Evaluation of the paramalleolar bypass for critical limb ischemia patients on hemodialysis with diabetes mellitus and chronic renal failure

Functional prognosis of critical limb ischemia and efficacy of restoration of direct flow below the ankle

Objective

Patients with critical limb ischemia have serious systemic comorbidities and are at high risk of impairment of limb function. In this study, we assessed the prognostic factors of limbs after revascularization.

Methods

In this retrospective single-center cohort study, from April 2008 to December 2012, we treated 154 limbs of 121 patients with critical limb ischemia by the endovascular therapy-first approach based on the patients’ characteristics. The primary end point was amputation-free survival. Secondary end points were patency of a revascularized artery, major adverse limb events, or death. Furthermore, we investigated the ambulatory status one year after revascularization as prognosis of limb function.

Results

Endovascular therapy was performed in 85 limbs in 65 patients as the initial therapy (endovascular therapy group) and surgical reconstructive procedures (bypass group) were performed in 69 limbs in 56 patients. Early mortality within 30 days was not observed in either group. The primary patency rate was significantly better in the bypass group than in the endovascular therapy group ( p < 0.0001). Furthermore, the secondary patency rate was similar between the two groups ( p = 0.0096). There were no significant differences in amputation-free survival and major adverse limb event between the two groups. Univariate analysis showed that ulcer healing ( p < 0.0001), no hypoalbuminemia ( p = 0.0019), restoration of direct flow below the ankle ( p = 0.0219), no previous cerebrovascular disease ( p = 0.0389), and Rutherford 4 ( p = 0.0469) were predictive factors for preservation of ambulatory status one year after revascularization. In multivariate analysis, ulcer healing ( p < 0.0001) and restoration of direct flow below the ankle ( p = 0.0060) were significant predictors.

Conclusions

Ulcer healing and restoration of direct flow below the ankle are independently associated with prognosis of limb functions in patients who undergo infrainguinal arterial reconstruction.

Hepatocyte growth factor exerts beneficial effects on mice with type II diabetes‑induced chronic renal failure via the NF‑κB pathway

Type II diabetes is associated with a low quality of life and inflammation, and is often accompanied by varying degrees of chronic renal failure. Chronic renal failure is considered one of the most important factors that aggravates diabetes and contributes to renal insufficiency in patients with diabetes though cellular fibrosis. It has previously been reported that hepatocyte growth factor (HGF) serves extensive biological roles, and is a multifunctional antifibrotic factor that is involved in kidney development, acute injury and regeneration. The present study aimed to investigate whether HGF exerts beneficial effects on type II diabetes‑induced chronic renal failure in a mouse model. Plasma concentration levels of HGF, tumor necrosis factor (TNF)‑α, monocyte chemoattractant protein (MCP)‑1, interleukin (IL)‑1 and IL‑6 were analyzed prior to and following treatment with HGF. Blood urea nitrogen, plasma creatinine concentrations, and electrolyte, total serum protein, parathyroid hormone and C‑reactive protein levels were analyzed by ELISA. The mechanism underlying the effects of the HGF‑mediated signaling pathway was also investigated in mice with type II diabetes‑induced chronic renal failure. Histological analysis was used to determine the therapeutic effects of HGF on mice with type II diabetes‑induced chronic renal failure. The results indicated that HGF exhibited lower plasma concentrations in mice with type II diabetes‑induced chronic renal failure compared with in healthy mice. In addition, treatment with HGF relieved chronic renal failure via inhibition of inflammation. The results indicated that TNF‑α, MCP‑1 and IL‑1 serum concentration levels were downregulated following treatment with HGF. Conversely, IL‑6 and vascular endothelial growth factor concentration was increased in the HGF‑treated mice compared with in the control mice. The results also demonstrated that HGF treatment downregulated the expression of nuclear factor (NF)‑κB molecules, and target molecules C‑C motif chemokine ligand (Ccl)2, Ccl5, intercellular adhesion molecule 1 and TNF‑α. The present study demonstrated that HGF markedly improved renal failure induced by type II diabetes in a mouse model; histological analyses revealed that renal cell injury was improved following treatment with HGF. In conclusion, these results suggested that HGF may exert beneficial effects on type II diabetes‑induced chronic renal failure via regulation of the NF‑κB signaling pathway.

Increase in skin perfusion pressure predicts amputation-free survival after lower extremity bypass surgery for critical limb ischemia

The objective of this study was to determine how postoperative skin perfusion pressure (SPP) as a measure of blood flow after revascularization affects limb prognosis in patients with critical limb ischemia (CLI). We retrospectively reviewed 223 consecutive bypass surgery cases performed in 192 patients with CLI during a 10-year period. SPP was measured 1–2 weeks before and after the procedure. An SPP of 40 mmHg was set as the cut-off value for revascularization. Patients were grouped according to their postoperative SPPs, and amputation-free survival (AFS) was analyzed. An SPP of ≥ 40 mmHg was recovered in 75% of the patients, but no significant difference was found between this group and the group that did not reach 40 mmHg. On the other hand, the values increased by ≥ 20 mmHg from the preoperative values in 70% of the patients. This group had a significantly better AFS than the group that did not increase by 20 mmHg. Logistic regression analysis revealed that (1) a preoperative SPP of < 20 mmHg and (2) a high serum albumin level (> 3.0 g/dL) were significant factors in increasing SPP by 20 mmHg. These results showed that an increase in SPP of ≥ 20 mmHg after bypass surgery was associated with better limb prognosis.

Risk factors for wound complications and 30-day mortality after major lower limb amputations in patients with peripheral arterial disease

Purpose Risk factors for wound complications or 30-day mortality after major amputation in patients with peripheral arterial disease remain unclear. We investigated the outcomes of major amputation in patients with peripheral arterial disease. Methods Patients who underwent major amputation from 2008 to 2015 were retrospectively analyzed. The main outcome measures were risk factors for wound complications and 30-day mortality after major lower limb amputations. Major amputation was defined as above-knee amputation or below-knee amputation. Wound complications were defined as surgical site infection or wound dehiscence. Results In total, 106 consecutive patients underwent major amputation. The average age was 77.3 ± 11.2 years, 67.9% of patients had diabetes mellitus and 35.8% were undergoing hemodialysis. Patients who underwent primary amputation constituted 61.9% of the cohort, and the proportions of above-knee amputation and below-knee amputation were 66.9% and 33.1%, respectively. The wound complication rate was 13.3% