer healing rate (70.4% in the DR group vs. 34.1% in the IR group, P < 0.01), the mean time to ulcer healing (7.01 ± 4.26 months vs. 10.09 ± 3.24months, P < 0.01), the survival rate (90.1% vs. 53.7%, P < 0.01), and the major amputation-free survival rate (81.7% vs. 48.8%, P < 0.01) were significantly higher in the DR group than in the IR group. Undergoing DR did not significantly reduce the major amputations rate compared with IR (13.4% and 34.1%, respectively, P = 0.15), but there might be a trend. In multivariate models, DR remained a significant predictor for ulcer healing (HR, 7.07; 95% confidence interval, 6.54-7.60, P < 0.01). Opening multiple infrapopliteal arteries in the DR group compared with restoring only one infrapopliteal artery did not significantly improve the the ulcer healing rate (P = 0.59), the mean time to ulcer healing (P = 0.70), major amputation rate (P = 0.83), the survival rate (P = 0.31), and the major amputation-free survival rate(P = 0.40). CONCLUSIONS Attaining a direct arterial flow based on the angiosome concept may be important for ulcer healing, survival, and amputation-free survival in diabetic foot patients. Opening multiple infrapopliteal arteries in DR patients may not improve the ulcer healing, survival, major amputation or amputation-free survival compared with single DR vessel patency.
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Affiliation(s)
- Xinhuang Hou
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350005, China
| | - Pingfan Guo
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350005, China
| | - Fanggang Cai
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350005, China
| | - Yichen Lin
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350005, China
| | - Jinchi Zhang
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou 350005, China.
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16
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Kantilaras A, Widyatmoko A. Role of Doppler Ultrasound and Percutaneous Transluminal Angioplasty in Early Diagnosis and Management of Peripheral Artery Disease. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2021.7855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Peripheral arterial disease (PAD) denotes vascular disorder which peripheral artery’s obstruction or constriction is found. PAD with diabetic history is more susceptible to ischemic ulcer than PAD with no diabetic. The presence of Diabetes mellitus (DM) in PAD can speed up 4 times greater risk of developing Critical Limb Ischemia. In our hospital, difficulty performing extremity perfusion assessment is often found because those examinations are not available, so possibility of PAD can be missed. Therefore, optimalization use of Doppler Ultrasound (DUS) is important in our case.
AIM: The purpose of our case writing is to give information about substantial parameter of DUS in determine presence of PAD and define the role of percutaneous transluminal angioplasty (PTA) in PAD. The earlier PAD discovered, faster further treatment conducted, especially PTA.
CASE REPORT: A 65-year-old female patient with intermittent left calf pain for 7 months who went to internal medicine outpatient has reported. She has history of type 2 DM and significant hyperlipidemia. On physical examination, vital signs revealed normal value. Body mass index was 28 kg/m2. Resting ankle-brachial index (ABI) measurement was 1.14 and 1.12 at the right and left dorsalis pedis, respectively. DUS showed spectral narrow, reversal flow and no clear spectral window in superficial femoral artery. There are clear spectral window, spectral narrow, and reversal flow in poplitea artery. No clear spectral window, no spectral narrow, and no reversal flow in anterior tibia artery. Clear spectral window, reversal flow, and no spectral narrow are appear in posterior tibia artery. Arteriogram of left inferior extremity showed middle part partial stenosis of anterior tibia artery. Dilatation with standard balloon for 1 min was done. After that, no stenosis in same location and she wasn’t feel calf pain again.
CONCLUSION: Compared with two other parameters, reversal flow in DUS is most important parameter to establish presence of stenosis. PTA is adequate to give revascularization stenosis in PAD.
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Lapébie FX, Bongard V, Lacroix P, Aboyans V, Constans J, Boulon C, Messas E, Thomas-Delecourt F, Rosenbaum D, Ferrières J, Bura-Rivière A. Mortality, Cardiovascular and Limb Events in Patients With Symptomatic Lower Extremity Artery Disease and Diabetes. Angiology 2021; 73:528-538. [PMID: 34836456 DOI: 10.1177/00033197211050144] [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] [Indexed: 01/09/2023]
Abstract
The aim of this study was to compare the prognosis of patients according to diabetes status, during a 1-year follow-up after hospital admission for lower extremity artery disease, in the prospective COPART (COhorte de Patients ARTériopathes) registry. Inclusion criteria were intermittent claudication, ischemic rest pain, tissue loss, or acute limb ischemia, with radiological and hemodynamic confirmation. Among 2494 patients, 1235 (49.5%) had diabetes. Incidence rates for major adverse cardiovascular events (MACE) were 18.0/100 person-years (95% confidence interval [CI], 15.4-21.0) for the diabetes group and 11.1/100 person-years (95% CI, 9.2-13.4) for the non-diabetes group. Incidence rates of all-cause mortality were 29.8/100 person-years (95% CI, 26.5-33.4) for the diabetes group and 19.7/100 person-years (95% CI, 17.2-22.7) for the non-diabetes group. Incidence rates of major limb amputation were 24.2/100 person-years (95% CI, 21.1-27.8) for the diabetes group and 11.6/100 person-years (95% CI, 9.6-14.0) for the non-diabetes group. Diabetes was associated with MACE, adjusted hazard ratio 1.60 (95% CI, 1.16-2.22), and all-cause mortality, unadjusted HR 1.49 (95% CI, 1.24-1.78). In the multivariate analysis, diabetes was no longer associated with major amputation, adjusted HR 1.15 (95% CI, .87-1.51). Patients hospitalized for LEAD with diabetes had a higher risk of MACE than those without diabetes.
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Affiliation(s)
- François-Xavier Lapébie
- Department of Vascular Medicine, 36760Toulouse University Hospital, Toulouse, France.,UMR 1295 INSERM, CERPOP, 36760Toulouse III, Paul Sabatier University, Toulouse, France
| | - Vanina Bongard
- UMR 1295 INSERM, CERPOP, 36760Toulouse III, Paul Sabatier University, Toulouse, France.,Department of Epidemiology, 36715Toulouse University Hospital, Toulouse, France.,Federation of Cardiology, 36715Toulouse University Hospital, Toulouse, France
| | - Philippe Lacroix
- Department of Cardiovascular and Thoracic Surgery, Vascular Medicine, 36715Limoges University Hospital, Limoges, France.,UMR 1094 INSERM & IRD, 36715Limoges University, Limoges, France
| | - Victor Aboyans
- UMR 1094 INSERM & IRD, 36715Limoges University, Limoges, France.,Department of Cardiology, 36715Limoges University Hospital, Limoges, France
| | - Joël Constans
- Department of Vascular Medicine, 36836Bordeaux University Hospital, Bordeaux, France.,36836Bordeaux University, Bordeaux, France
| | - Carine Boulon
- Department of Vascular Medicine, 36836Bordeaux University Hospital, Bordeaux, France
| | - Emmanuel Messas
- Department of Vascular Medicine, 55647Assistance Publique - Hôpitaux de Paris, Paris, France.,UMR 970 INSERM, 55647Paris Descartes University, Paris, France
| | | | | | - Jean Ferrières
- UMR 1295 INSERM, CERPOP, 36760Toulouse III, Paul Sabatier University, Toulouse, France.,Department of Epidemiology, 36715Toulouse University Hospital, Toulouse, France.,Federation of Cardiology, 36715Toulouse University Hospital, Toulouse, France
| | - Alessandra Bura-Rivière
- Department of Vascular Medicine, 36760Toulouse University Hospital, Toulouse, France.,UMR 1031 INSERM, StromaLab, Toulouse III, Paul Sabatier University Toulouse, France
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Autologous Stem Cell Therapy for Chronic Lower Extremity Wounds: A Meta-Analysis of Randomized Controlled Trials. Cells 2021; 10:cells10123307. [PMID: 34943815 PMCID: PMC8699089 DOI: 10.3390/cells10123307] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 12/15/2022] Open
Abstract
Lower extremity chronic wounds (LECWs) commonly occur in patients with diabetes mellitus (DM) and peripheral arterial disease (PAD). Autologous stem cell therapy (ASCT) has emerged as a promising alternative treatment for those who suffered from LECWs. The purpose of this study was to assess the effects of ASCT on LECWs. Two authors searched three core databases, and independently identified evidence according to predefined criteria. They also individually assessed the quality of the included randomized controlled trials (RCTs), and extracted data on complete healing rate, amputation rate, and outcomes regarding peripheral circulation. The extracted data were pooled using a random-effects model due to clinical heterogeneity among the included RCTs. A subgroup analysis was further performed according to etiology, source of stem cells, follow-up time, and cell markers. A total of 28 RCTs (n = 1096) were eligible for this study. The pooled results showed that patients receiving ASCT had significantly higher complete healing rates (risk ratio (RR) = 1.67, 95% confidence interval (CI) 1.28–2.19) as compared with those without ASCT. In the CD34+ subgroup, ASCT significantly led to a higher complete healing rate (RR = 2.70, 95% CI 1.50–4.86), but there was no significant difference in the CD34− subgroup. ASCT through intramuscular injection can significantly improve wound healing in patients with LECWs caused by either DM or critical limb ischemia. Lastly, CD34+ is an important cell marker for potential wound healing. However, more extensive scale and well-designed studies are necessary to explore the details of ASCT and chronic wound healing.
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Impact of Tibial Bypass Conduit on Long-Term Amputation-Free Survival and Primary Patency in the Vascular Quality Initiative. J Vasc Surg 2021; 75:1351-1357.e2. [PMID: 34788646 DOI: 10.1016/j.jvs.2021.10.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 10/27/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Much research remains focused on tibial bypass conduit selection. We sought to describe long-term amputation-free survival (AFS) and primary patency (PP) of patients undergoing tibial bypass by conduit type and configuration across several permutations in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI). METHODS Patients in the VQI registry undergoing elective first-time femoral- or popliteal-to-tibial bypass for occlusive disease involving rest pain or tissue loss were identified. Prior ipsilateral infrainguinal bypass or concomitant procedures were excluded. Outcomes of interest included patient AFS at 22 months and PP at 1 year (defined as freedom from revision, thrombectomy, or graft occlusion). RESULTS A total of 4,192 bypasses were identified. The majority utilized Great Saphenous Vein (GSV) (76.2%), followed by polytetrafluoroethylene (PTFE) (10.6%), non-autologous biologic (NABC) (6.5%), composite (3.3%), arm vein (2.8%), and Small Saphenous Vein (SSV) (0.6%). Compared to all prosthetic and composite bypasses, vein grafts had the best AFS (76.4%, p<0.0001) and PP (68.1%, p=0.041). Of the single segment vein conduits, GSV bypasses had the best PP (69.1%) and arm vein the worst (60.2%). AFS and PP were similar between single segment GSV orientations. Single segment GSV bypasses exhibited better PP than multiple segment bypasses (69.1% vs 54.6%, p=0.0016). PP was significantly better for PTFE compared to NABC (68.4% vs 51.2%, p=0.0039). PP did not significantly differ between vein cuff (PWC) for prosthetic bypass compared to no vein cuff (PNC) (69.1% vs 59.7%, p=0.091). PP was not significantly different between single segment GSV and prosthetic grafts with vein cuff (69.1% vs 69.1%, p=0.51). There were no significant differences in AFS comparing arm vein, PWC, or composite grafts (67.2% vs 63.8% vs 59.3%, p=0.092), as well as in PP (60.2% vs 69.1% vs 54.8%, p=0.14). CONCLUSIONS Single-segment vein bypass was only marginally the most optimal conduit. Surprisingly, there may be more equipoise among conduit types, particularly in the absence of adequate GSV. Prosthetic grafts overall may not be as disadvantaged in the long term as initially thought, especially when compared to arm vein, as PWC did not significantly differ in primary patency. Similarly, a composite conduit may not impact long-term outcomes. These data suggest that conduit choice may not impact outcomes to the degree previously thought and that other factors may have a greater impact than presumed, especially in conduit limited situations.
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van Overhagen H. The Singa-Pacli Trial, Another RCT that Lacks to Encourage the use of DEB BTK. Cardiovasc Intervent Radiol 2021; 44:2018-2019. [PMID: 34767038 DOI: 10.1007/s00270-021-02937-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/23/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Hans van Overhagen
- Haga Teaching Hospital, Els Borst Eilersplein 275, 2545AA, Den Haag, The Netherlands.
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21
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Hertanto DM, Sutanto H, Adi S. Case Report: Diabetic nephropathy aggravates the progression and prognosis of COVID-19-associated acute limb ischemia. F1000Res 2021; 10:584. [PMID: 34642600 PMCID: PMC8430448 DOI: 10.12688/f1000research.54193.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 12/23/2022] Open
Abstract
Hypercoagulation is a hallmark of both the novel coronavirus disease (COVID-19) and type 2 diabetes mellitus (T2DM). It increases the risk for vascular thrombosis, including peripheral artery diseases. Among others, acute limb ischemia (ALI) is one of most common complications that requires immediate and prompt treatments to reduce morbidity and mortality. However, the complex interplay between COVID-19, T2DM and its complications (e.g., diabetic nephropathy), and ALI creates a great challenge in the management of the disease. Here, we present a case of a 59-year-old diabetic female with progressive pain in her left leg in the last five years, which was significantly intensified following COVID-19 diagnosis. Bluish coloration, numbness and functional impairments were observed during examinations with no palpable pulsation on left posterior tibial and dorsalis pedis arteries. The patient also had diabetic nephropathy (stage III), hypoalbuminemia, anemia and a urinary tract infection that complicated the management of the disease. Due to the excruciating pain and the worsening of the limb conditions, right leg revascularization and left leg amputation were performed at day 14 after admission. Following the surgeries, no more pain was observed and patient was discharged for further follow-up at the outpatient clinic.
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Affiliation(s)
- Decsa Medika Hertanto
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, Jawa Timur, 60132, Indonesia.,Department of Internal Medicine, Dr. Soetomo Hospital, Surabaya, Jawa Timur, 60286, Indonesia
| | - Henry Sutanto
- Department of Cardiology, Maastricht University, Maastricht, Limburg, 6229ER, The Netherlands.,Department of Physiology and Pharmacology, SUNY Downstate Medical Center, Brooklyn, New York, 11203, USA
| | - Soebagijo Adi
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, Jawa Timur, 60132, Indonesia.,Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Dr. Soetomo Hospital, Surabaya, Jawa Timur, 60286, Indonesia
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22
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Tay S, Abdulnabi S, Saffaf O, Harroun N, Yang C, Semenkovich CF, Zayed MA. Comprehensive Assessment of Current Management Strategies for Patients With Diabetes and Chronic Limb-Threatening Ischemia. Clin Diabetes 2021; 39:358-388. [PMID: 34866779 PMCID: PMC8603325 DOI: 10.2337/cd21-0019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Chronic limb-threatening ischemia (CLTI) is the most severe form of peripheral artery disease. It is estimated that 60% of all nontraumatic lower-extremity amputations performed annually in the United States are in patients with diabetes and CLTI. The consequences of this condition are extraordinary, with substantial patient morbidity and mortality and high socioeconomic costs. Strategies that optimize the success of arterial revascularization in this unique patient population can have a substantial public health impact and improve patient outcomes. This article provides an up-to-date comprehensive assessment of management strategies for patients afflicted by both diabetes and CLTI.
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Affiliation(s)
- Shirli Tay
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Sami Abdulnabi
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Omar Saffaf
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Nikolai Harroun
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Chao Yang
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Clay F. Semenkovich
- Department of Internal Medicine, Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, MO
| | - Mohamed A. Zayed
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
- Division of Molecular Cell Biology, Washington University School of Medicine, St. Louis, MO
- Department of Biomedical Engineering, Washington University McKelvey School of Engineering, St. Louis, MO
- Veterans Affairs St. Louis Health Care System, St. Louis, MO
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23
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Elgzyri T, Apelqvist J, Lindholm E, Örneholm H, Annersten Gershater M. Healing below the ankle is possible in patients with diabetes mellitus and a forefoot gangrene. SAGE Open Med 2021; 9:20503121211029180. [PMID: 34262765 PMCID: PMC8246462 DOI: 10.1177/20503121211029180] [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: 01/20/2021] [Accepted: 06/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background Forefoot gangrene in patients with diabetes is a severe form of foot ulcers with risk of progress and major amputation. No large cohort studies have examined clinical characteristics and outcome of forefoot gangrene in patients with diabetes. The aim was to examine clinical characteristics and outcome of forefoot gangrene in patients with diabetes admitted to a diabetic foot centre. Methods Patients with diabetes and foot ulcer consecutively presenting were included if they had forefoot gangrene (Wagner grade 4) at initial visit or developed forefoot gangrene during follow-up at diabetic foot centre. Patients were prospectively followed up until final outcome, either healing or death. The median follow-up period until healing was 41 (3-234) weeks. Results Four hundred and seventy-six patients were included. The median age was 73 (35-95) years and 63% were males. Of the patients, 82% had cardiovascular disease and 16% had diabetic nephropathy. Vascular intervention was performed in 64%. Fifty-one patients (17% of surviving patients) healed after auto-amputation, 150 after minor amputation (48% of surviving patients), 103 had major amputation (33% of surviving patients) and 162 patients deceased unhealed. Ten patients were lost at follow-up. The median time to healing for all surviving patients was 41 (3-234) weeks; for auto-amputated, 48 (10-228) weeks; for minor amputated, 48 (6-234) weeks; and for major amputation, 32 (3-116) weeks. Conclusion Healing without major amputation is possible in a large proportion of patients with diabetes and forefoot gangrene, despite these patients being elderly and with extensive co-morbidity.
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Affiliation(s)
- Targ Elgzyri
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Jan Apelqvist
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Eero Lindholm
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Hedvig Örneholm
- Department of Orthopaedic Surgery, Skåne University Hospital, Malmö, Sweden
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24
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Kim C, Yang YS, Ryu GW, Choi M. Risk factors associated with amputation-free survival for patients with peripheral arterial disease: a systematic review. Eur J Cardiovasc Nurs 2021; 20:295-304. [PMID: 33786599 DOI: 10.1093/eurjcn/zvaa022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/01/2020] [Accepted: 11/09/2020] [Indexed: 12/24/2022]
Abstract
AIMS Peripheral arterial disease (PAD) is associated with morbidity and mortality, comprising a significant percentage of amputations. As it affects the quality of life of patients with PAD, it is an important health issue. Therefore, the risk factors affecting the outcomes of limb salvage after revascularization should be well investigated. The aim of this review is to summarize risk factors of amputation-free survival (AFS) after interventions targeting patients with PAD to develop evidence-based intervention for improving patient outcomes. METHODS AND RESULTS A systematic review following PRISMA guidelines was conducted, and the protocol was registered on PROSPERO (CRD42020183076). PubMed, CINAHL, EMBASE, Cochrane Library, and Web of Science were searched for observational studies published between 2008 and 2019. Search terms included 'peripheral arterial disease', 'risk factors', and 'amputation-free survival'. The quality of the studies was evaluated using the Joanna Briggs Institute's Critical Appraisal Tools. Seventeen cohort studies were included in our study, and 16 risk factors were identified. Risk factors exemplifying a significant influence on decreased AFS were divided into three categories: sociodemographic (e.g. older age, male gender, African-American race, low body mass index, high nutritional risk, frailty), disease-related characteristics (e.g. severity of the disease, intervention site), and comorbidities (e.g. cardiovascular disease, kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, dementia, wide pulse pressure). CONCLUSION We found that managing modifiable risk factors, as well as addressing high-risk populations, has the potential to improve outcomes of PAD interventions. More high-quality cohort studies are needed to confirm these findings.
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Affiliation(s)
- Changhwan Kim
- Department of Critical Care Nursing, Samsung Medical Center, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
| | - Yong Sook Yang
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1 Yonsei-ro, College of Nursing Yonsei University, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Gi Wook Ryu
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1 Yonsei-ro, College of Nursing Yonsei University, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Mona Choi
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1 Yonsei-ro, College of Nursing Yonsei University, Seodaemun-gu, Seoul 03722, Republic of Korea.,Yonsei Evidence Based Nursing Centre of Korea, JBI Centre of Excellence, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
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25
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Santopaolo M, Sullivan N, Thomas AC, Alvino VV, Nicholson LB, Gu Y, Spinetti G, Kallikourdis M, Blom A, Madeddu P. Activation of Bone Marrow Adaptive Immunity in Type 2 Diabetes: Rescue by Co-stimulation Modulator Abatacept. Front Immunol 2021; 12:609406. [PMID: 33746953 PMCID: PMC7969721 DOI: 10.3389/fimmu.2021.609406] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 01/27/2021] [Indexed: 01/10/2023] Open
Abstract
Background: Chronic low-grade inflammation and alterations in innate and adaptive immunity were reported in Type 2 diabetes (T2D). Here, we investigated the abundance and activation of T cells in the bone marrow (BM) of patients with T2D. We then verified the human data in a murine model and tested if the activation of T cells can be rescued by treating mice with abatacept, an immunomodulatory drug employed for the treatment of rheumatoid arthritis. Clinical evidence indicated abatacept can slow the decline in beta-cell function. Methods: A cohort of 24 patients (12 with T2D) undergoing hip replacement surgery was enrolled in the study. Flow cytometry and cytokine analyses were performed on BM leftovers from surgery. We next compared the immune profile of db/db and control wt/db mice. In an additional study, db/db mice were randomized to receive abatacept or vehicle for 4 weeks, with endpoints being immune cell profile, indices of insulin sensitivity, and heart performance. Results: Patients with T2D showed increased frequencies of BM CD4+ (2.8-fold, p = 0.001) and CD8+ T cells (1.8-fold, p = 0.01), with the upregulation of the activation marker CD69 and the homing receptor CCR7 in CD4+ (1.64-fold, p = 0.003 and 2.27-fold, p = 0.01, respectively) and CD8+ fractions (1.79-fold, p = 0.05 and 1.69-fold, p = 0.02, respectively). These differences were confirmed in a multivariable regression model. CCL19 (CCR7 receptor ligand) and CXCL10/11 (CXCR3 receptor ligands), implicated in T-cell migration and activation, were the most differentially modulated chemokines. Studies in mice confirmed the activation of adaptive immunity in T2D. Abatacept reduced the activation of T cells and the levels of proinflammatory cytokines and improved cardiac function but not insulin sensitivity. Conclusions: Results provide proof-of-concept evidence for the activation of BM adaptive immunity in T2D. In mice, treatment with abatacept dampens the activation of adaptive immunity and protects from cardiac damage.
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Affiliation(s)
- Marianna Santopaolo
- Bristol Medical School, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Niall Sullivan
- University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Anita Coral Thomas
- Bristol Medical School, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Valeria Vincenza Alvino
- Bristol Medical School, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Lindsay B Nicholson
- Bristol Medical School, School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Yue Gu
- Bristol Medical School, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Gaia Spinetti
- Laboratory of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico MultiMedica, Milan, Italy
| | - Marinos Kallikourdis
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Adaptive Immunity Laboratory, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Ashley Blom
- Bristol Medical School, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Paolo Madeddu
- Bristol Medical School, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
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Current Status of Angiogenic Cell Therapy and Related Strategies Applied in Critical Limb Ischemia. Int J Mol Sci 2021; 22:ijms22052335. [PMID: 33652743 PMCID: PMC7956816 DOI: 10.3390/ijms22052335] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/20/2021] [Accepted: 02/23/2021] [Indexed: 02/06/2023] Open
Abstract
Critical limb ischemia (CLI) constitutes the most severe form of peripheral arterial disease (PAD), it is characterized by progressive blockade of arterial vessels, commonly correlated to atherosclerosis. Currently, revascularization strategies (bypass grafting, angioplasty) remain the first option for CLI patients, although less than 45% of them are eligible for surgical intervention mainly due to associated comorbidities. Moreover, patients usually require amputation in the short-term. Angiogenic cell therapy has arisen as a promising alternative for these "no-option" patients, with many studies demonstrating the potential of stem cells to enhance revascularization by promoting vessel formation and blood flow recovery in ischemic tissues. Herein, we provide an overview of studies focused on the use of angiogenic cell therapies in CLI in the last years, from approaches testing different cell types in animal/pre-clinical models of CLI, to the clinical trials currently under evaluation. Furthermore, recent alternatives related to stem cell therapies such as the use of secretomes, exosomes, or even microRNA, will be also described.
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27
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Trans-endothelial trafficking of metabolic substrates and its importance in cardio-metabolic disease. Biochem Soc Trans 2021; 49:507-517. [PMID: 33616631 DOI: 10.1042/bst20200991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 11/17/2022]
Abstract
The endothelium acts as a gatekeeper, controlling the movement of biomolecules between the circulation and underlying tissues. Although conditions of metabolic stress are traditionally considered as causes of endothelial dysfunction, a principal driver of cardiovascular disease, accumulating evidence suggests that endothelial cells are also active players in maintaining local metabolic homeostasis, in part, through regulating the supply of metabolic substrates, including lipids and glucose, to energy-demanding organs. Therefore, endothelial dysfunction, in terms of altered trans-endothelial trafficking of these substrates, may in fact be an early contributor towards the establishment of metabolic dysfunction and subsequent cardiovascular disease. Understanding the molecular mechanisms that underpin substrate trafficking through the endothelium represents an important area within the vascular and metabolism fields that may offer an opportunity for identifying novel therapeutic targets. This mini-review summarises the emerging mechanisms regulating the trafficking of lipids and glucose through the endothelial barrier and how this may impact on the development of cardio-metabolic disease.
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Ezeofor V‘S, Bray N, Bryning L, Hashmi F, Hoel H, Parker D, Edwards RT. Economic model to examine the cost-effectiveness of FlowOx home therapy compared to standard care in patients with peripheral artery disease. PLoS One 2021; 16:e0244851. [PMID: 33444396 PMCID: PMC7808667 DOI: 10.1371/journal.pone.0244851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 12/17/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Critical limb ischaemia is a severe stage of lower limb peripheral artery disease which can lead to tissue loss, gangrene, amputation and death. FlowOx™ therapy is a novel negative-pressure chamber system intended for home use to increase blood flow, reduce pain and improve wound healing for patients with peripheral artery disease and critical limb ischaemia. METHODS A Markov model was constructed to assess the relative cost-effectiveness of FlowOx™ therapy compared to standard care in lower limb peripheral artery disease patients with intermittent claudication or critical limb ischaemia. The model used data from two European trials of FlowOx™ therapy and published evidence on disease progression. From an NHS analysis perspective, various FlowOx™ therapy scenarios were modelled by adjusting the dose of FlowOx™ therapy and the amount of other care received alongside FlowOx™ therapy, in comparison to standard care. RESULTS In the base case analysis, consisting of FlowOx™ therapy plus nominal care, the cost estimates were £12,704 for a single dose of FlowOx™ therapy per annum as compared with £15,523 for standard care. FlowOx™ therapy patients gained 0.27 additional quality adjusted life years compared to standard care patients. This equated to a dominant incremental cost-effectiveness ratio per QALY gained. At the NICE threshold WTP of £20,000 and £30,000 per QALY gained, FlowOx™ therapy in addition to standard care had a 0.80 and 1.00 probability of being cost-effectiveness respectively. CONCLUSIONS FlowOx™ therapy delivered as a single annual dose may be a cost-effective treatment for peripheral artery disease. FlowOx™ therapy improved health outcomes and reduced treatment costs in this modelled cohort. The effectiveness and cost-effectiveness of FlowOx™ therapy is susceptible to disease severity, adherence, dose and treatment cost. Research assessing the impact of FlowOx™ therapy on NHS resource use is needed in order to provide a definitive economic evaluation.
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Affiliation(s)
- Victory ‘Segun Ezeofor
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Gwynedd, Wales, United Kingdom
- * E-mail:
| | - Nathan Bray
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Gwynedd, Wales, United Kingdom
| | - Lucy Bryning
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Gwynedd, Wales, United Kingdom
| | - Farina Hashmi
- School of Health and Society, University of Salford, Manchester, United Kingdom
| | - Henrik Hoel
- Otivio AS, Oslo, Norway
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway
| | - Daniel Parker
- School of Health and Society, University of Salford, Manchester, United Kingdom
| | - Rhiannon Tudor Edwards
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Gwynedd, Wales, United Kingdom
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Marco M, Valentina I, Daniele M, Valerio DR, Andrea P, Roberto G, Laura G, Luigi U. Peripheral Arterial Disease in Persons with Diabetic Foot Ulceration: a Current Comprehensive Overview. Curr Diabetes Rev 2021; 17:474-485. [PMID: 33023453 DOI: 10.2174/1573399816999201001203111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 11/22/2022]
Abstract
In developed countries, the prevalence of persons with diabetes and peripheral arterial disease (PAD) is approximately 50%. The presence of PAD is associated with non-healing ulcers, major amputation, cardiovascular morbidity, and mortality. It is estimated that persons with diabetes, foot ulceration and PAD have 50% of 5-years mortality rate. Therefore, subjects with ischemic diabetic foot ulcers (DFUs) should be considered a special group of patients with specific clinical characteristics, general health status and prognosis. In persons with ischemic DFUs, an early diagnosis and treatment are mandatory to reduce the risk of worse outcomes such as major amputation. Revascularization of occluded lower extremity arteries is the main treatment to restore blood flow in the foot and promote wound healing. Nonetheless, there are several unmet needs in the management of diabetic subjects with PAD and foot ulceration as medical therapy, diagnostic criteria and indications for revascularization, revascularization strategy and technical approach as well as the management of no-option critical limb ischemia patients. It is a common opinion that there is an evolution of PAD features in diabetic persons, which seems to present a more aggressive pattern. This may be related to the frequent presence of concomitant comorbidities such as renal failure which could influence the characteristics of atherosclerotic plaques and their distribution. The aim of this review is to commence a complete overview and state of the art in the treatment of patients with diabetes, PAD, and foot ulceration and to describe the current challenges and future perspectives.
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Affiliation(s)
- Meloni Marco
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Izzo Valentina
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Morosetti Daniele
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Da Ros Valerio
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Panunzi Andrea
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Gandini Roberto
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Giurato Laura
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Uccioli Luigi
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
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30
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Lee CY, Wu TC, Lin SJ. Effects of Postoperative Percutaneous Coronary Intervention, Pharmacologic Treatment, and Predisposing Factors on Clinical Outcomes in Patients With and Without Type 2 Diabetes Along With Critical Limb Ischemia. Clin Ther 2020; 43:195-210.e2. [PMID: 33358255 DOI: 10.1016/j.clinthera.2020.11.013] [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: 08/08/2020] [Revised: 10/29/2020] [Accepted: 11/22/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Critical limb ischemia (CLI) has been identified as being connected to rates of cardiovascular mortality and lower extremity amputation (LEA). This prospective study investigated the effects of percutaneous coronary intervention (PCI), pharmacologic treatment, and predisposing factors on clinical outcomes in patients with and without type 2 diabetes mellitus (DM) along with CLI after endovascular intervention. METHODS 249 consecutive patients with CLI (Fontaine stages III-IV) received pharmacologic treatment after successful endovascular intervention. Their primary patency rates of infrapopliteal lesions and cardiovascular and amputation events during a 36-month follow-up period were assessed. FINDINGS Patients with DM were more likely to be younger (P = 0.026); 50% (n = 63), 42.9% (n = 54), 52.4% (n = 66), and 77% (n = 97) of DM patients had arterial calcification, end-stage renal disease, diabetic neuropathy, and Fontaine stage IV (P < 0.001, P < 0.001, P < 0.001, and P = 0.019, respectively). The primary patency rates were 61%, 48.8%, and 42.3% at 12, 24, and 36 months, in the patients without DM (P = 0.034, P = 0.013, and P = 0.005). Patients with DM had higher risks of 36-month coronary artery disease, cerebrovascular accident, mortality, and LEA (P = 0.005, P = 0.042, P = 0.042, and P < 0.001). Patients with CLI receiving long-term cilostazol treatment had a better primary patency and amputation-free survival, and a lower risk of mortality at 36 months (P < 0.001, P < 0.001, and P = 0.001). Statin use was associated with 36-month amputation-free survival but not with primary patency (P = 0.032 and P = 0.088). Subgroup multivariate Cox analyses showed that primary patency was independently associated with long-term cilostazol treatment, PCI in the first postoperative year, and direct revascularization in the DM group, whereas in the control group, long-term cilostazol treatment was the main independent factor. The risk of amputation was independently associated with a high high-sensitivity chronic reactive protein level, diabetic neuropathy, sole use of an oral hypoglycemic agent, and lack of supervised exercise. IMPLICATIONS Long-term cilostazol treatment, aggressive management of dyslipidemia, and meticulous assessment and prevention of postoperative unstable coronary artery disease should be considered in CLI patients with and without DM to maximize clinical outcomes. PCI in the first postoperative year may be a predisposing factor for patency failure in patients with CLI, especially those with DM. A large-scale prospective randomized trial should be conducted to confirm these findings (TVGH IRB No. 2013-08-020B).
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Affiliation(s)
- Chiu-Yang Lee
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei City, Taiwan; Institute of Clinical Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan.
| | - Tao-Cheng Wu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shing-Jong Lin
- Institute of Clinical Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan; Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan; Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan.
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Rojas-Torres M, Jiménez-Palomares M, Martín-Ramírez J, Beltrán-Camacho L, Sánchez-Gomar I, Eslava-Alcon S, Rosal-Vela A, Gavaldá S, Durán-Ruiz MC. REX-001, a BM-MNC Enriched Solution, Induces Revascularization of Ischemic Tissues in a Murine Model of Chronic Limb-Threatening Ischemia. Front Cell Dev Biol 2020; 8:602837. [PMID: 33363160 PMCID: PMC7755609 DOI: 10.3389/fcell.2020.602837] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/19/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Bone Marrow Mononuclear Cells (BM-MNC) constitute a promising alternative for the treatment of Chronic Limb-Threatening ischemia (CLTI), a disease characterized by extensive blockade of peripheral arteries, clinically presenting as excruciating pain at rest and ischemic ulcers which may lead to gangrene and amputation. BM-MNC implantation has shown to be efficient in promoting angiogenesis and ameliorating ischemic symptoms in CLTI patients. However, the variability seen between clinical trials makes necessary a further understanding of the mechanisms of action of BM-MNC, and moreover, to improve trial characteristics such as endpoints, inclusion/exclusion criteria or drug product compositions, in order to implement their use as stem-cell therapy. Materials: Herein, the effect of REX-001, a human-BM derived cell suspension enriched for mononuclear cells, granulocytes and CD34+ cells, has been assessed in a murine model of CLTI. In addition, a REX-001 placebo solution containing BM-derived red blood cells (BM-RBCs) was also tested. Thus, 24 h after double ligation of the femoral artery, REX-001 and placebo were administrated intramuscularly to Balb-c nude mice (n:51) and follow-up of ischemic symptoms (blood flow perfusion, motility, ulceration and necrosis) was carried out for 21 days. The number of vessels and vascular diameter sizes were measured within the ischemic tissues to evaluate neovascularization and arteriogenesis. Finally, several cell-tracking assays were performed to evaluate potential biodistribution of these cells. Results: REX-001 induced a significant recovery of blood flow by increasing vascular density within the ischemic limbs, with no cell translocation to other organs. Moreover, cell tracking assays confirmed a decrease in the number of infused cells after 2 weeks post-injection despite on-going revascularization, suggesting a paracrine mechanism of action. Conclusion: Overall, our data supported the role of REX-001 product to improve revascularization and ischemic reperfusion in CLTI.
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Affiliation(s)
- Marta Rojas-Torres
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cadiz (INIBICA), Cádiz, Spain
| | - Margarita Jiménez-Palomares
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cadiz (INIBICA), Cádiz, Spain
| | | | - Lucía Beltrán-Camacho
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cadiz (INIBICA), Cádiz, Spain
| | - Ismael Sánchez-Gomar
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cadiz (INIBICA), Cádiz, Spain
| | - Sara Eslava-Alcon
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cadiz (INIBICA), Cádiz, Spain
| | - Antonio Rosal-Vela
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cadiz (INIBICA), Cádiz, Spain
| | - Sandra Gavaldá
- R&D Department at Rexgenero Biosciences Sociedad Limitada (SL), Seville, Spain
| | - Mª Carmen Durán-Ruiz
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cadiz (INIBICA), Cádiz, Spain
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Koivunen V, Juonala M, Mikkola K, Hakovirta HH. CHRONIC LIMB THREATENING ISCHEMIA AND DIABETES MELLITUS: THE SEVERITY OF TIBIAL ATHEROSCLEROSIS AND OUTCOME AFTER INFRAPOPLITEAL REVASCULARIZATION. Scand J Surg 2020; 110:472-482. [PMID: 33225841 PMCID: PMC8688977 DOI: 10.1177/1457496920968679] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background and objective: Diabetes mellitus associates with poor outcomes in chronic limb threatening ischemia but data on different hypoglycemic regimens and outcomes are lacking. We analyzed insulin-treated diabetes mellitus, non-insulin-treated diabetes mellitus, and patients without diabetes mellitus. Methods: All patients with peripheral artery disease and/or diabetes mellitus and infrapopliteal revascularization in the Department of Vascular Surgery, Turku University Hospital during 2007–2015 were included. Tibial atherosclerosis was categorized into crural index classes of I–IV. Results: Of the 497 patients, 180 were insulin-treated diabetes mellitus, 94 non-insulin-treated diabetes mellitus, and 223 patients without diabetes mellitus groups (diabetes mellitus 55.1%). Insulin-treated diabetes mellitus was the most ill, youngest (insulin-treated diabetes mellitus—median: 72.4, interquartile range: 64.0–79.5 versus non-insulin-treated diabetes mellitus—76.0, interquartile range: 67.9–83.6 versus patients without diabetes mellitus—77.3, interquartile range: 68.5–83.7, p < 0.001), had the highest body mass index (insulin-treated diabetes mellitus—median: 27.7, interquartile range: 24.0–31.8 versus non-insulin-treated diabetes mellitus—26.3, interquartile range: 23.2–30.3 versus patients without diabetes mellitus—23.9, interquartile range: 21.5–26.9, p < 0.001), and Charlson comorbidity index (insulin-treated diabetes mellitus—65.6% versus non-insulin-treated diabetes mellitus—46.8% versus patients without diabetes mellitus—10.8%, p < 0.001). After endovascular revascularization, limb salvage was poorer for insulin-treated diabetes mellitus (p = 0.046) and non-insulin-treated diabetes mellitus groups (p = 0.011) compared to surgery, but not for patients without diabetes mellitus (p = 0.15). Patients with crural index IV in insulin-treated diabetes mellitus (p = 0.001) and non-insulin-treated diabetes mellitus (p = 0.013) had higher mortality after revascularization. Crural index IV was a risk factor for limb loss (hazard ratio: 1.37, 95% confidence interval: 1.08–1.74, p = 0.008). Conclusions: Limb salvage after bypass is better for insulin and non-insulin diabetics, compared to the endovascular approach. Extensive tibial atherosclerosis is an independent risk factor for limb loss. It associates with increased mortality in both insulin and non-insulin diabetics.
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Affiliation(s)
- V Koivunen
- Faculty of Medicine, Turku University Hospital, University of Turku, Turku, Finland
| | - M Juonala
- Department of Internal Medicine, University of Turku, Turku, Finland.,Division of Medicine, Turku University Hospital, Turku, Finland
| | - K Mikkola
- Department of Computer Science, Aalto University, Helsinki, Finland
| | - H H Hakovirta
- Faculty of Medicine, Turku University Hospital, University of Turku, Turku, Finland.,Department of Surgery, Satakunta Central Hospital, Pori, Finland.,Department of Vascular Surgery, Turku University Hospital, University of Turku, Turku, Finland
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Lee KB, Macsata RA, Lala S, Sparks AD, Amdur RL, Ricotta JJ, Sidawy AN, Nguyen BN. Outcomes of open and endovascular interventions in patients with chronic limb threatening ischemia. Vascular 2020; 29:693-703. [PMID: 33190618 DOI: 10.1177/1708538120971972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Widespread adoption of endovascular therapy for the treatment of chronic limb-threatening ischemia has transformed the field of vascular surgery. In this modern era, we aimed to define where open surgical interventions are of greatest benefit for limb salvage. METHODS Patients who underwent interventions for chronic limb-threatening ischemia were identified in the vascular-targeted lower extremity National Surgical Quality Improvement Program database for open surgical interventions (OPEN) and endovascular surgical interventions (ENDO) from 2011 to 2017. Patients were further stratified based on the criteria of chronic limb-threatening ischemia (rest pain or tissue loss), and the location of the diseased arteries (femoropopliteal or tibioperoneal). The main outcomes measured included 30-day mortality, amputation, and major adverse cardiovascular events. RESULTS A total of 17,193 patients were revascularized for chronic limb-threatening ischemia: 10,532 were OPEN and 6661 were ENDO. OPEN had higher 30-day mortality, major adverse cardiovascular events, pulmonary, renal dysfunction, and wound complications. However, OPEN resulted in significantly lower 30-day major amputation (3.8% vs. 5.0%, odds ratio (OR): 0.83 [0.72-0.97], P = .018). Subgroup analysis revealed a higher mortality rate in OPEN was observed only in tibioperoneal intervention for tissue loss. Major adverse cardiovascular event was higher in OPEN for most subgroups. OPEN for patients with tissue loss had significantly lower amputation rate than ENDO in both femoropopliteal and tibioperoneal subgroups (3.7% vs. 5.1%, OR: 0.76 [0.59-0.98], P = .036, and 4.7% vs. 6.6%, OR: 0.74 [0.57-0.96], P = .024, respectively). The benefit of open surgery in reducing the amputation rate was not seen in patients with rest pain. CONCLUSIONS Open surgical intervention is associated with significantly better limb salvage than endovascular intervention in patients with tissue loss. Surgical options should be given more emphasis as the first-line option in this cohort of patients unless the cardiopulmonary risk is prohibitive.
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Affiliation(s)
- K Benjamin Lee
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Robyn A Macsata
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Salim Lala
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Andrew D Sparks
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Richard L Amdur
- Department of Surgery, George Washington University, Washington, DC, USA
| | - John J Ricotta
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Anton N Sidawy
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Bao-Ngoc Nguyen
- Department of Surgery, George Washington University, Washington, DC, USA
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Ni WW, Leong S, Irani F, Patel A, Damodharan K, Venkataranasimha N, Chandramohan S, Kumar P, Chua J, Gogna A, Da Zhuang K, Chong TT, Tang TY, Chng SP, Tay KH. "Angioplasty-First" Approach for Limb Salvage in Asian Patients with Critical Limb Ischemia: Outcomes from 3,303 Angioplasties on 2,402 Limbs in a Single Tertiary Hospital. J Vasc Interv Radiol 2020; 31:1969-1977.e1. [PMID: 33139186 DOI: 10.1016/j.jvir.2020.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 01/16/2023] Open
Abstract
PURPOSE To review outcomes of patients with critical limb ischemia (CLI) who underwent conventional percutaneous transluminal angioplasty (PTA) as first-line treatment for revascularization. MATERIALS AND METHODS Retrospective review of 3,303 angioplasty procedures on 2,402 limbs in 1,968 patients with CLI was conducted. Mean patient age was 68 years ± 11, and 1,057 patients (54%) were male. Diabetes mellitus (DM) was present in 1,736 patients (88%), and end-stage renal disease (ESRD) in 579 (29%). A majority of patients (90%) had tissue loss. Limb salvage rates were generated by Kaplan-Meier plot. Univariate and multivariate Cox regression analysis was conducted to investigate associations between clinical predictors and time-to-event outcome. RESULTS Limb salvage rates at 1, 3, 5, and 10 years were 75%, 73%, 72%, and 62%, respectively, and overall survival rates were 79%, 64%, 56%, and 34%, respectively. In multivariable Cox regression analysis with the outcome of major amputation, significant predictors included age < 69 years (P = .032), Malay race (P = .029), DM (P < .001), history of cerebral vascular disease (P = .003), ESRD (P < .001), Rutherford classification (P = .042), repeat intervention (P = .034), and number of straight-line flows (P < .001) and plantar arch integrity (P < .001) on completion angiography. Significant associations with mortality were age < 69 years (P < .001), male sex (P = .030), Malay race (P = .027), history of ischemic heart disease (P < .001), ESRD (P < .001), and repeat intervention (P < .001). CONCLUSIONS PTA as first-line revascularization for patients with CLI is safe and effective. Further studies are suggested to validate the outcome predictive model.
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Affiliation(s)
- Wen Wen Ni
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Sum Leong
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Farah Irani
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Ankur Patel
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Karthikeyan Damodharan
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Nanda Venkataranasimha
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Sivanathan Chandramohan
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Pradesh Kumar
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Jasmine Chua
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Apoorva Gogna
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Kun Da Zhuang
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Outram Road, Singapore
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Outram Road, Singapore
| | - Siew Ping Chng
- Department of Vascular Surgery, Singapore General Hospital, Outram Road, Singapore
| | - Kiang Hiong Tay
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore.
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Faulkner A, Tamiato A, Cathery W, Rampin A, Caravaggi CM, Jover E, Allen S, Mellor H, Hauton D, Heather LC, Spinetti G, Madeddu P. Dimethyl-2-oxoglutarate improves redox balance and mitochondrial function in muscle pericytes of individuals with diabetes mellitus. Diabetologia 2020; 63:2205-2217. [PMID: 32728894 PMCID: PMC7476972 DOI: 10.1007/s00125-020-05230-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 05/22/2020] [Indexed: 12/28/2022]
Abstract
AIMS/HYPOTHESIS Treatment of vascular complications of diabetes remains inadequate. We reported that muscle pericytes (MPs) from limb muscles of vascular patients with diabetes mellitus display elevated levels of oxidative stress causing a dysfunctional phenotype. Here, we investigated whether treatment with dimethyl-2-oxoglutarate (DM-2OG), a tricarboxylic acid cycle metabolite with antioxidant properties, can restore a healthy metabolic and functional phenotype. METHODS MPs were isolated from limb muscles of diabetes patients with vascular disease (D-MPs) and from non-diabetic control participants (ND-MPs). Metabolic status was assessed in untreated and DM-2OG-treated (1 mmol/l) cells using an extracellular flux analyser and anion-exchange chromatography-mass spectrometry (IC-MS/MS). Redox status was measured using commercial kits and IC-MS/MS, with antioxidant and metabolic enzyme expression assessed by quantitative RT-PCR and western blotting. Myogenic differentiation and proliferation and pericyte-endothelial interaction were assessed as functional readouts. RESULTS D-MPs showed mitochondrial dysfunction, suppressed glycolytic activity and reduced reactive oxygen species-buffering capacity, but no suppression of antioxidant systems when compared with ND-MP controls. DM-2OG supplementation improved redox balance and mitochondrial function, without affecting glycolysis or antioxidant systems. Nonetheless, this was not enough for treated D-MPs to regain the level of proliferation and myogenic differentiation of ND-MPs. Interestingly, DM-2OG exerted a positive effect on pericyte-endothelial cell interaction in the co-culture angiogenesis assay, independent of the diabetic status. CONCLUSIONS/INTERPRETATION These novel findings support the concept of using DM-2OG supplementation to improve pericyte redox balance and mitochondrial function, while concurrently allowing for enhanced pericyte-endothelial crosstalk. Such effects may help to prevent or slow down vasculopathy in skeletal muscles of people with diabetes. Graphical abstract.
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Affiliation(s)
- Ashton Faulkner
- Bristol Medical School, Translational Health Sciences, University of Bristol, Upper Maudlin Street, Bristol, BS2 8HW, UK.
- School of Biochemistry, University of Bristol, University Walk, Bristol, BS8 1TD, UK.
| | - Anita Tamiato
- Bristol Medical School, Translational Health Sciences, University of Bristol, Upper Maudlin Street, Bristol, BS2 8HW, UK
| | - William Cathery
- Bristol Medical School, Translational Health Sciences, University of Bristol, Upper Maudlin Street, Bristol, BS2 8HW, UK
| | | | | | - Eva Jover
- Bristol Medical School, Translational Health Sciences, University of Bristol, Upper Maudlin Street, Bristol, BS2 8HW, UK
| | - Steve Allen
- Department of Comparative Biomedical Sciences, Royal Veterinary College, London, UK
| | - Harry Mellor
- School of Biochemistry, University of Bristol, University Walk, Bristol, BS8 1TD, UK
| | - David Hauton
- Department of Chemistry, University of Oxford, Oxford, UK
| | - Lisa C Heather
- Department of Physiology, Anatomy & Genetics, University of Oxford, Oxford, UK
| | | | - Paolo Madeddu
- Bristol Medical School, Translational Health Sciences, University of Bristol, Upper Maudlin Street, Bristol, BS2 8HW, UK.
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Lee CY, Wu TC, Lin SJ. Long-Term Cilostazol Treatment and Predictive Factors on Outcomes of Endovascular Intervention in Patients with Diabetes Mellitus and Critical Limb Ischemia. Diabetes Ther 2020; 11:1757-1773. [PMID: 32564334 PMCID: PMC7376806 DOI: 10.1007/s13300-020-00860-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Despite improvements in endovascular interventions and multidisciplinary approaches, improving clinical outcomes and increasing limb salvage have become increasingly challenging. This prospective study investigated the associations of cilostazol treatment with clinical outcomes and predictive factors in patients with diabetes mellitus (DM) and critical limb ischemia (CLI) after endovascular revascularization of the affected angiosome. METHODS In this study, 172 consecutive patients with CLI (Fontaine levels III-IV) received cilostazol treatment after successful endovascular intervention according to the angiosome concept, and their primary patency rates and cardiovascular and amputation events during a 24-month follow-up period were assessed. RESULT The 24-month primary patency rate, mortality rate, and amputation rate were better in the patients under long-term cilostazol treatment (P < 0.001, P = 0.029, and P = 0.014). Weighted multivariate Cox analyses with a propensity scoring-based method showed that long-term cilostazol treatment [hazard ratio (HR) 0.2, 95% confidence interval (CI) 0.11-0.36, P < 0.001], direct revascularization (DR) (HR 0.46, 95% CI 0.28-0.74, P = 0.002), and supervised exercise (HR 0.4, 95% CI 0.24-0.66, P < 0.001) were independently associated with primary patency. Patients with lower-extremity amputation (LEA) had a higher risk of coronary artery disease (CAD) and mortality. Cellulitis and neuropathy were independently associated with LEA events (cellulitis: HR 2.89, 95% CI 1.66-5.05, P < 0.001; neuropathy: HR 2.2, 95% CI 1.31-3.7, P = 0.003). CONCLUSION Our results showed that patients with DM who received cilostazol treatment for more than 3 months had significantly better outcomes and decreased amputation and mortality rates after DR, and cellulitis and neuropathy were highly associated with the risk of limb loss. A large-scale randomized trial should be conducted in the future to confirm these results. TRIAL REGISTRATION Taipei Veterans General Hospital (TVGH) IRB no. 2013-08-020B. Registered 30 August 2013.
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Affiliation(s)
- Chiu-Yang Lee
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, No. 201, Section 2 Shih-Pai Road, Beitou District, Taipei, 11217 Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Tao-Cheng Wu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shing-Jong Lin
- Institute of Clinical Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
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Missed Opportunities for Timely Recognition of Chronic Limb Threatening Ischaemia in Patients Undergoing a Major Amputation: A Population Based Cohort Study Using the UK's Clinical Practice Research Datalink. Eur J Vasc Endovasc Surg 2020; 60:703-710. [PMID: 32718828 DOI: 10.1016/j.ejvs.2020.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 04/09/2020] [Accepted: 05/05/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Opportunities for timely recognition of chronic limb-threatening ischaemia (CLTI) within primary care, such as performing cardiovascular assessment during clinical consultation, are possibly being missed. This study aimed to investigate for potential "missed opportunities" within primary care. METHODS This was a population based cohort study, using the UK's Clinical Practice Research Datalink (CPRD). Patients undergoing a major amputation for CLTI between 1 January 2000 and 31 December 2016 were included. Primary care consultation and patient clinical data within the one year period prior to amputation were extracted from the CPRD. Dates of last primary care consultation and cardiovascular assessment prior to amputation were evaluated. Timings of latest cardiovascular assessments were stratified into "recent" (7-90 days before amputation) and "late" (> 91 days). RESULTS In total, 3 260 patients were included. In the year prior to amputation, patients attended a median of 19 (range 9-32) primary care consultations; however, prescription of secondary preventive medications was poor (antiplatelet 49.7%; lipid lowering agent 40.7%). Overall, 2 175 patients (66.7%) attended a primary care consultation 7-30 days before their amputation. However, only 416 (12.8%) underwent a cardiovascular assessment within this period, with 2 073 (63.6%) undergoing no assessment within 90 days of their amputation. Of these 2 073 patients, 1 230 (59.3%) had a primary care consultation 7-30 days before their procedure. Patients undergoing "late" assessment were younger (p = .003), with higher systolic (p = .008) and diastolic (p = .001) blood pressures than those undergoing "recent" assessment. Differences were also observed between assessment timings by deprivation (p = .003) and ethnicity (p = .006). CONCLUSION Missed opportunities for timely recognition potentially exist and may be related to age, deprivation, and ethnicity. Further work is required to investigate these factors, as well as individual amputations to identify the causes precipitating amputation. Greater emphasis on the medical management of peripheral arterial disease and identifying cardiovascular risk factors in patients who may not fit the "at risk" stereotype, are also required.
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Meloni M, Izzo V, Giurato L, Lázaro-Martínez JL, Uccioli L. Prevalence, Clinical Aspects and Outcomes in a Large Cohort of Persons with Diabetic Foot Disease: Comparison between Neuropathic and Ischemic Ulcers. J Clin Med 2020; 9:E1780. [PMID: 32521700 PMCID: PMC7356179 DOI: 10.3390/jcm9061780] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/01/2020] [Accepted: 06/04/2020] [Indexed: 01/26/2023] Open
Abstract
This study aims to evaluate clinical and ulcer characteristics as well the outcomes of patients with diabetic foot ulcers (DFUs). The study group was composed of DFUs patients managed by a limb salvage protocol according to guidance. Clinical and ulcers findings were described, and 1-year outcomes defined as limb salvage, healing, healing time, major amputation and death were compared between neuropathic and ischemic DFUs. One thousand, one hundred and ninety-eight subjects were included; 386 (32.2%) neuropathic and 812 (67.8%) ischemic DFUs. Neuropathic patients were younger (69.5 ± 11.5 vs. 74.5 ± 11.5, p < 0.0001) and reported less cases of nephropathy (22.8 vs. 39.6%, p < 0.0001), ischemic heart disease (22.8 vs. 36.9, p = 0.0004), cerebrovascular disease (8.3 vs. 17.2%, p = 0.002), heart failure (10.1 vs. 24.7%, p = 0.0002) and end-stage-renal-disease (ESRD) (5.4 vs. 27%, p = 0.0001) than ischemic patients; they also showed less cases of large (>5 cm2) (10.3 vs. 22.9%, p = 0.0007), infected (40.4 vs. 55.7%, p = 0.0005) and deep to the bone (22.3 vs. 39.2, p = 0.0002) ulcers, as well less multiple ulcerations (21.8 vs. 32.8%, p = 0.006) than patients with ischemic DFUs. The outcomes for neuropathic and ischemic DFUs were limb salvage (98.4 vs. 82.3%, p < 0.0001), healing (97.3 vs. 79.6%, p < 0.0001), healing time (34.9 vs. 35.6 weeks, p = 0.8), major amputation (0.5 vs. 6.6%, p = 0.0001), death (1.1 vs. 11%, p < 0.0001) respectively. Revascularization failure and ESRD were independent predictors of major amputation, while heart failure and number of co-morbidities (³5) were independent predictors of death. Ischemic DFUs patients showed more severe clinical and ulcers features as well worse outcomes than neuropathic DFUs patients.
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Affiliation(s)
- Marco Meloni
- Diabetic Foot Unit, Department of Medicina dei Sistemi, University of Tor Vergata, 00133 Rome, Italy; (V.I.); (L.G.); (L.U.)
| | - Valentina Izzo
- Diabetic Foot Unit, Department of Medicina dei Sistemi, University of Tor Vergata, 00133 Rome, Italy; (V.I.); (L.G.); (L.U.)
| | - Laura Giurato
- Diabetic Foot Unit, Department of Medicina dei Sistemi, University of Tor Vergata, 00133 Rome, Italy; (V.I.); (L.G.); (L.U.)
| | - José Luis Lázaro-Martínez
- Diabetic Foot Unit, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigacion Sanitaria de Hospital Clinico San Carlos (IdISSC), 28040 Madrid, Spain;
| | - Luigi Uccioli
- Diabetic Foot Unit, Department of Medicina dei Sistemi, University of Tor Vergata, 00133 Rome, Italy; (V.I.); (L.G.); (L.U.)
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Chan CB, Dmytruk K, Labbie M, O’Connell P. Organizational changes in diabetic foot care practices for patients at low and moderate risk after implementing a comprehensive foot care program in Alberta, Canada. J Foot Ankle Res 2020; 13:26. [PMID: 32430079 PMCID: PMC7236492 DOI: 10.1186/s13047-020-00393-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/11/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Neuropathy and vasculopathy can lead to costly and debilitating complications in people with diabetes. The purpose of this study was to evaluate, at an organizational level, uptake of practices included in a diabetic foot care clinical pathway and associated resources. This research focused on patients at low and moderate risk in Alberta, Canada between 2014 to 2019. METHODS Serial surveys (2014, 2019) of practices related to screening and care of the feet of people with diabetes. Surveys were administered using a combination of targeted and snowball sampling in order to assess the impact of the clinical pathway first implemented in 2015. The pathway focused on screening, assessment and referral of patients from primary care. High-risk foot teams (HRFT) were established at six sites to provide increased access to specialty care. Comparative statistics were performed to assess differences in footcare practices between 2014 and 2019 using two-tailed Fisher's exact test or Chi-square test. RESULTS Respondents (n = 104, 2014 and n = 75, 2019) included personnel from primary health care, home care and long-term care, acute and emergency care, specialty clinics, diabetes-specific programs and private contractors. The proportion of primary care and home care/long-term care (HC/LTC) sites providing screening increased significantly (p < 0.05). A significant increase in the proportion of sites providing assessment for patients designated as moderate risk also increased from 35% (34 out of 96 sites) to 55% (36 out of 65 sites) (p < 0.05), particularly with respect to vascular assessment, and the proportion of sites reporting appropriate follow-up intervals according to the pathway recommendation was also improved. CONCLUSION Provision of a clinical pathway for diabetic foot care along with education and resources led to increased screening in primary care and HC/LTC settings in Alberta, Canada. HRFT provided primary healthcare providers with an important option for referral and also provided increased expertise for procedures such as vascular assessment for patients with moderate risk of ulceration. This comprehensive model has the potential to reduce progression of foot problems and overall health services utilization. Further analyses of outcomes such as incident lower limb amputation and long-term cost-effectiveness of pathway implementation are underway.
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Affiliation(s)
- Catherine B. Chan
- Diabetes, Obesity and Nutrition Strategic Clinical Network, Alberta Health Services, 10101 Southport Road, Calgary, Alberta T2W 1S7 Canada
- Department of Agricultural, Food and Nutritional Sciences, University of Alberta, 4-126 Li Ka Shing Centre, Edmonton, Alberta T6G 2E1 Canada
- Department of Physiology, University of Alberta, 7-55 Medical Sciences Building, Edmonton, Alberta T6G 2H7 Canada
| | - Kathy Dmytruk
- Diabetes, Obesity and Nutrition Strategic Clinical Network, Alberta Health Services, 10101 Southport Road, Calgary, Alberta T2W 1S7 Canada
| | - Michele Labbie
- WestView Health Centre, 4405 South Park Drive, Stony Plain, Alberta T7Z 2M7 Canada
| | - Petra O’Connell
- Diabetes, Obesity and Nutrition Strategic Clinical Network, Alberta Health Services, 10101 Southport Road, Calgary, Alberta T2W 1S7 Canada
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Khan A, Hughes M, Ting M, Riding G, Simpson J, Egun A, Banihani M. A 'hot clinic' for cold limbs: the benefit of urgent clinics for patients with critical limb ischaemia. Ann R Coll Surg Engl 2020; 102:412-417. [PMID: 32306742 DOI: 10.1308/rcsann.2020.0068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The national reconfiguration of vascular surgery means that arterial centres serve larger populations with increased demand on resources. Emergency general surgery ambulatory clinics facilitate timely review and intervention, avoiding admission; a critical limb ischaemia (CLI) 'hot clinic' (HC) was implemented to achieve similar for vascular patients. The aim of the study was to determine HC efficacy. METHODS This was a prospective cohort study comparing HC patients with emergency admission (EA) patients between 1 May and 1 December 2017. Age, sex, comorbidities, CLI severity and smoking status were noted. HC patients were provided with satisfaction surveys. Primary outcome measures were freedom from reintervention and major amputation. Secondary outcome measures included time to procedure, length of stay, returns to theatre and 30-day readmission. RESULTS A total of 147 patients (72 HC, 75 EA) were enrolled in the study. No statistical difference was found in age, sex, smoking status, severity of CLI or prevalence of comorbidities between the groups except that diabetes was more prevalent in EA patients (p=0.028). The median length of stay for the HC cohort was shorter (3 days vs 17 days, p<0.001), with no difference between time to procedure, return to theatre or 30-day readmission. HC patients were nearly 6 times more likely to experience freedom from reintervention (odds ratio: 5.824, p<0.001) and 2.5 times less likely to undergo amputation (odds ratio: 2.616, p=0.043). HC utilisation saved a total of 441 bed days. Over 90% of attendees responded with 100% positive feedback. CONCLUSIONS A vascular HC facilitates urgent review and revascularisation. It provides comparable in-hospital outcomes and better long-term outcomes, with greater efficiency than hospital admission, demonstrating its value in treating CLI.
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Affiliation(s)
- A Khan
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
| | - M Hughes
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
| | - M Ting
- University of Manchester, UK
| | - G Riding
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
| | - J Simpson
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
| | - A Egun
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
| | - M Banihani
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
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Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Padula WV, Bus SA. Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res 2020; 13:16. [PMID: 32209136 PMCID: PMC7092527 DOI: 10.1186/s13047-020-00383-2] [Citation(s) in RCA: 342] [Impact Index Per Article: 85.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/17/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In 2007, we reported a summary of data comparing diabetic foot complications to cancer. The purpose of this brief report was to refresh this with the best available data as they currently exist. Since that time, more reports have emerged both on cancer mortality and mortality associated with diabetic foot ulcer (DFU), Charcot arthropathy, and diabetes-associated lower extremity amputation. METHODS We collected data reporting 5-year mortality from studies published following 2007 and calculated a pooled mean. We evaluated data from DFU, Charcot arthropathy and lower extremity amputation. We dichotomized high and low amputation as proximal and distal to the ankle, respectively. This was compared with cancer mortality as reported by the American Cancer Society and the National Cancer Institute. RESULTS Five year mortality for Charcot, DFU, minor and major amputations were 29.0, 30.5, 46.2 and 56.6%, respectively. This is compared to 9.0% for breast cancer and 80.0% for lung cancer. 5 year pooled mortality for all reported cancer was 31.0%. Direct costs of care for diabetes in general was $237 billion in 2017. This is compared to $80 billion for cancer in 2015. As up to one-third of the direct costs of care for diabetes may be attributed to the lower extremity, these are also readily comparable. CONCLUSION Diabetic lower extremity complications remain enormously burdensome. Most notably, DFU and LEA appear to be more than just a marker of poor health. They are independent risk factors associated with premature death. While advances continue to improve outcomes of care for people with DFU and amputation, efforts should be directed at primary prevention as well as those for patients in diabetic foot ulcer remission to maximize ulcer-free, hospital-free and activity-rich days.
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Affiliation(s)
- David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, USA.
| | - Mark A Swerdlow
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, USA
| | - Alexandria A Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, USA
| | - Michael S Conte
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, USA
| | - William V Padula
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, USA
| | - Sicco A Bus
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, USA
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Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S, Reekers J, Venermo M, Zierler RE, Schaper NC, Hinchliffe RJ. Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: A systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3277. [PMID: 32176448 DOI: 10.1002/dmrr.3277] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 01/13/2023]
Abstract
The accurate identification of peripheral artery disease (PAD) in patients with diabetes and foot ulceration is important, in order to inform timely management and to plan intervention including revascularisation. A variety of non-invasive tests are available to diagnose PAD at the bedside, but there is no consensus as to the most useful test, or the accuracy of these bedside investigations when compared to reference imaging tests such as magnetic resonance angiography, computed tomography angiography, digital subtraction angiography or colour duplex ultrasound. Members of the International Working Group of the Diabetic Foot updated our previous systematic review, to include all eligible studies published between 1980 and 2018. Some 15 380 titles were screened, resulting in 15 eligible studies (comprising 1563 patients, of which >80% in each study had diabetes) that evaluated an index bedside test for PAD against a reference imaging test. The primary endpoints were positive likelihood ratio (PLR) and negative likelihood ratio (NLR). We found that the most commonly evaluated test parameter was ankle brachial index (ABI) <0.9, which may be useful to suggest the presence of PAD (PLR 6.5) but an ABI value between 0.9 and 1.3 does not rule out PAD (NLR 0.31). A toe brachial index >0.75 makes the diagnosis of PAD less likely (NLR 0.14-0.24), whereas pulse oximetry may be used to suggest the presence of PAD (if toe saturation < 2% lower than finger saturation; PLR 17.23-30) or render PAD less likely (NLR 0.2-0.27). We found that the presence of triphasic tibial waveforms has the best performance value for excluding a diagnosis of PAD (NLR 0.09-0.28), but was evaluated in only two studies. In addition, we found that beside clinical examination (including palpation of foot pulses) cannot reliably exclude PAD (NLR 0.75), as evaluated in one study. Overall, the quality of data is generally poor and there is insufficient evidence to recommend one bedside test over another. While there have been six additional publications in the last 4 years that met our inclusion criteria, more robust evidence is required to achieve consensus on the most useful non-invasive bedside test to diagnose PAD.
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Affiliation(s)
- Rachael O Forsythe
- British Heart Foundation, University of Edinburgh Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Centre, Department of Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, Washington
| | - Robert Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joon Pio Hong
- Asan Medical Center, University of Ulsan, Seoul, South Korea
| | | | - Joseph L Mills
- SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona Health Sciences Center, Tucson, Arizona
| | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Jim Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki University Hospital, Helsinki, Finland
| | - R Eugene Zierler
- Department of Surgery, University of Washington, Seattle, Washington
| | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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Hinchliffe RJ, Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S, Reekers J, Venermo M, Zierler RE, Schaper NC. Guidelines on diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3276. [PMID: 31958217 DOI: 10.1002/dmrr.3276] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 12/24/2022]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis, prognosis, and management of peripheral artery disease (PAD) in patients with foot ulcers and diabetes and updates the previous IWGDF Guideline. Up to 50% of patients with diabetes and foot ulceration have concurrent PAD, which confers a significantly elevated risk of adverse limb events and cardiovascular disease. We know that the diagnosis, prognosis, and treatment of these patients are markedly different to patients with diabetes who do not have PAD and yet there are few good quality studies addressing this important subset of patients. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to devise clinical questions and critically important outcomes in the patient-intervention-comparison-outcome (PICO) format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We here present the updated 2019 guidelines on diagnosis, prognosis, and management of PAD in patients with a foot ulcer and diabetes, and we suggest some key future topics of particular research interest.
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Affiliation(s)
| | - Rachael O Forsythe
- British Heart Foundation/Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Centre, Department of Veterans Affairs Puget Sound Health Care System and the University of Washington, Seattle, WA
| | - Robert Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joon Pio Hong
- Asan Medical Center University of Ulsan, Seoul, South Korea
| | | | - Joseph L Mills
- SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona Health Sciences Center, Tucson, AZ
| | - Sigrid Nikol
- Department of Interventional Angiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Jim Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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Santopaolo M, Sambataro M, Spinetti G, Madeddu P. Bone marrow as a target and accomplice of vascular complications in diabetes. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3240. [PMID: 31840418 DOI: 10.1002/dmrr.3240] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/19/2019] [Indexed: 12/16/2022]
Abstract
Peripheral vascular complications are common in diabetic patients. While pathogenic mechanisms have received much consideration, only recently regenerative processes captured attention. There is now a consensus that the bone marrow is a source of reparative cells and that this healing mechanism is lost in people with diabetes, especially in those suffering from ischemic complications. This failure was thought to occur due to a negative impact of diabetes on the mobilization of stem/progenitor cells with angiogenic properties from the bone marrow to the circulation. Moreover, those patients showing severely reduced bone marrow cell mobilization also bared a very high risk for adverse cardiovascular events. More recently, the structural integrity of the bone marrow was recognized to be altered because of the rarefaction of local microvasculature and innervation, thus mirroring anatomical features that typically occur in peripheral tissues. Ensuing hypoxia, nutrient starvation, and creation of an acidic and oxidative environment concur in causing the depletion of stem/progenitor cells in the endosteal niche and in forcing stromal cells to activate an adipogenesis program. Moreover, stem/progenitor cells acquire a pathogenic phenotype and, once mobilized, can pass harmful signalling molecules to vascular cells of peripheral tissues thereby contributing to ischemic complications. These new pieces of evidence indicate that the bone marrow should deserve more attention in the current care of critical limb ischemia and diabetic foot. Owing to powerful reserve capacities, the bone marrow integrity could be preserved and even rescued using rehabilitation programs and pharmacological treatments with consequent benefit for local and whole-organism homeostasis.
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Affiliation(s)
- Marianna Santopaolo
- Bristol Heart Institute, Translational Health Sciences, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Maria Sambataro
- Endocrine, Metabolism, and Nutrition Disease Unit, Santa Maria di Ca' Foncello Hospital, Treviso, Italy
| | - Gaia Spinetti
- Laboratory of Cardiovascular Research, IRCCS MultiMedica, Milan, Italy
| | - Paolo Madeddu
- Bristol Heart Institute, Translational Health Sciences, University of Bristol, Bristol Royal Infirmary, Bristol, UK
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Choke E, Tang TY, Cheng SC, Tay JS. Treatment of lower limb ischaemia in patients with diabetes. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3262. [PMID: 31833236 DOI: 10.1002/dmrr.3262] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 11/25/2019] [Indexed: 11/11/2022]
Abstract
Diabetic chronic limb-threatening ischaemia is a challenging clinical problem with patients at high risk of diabetic foot ulceration (DFU) and limb loss. Patients often remain asymptomatic even in the presence of severe pedal ischaemia until first presenting with tissue loss such as DFU or frank gangrene. Limb salvage units should have the facilities and expertise to provide multidisciplinary team-based holistic care through best medical therapy, rapid diagnosis, prompt revascularisation with endovascular or open surgical techniques and expert wound management. Endovascular revascularisation has become the first line strategy in contemporary clinical practice because of similar outcomes in wound healing and amputation rates in most patients when compared with open surgery. The primary goal is restoration of pulsatile in-line blood flow to the ankle or foot, with an angiosome-directed approach possibly achieving superior outcomes especially in diabetics with poor collaterals. A comprehensive overview of conventional endovascular techniques (such as antegrade true lumen and subintimal approaches), advanced techniques for complex disease (such as retrograde subintimal and pedal-plantar loop approaches or even deep venous arterialisation) and the various treatment options are described. Diabetic limb salvage rates can be excellent with suitable multidisciplinary expertise and care.
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Affiliation(s)
- Edward Choke
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Tjun Y Tang
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Shin C Cheng
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Jia S Tay
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
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Cost-Effectiveness of Drug-Eluting Stents for Infrapopliteal Lesions in Patients with Critical Limb Ischemia: The PADI Trial. Cardiovasc Intervent Radiol 2019; 43:376-381. [PMID: 31807849 DOI: 10.1007/s00270-019-02385-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/25/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Drug-eluting stents (DES) improve clinical and morphological long-term results compared to percutaneous transluminal angioplasty (PTA) with bailout bare metal stenting (BMS) in patients with critical limb ischemia (CLI) and infrapopliteal lesions (PADI trial). We performed a cost-effectiveness analysis of DES compared to PTA ± BMS in cooperation with Dutch health insurance company VGZ, using data from the PADI trial. MATERIALS AND METHODS In the PADI trial, adults with CLI (Rutherford category ≥ 4) and infrapopliteal lesions were randomized to receive DES with paclitaxel or PTA ± BMS. Seventy-four limbs (73 patients) were treated with DES and 66 limbs (64 patients) with PTA ± BMS. The costs were calculated by using the mean costs per stent multiplied by the mean number of stents used per patient (€750 × 1.8 for DES vs €250 × 0.3 for PTA ± BMS). These costs were compared with the costs of major amputation (€16.000) and rehabilitation (first year €15.750, second year €7.375 and third year €3.600). RESULTS The 5-year major amputation rate was lower in the DES group (19.3% vs 34.0% for PTA ± BMS; p = 0.091). In addition, the 5-year amputation-free survival and event-free survival were significantly higher in the DES group (31.8% vs 20.4%, p=0.043; and 26.2% vs 15.3%, p=0.041, respectively). After 1 year, the cost difference per patient between DES and PTA ± BMS is €1.679 in favor of DES and €2.694 after 3 years. CONCLUSION In our analysis, DES are cost-effective due to the higher hospital costs of amputation and rehabilitation in the PTA ± BMS group. LEVEL OF EVIDENCE Level 1b, analysis based on clinically sensible costs and randomized controlled trial.
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Abstract
PURPOSE OF THE REVIEW Peripheral artery disease (PAD) affects close to 200 million people worldwide. Claudication is the most common presenting symptom for patients with PAD. This review summarizes the current diagnostic and treatment options for patients with claudication. Comprehensive history and physical examination in order to differentiate between claudication secondary to vascular disease vs. neurogenic causes is paramount for initial diagnosis. Ankle-brachial index is the most commonly used test for screening and diagnostic purposes. Treatment consists of four different approaches, which are best utilized in combination: non-pharmacological treatment for claudication improvement, pharmacological treatment for claudication improvement, pharmacological treatment for secondary risk reduction, and interventional treatment for claudication improvement. RECENT FINDINGS Cilostazol is the only Food and Drug Administration (FDA)-approved agent for symptomatic treatment of claudication. Supervised exercise programs provide the maximum benefit for claudication improvement, but home-based exercise programs are an alternative. High-intensity statins and an antiplatelet agent should be prescribed to all patients with PAD. Angiotensin-converting-enzyme inhibitors can provide additional risk reduction, especially in patients with diabetes or hypertension. Rivaroxaban of low dosage (2.5 mg twice daily) in combination with aspirin further decreases cardiovascular risk, but this reduction comes at the cost of higher bleeding risk. Peripheral artery disease (PAD) is a form of atherosclerotic disease that affects hundreds of millions of people worldwide-one of its most common manifestations is intermittent claudication (IC), which results from insufficient blood flow to meet the metabolic demands of an affected extremity. This paper reviews the current literature regarding the workup, diagnosis, diagnostic modalities, treatment options, and management of intermittent claudication.
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Affiliation(s)
- Prio Hossain
- UC Davis School of Medicine, Sacramento, CA, USA
| | - Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Division of Cardiology, Rocky Mountain VA Medical Center and University of Colorado, 1600 North Wheeling Street, Aurora, Denver, CO, 80045, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain VA Medical Center and University of Colorado, 1600 North Wheeling Street, Aurora, Denver, CO, 80045, USA.
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A systematic review investigating the identification, causes, and outcomes of delays in the management of chronic limb-threatening ischemia and diabetic foot ulceration. J Vasc Surg 2019; 71:669-681.e2. [PMID: 31676182 DOI: 10.1016/j.jvs.2019.08.229] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 08/11/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Patients presenting with chronic limb-threatening ischemia and diabetic foot ulceration (DFU) are at high risk of major lower limb amputation. Long-standing concern exists regarding late presentation and delayed management contributing to increased amputation rates. Despite multiple guidelines existing on the management of both conditions, there is currently no accepted time frame in which to enact specialist care and treatment. This systematic review aimed to investigate potential time delays in the identification, referral, and management of both chronic limb-threatening ischemia and DFU. METHODS A systematic review conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards was performed searching MEDLINE, Embase, The Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature from inception to November 14, 2018. All English-language qualitative and quantitative articles investigating or reporting the identification, causes, and outcomes of time delays within "high-income" countries (annual gross domestic product per person >$15,000) were included. Data were extracted independently by the investigators. Given the clinical crossover, both conditions were investigated together. A study protocol was designed and registered at the International Prospective Register of Systematic Reviews. RESULTS A total of 4780 articles were screened, of which 32 articles, involving 71,310 patients and 1388 health care professionals, were included. Twenty-three articles focused predominantly on DFU. Considerable heterogeneity was noted, and only 12 articles were deemed of high quality. Only four articles defined a delay, but this was not consistent between studies. Median times from symptom onset to specialist health care assessment ranged from 15 to 126 days, with subsequent median times from assessment to treatment ranging from 1 to 91 days. A number of patient and health care factors were consistently reported as potentially causative, including poor symptom recognition by the patient, inaccurate health care assessment, and difficulties in accessing specialist services. Twenty articles reported outcomes of delays, namely, rates of major amputation, ulcer healing, and all-cause mortality. Although results were heterogeneous, they allude to delays being associated with detrimental outcomes for patients. CONCLUSIONS Time delays exist in all aspects of the management pathway, which are in some cases considerable in length. The causes of these are complex but reflect poor patient health-seeking behaviors, inaccurate health care assessment, and barriers to referral and treatment within the care pathway. The adoption of standardized limits for referral and treatment times, exploration of missed opportunities for diagnosis, and investigation of novel strategies for providing specialist care are required to help reduce delays.
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A Pro-Inflammatory Biomarker-Profile Predicts Amputation-Free Survival in Patients with Severe Limb Ischemia. Sci Rep 2019; 9:10740. [PMID: 31341203 PMCID: PMC6656730 DOI: 10.1038/s41598-019-47217-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 07/08/2019] [Indexed: 12/13/2022] Open
Abstract
Patients with Severe Limb Ischemia (SLI) have a high risk of amputation and mortality. Here, we investigated a panel of serum biomarkers with the aim of identifying biomarkers for major events and mechanisms that contribute to disease progression in established SLI. A panel of biomarkers including GROα, HGF, SCF, SCGFβ, SDF1α, TRAIL, IL-6, IL-8, FGFβ, GCSF, GMCSF, IP10, MCP1, PDGFbb, RANTES, TNFα, VEGF, sICAM, sVCAM, TM, and E-selectin was measured in serum samples from a subset (n = 108) of the JUVENTAS cohort. The primary outcome was major events, defined as major amputation or death. The inflammatory biomarkers IL-6, IL-8, GROα and IP-10 were significantly elevated in patients who reached a major endpoint. Results were validated in a secondary cohort (n = 146). Cox regression showed that adjusted hazard ratios were 1.40 (95% CI: 1.15-1.70, p = 0.0007) and 1.48 (95% CI 1.16-1.87, p = 0.001) for IL-6 and IP-10 in a fully adjusted model containing both biomarkers. A prediction model using IL-6 and IP-10 showed predictive accuracy with an AUC of ~ 78% in both discovery and validation cohorts, which is higher than previously published models. We conclude that inflammatory biomarkers predict major events in patients with SLI and allow the creation of biomarker-based risk-prediction models.
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Lu D, Jiang Y, Deng W, Zhang Y, Liang Z, Wu Q, Jiang X, Zhang L, Gao F, Cao Y, Chen B, Xue Y. Long-Term Outcomes of BMMSC Compared with BMMNC for Treatment of Critical Limb Ischemia and Foot Ulcer in Patients with Diabetes. Cell Transplant 2019; 28:645-652. [PMID: 30917698 PMCID: PMC7103602 DOI: 10.1177/0963689719835177] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We first compared long-term clinical outcomes in treating critical limb ischemia (CLI) and foot ulcer in patients with diabetes between autologous bone marrow mesenchymal stem cell (BMMSC) and bone-marrow-derived mononuclear cell (BMMNC) transplants. Forty-one patients were enrolled and followed up for 3 years. They received an 18-day standard treatment before stem cell transplantation. Patients with bilateral CLI and foot ulcer were injected intramuscularly or basally with BMMSC, BMMNC, or normal saline (NS). Cox model analysis showed significant differences in the hazard ratio (HR) for amputation with treatment by BMMSC (HR 0.21 [95% CI (0.05, 0.95)], P = 0.043), infection of foot (HR 5.30 [95% CI (1.89, 14.92)], P = 0.002), and age ≥64 (HR 3.01 [95% CI (1.11, 8.15)], P = 0.030), but no significant differences by BMMNC at 9 months after transplantation. Regarding ulcer healing and recurrence rate, the BMMSC group demonstrated a significant difference from the NS group during the 3-6 months after transplantation or healing, but the BMMNC group did not. This trial suggests that, compared with BMMNC treatment, BMMSC treatment leads to a longer time of limb salvage and blood flow improvement, and, when compared with conventional therapy, it can promote limb blood flow and ulcerative healing, and reduce ulcer recurrence and amputation within 9 months.
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Affiliation(s)
- Debin Lu
- 1 Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, PR China.,2 Department of Endocrinology and Metabolism, Southwest Hospital, Third Military Medical University, Chongqing, PR China.,* All three authors contributed equally to the study of this article
| | - Youzhao Jiang
- 3 Department of Endocrinology, Banan People's Hospital of Chongqing, PR China.,* All three authors contributed equally to the study of this article
| | - Wuquan Deng
- 4 Department of Endocrinology, Chongqing Emergency Medical Center (Chongqing Fourth People's Hospital), Chongqing, PR China.,* All three authors contributed equally to the study of this article
| | - Yan Zhang
- 5 Department of Neurology, Chongqing Emergency Medical Center (Chongqing Fourth People's Hospital), Chongqing, PR China
| | - Ziwen Liang
- 2 Department of Endocrinology and Metabolism, Southwest Hospital, Third Military Medical University, Chongqing, PR China
| | - Qinan Wu
- 2 Department of Endocrinology and Metabolism, Southwest Hospital, Third Military Medical University, Chongqing, PR China
| | - Xiaoyan Jiang
- 2 Department of Endocrinology and Metabolism, Southwest Hospital, Third Military Medical University, Chongqing, PR China
| | - Ling Zhang
- 6 Outpatient Department, Southwest Hospital, Third Military Medical University, Chongqing, PR China
| | - Fang Gao
- 1 Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, PR China
| | - Ying Cao
- 1 Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, PR China
| | - Bing Chen
- 2 Department of Endocrinology and Metabolism, Southwest Hospital, Third Military Medical University, Chongqing, PR China
| | - Yaoming Xue
- 1 Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, PR China
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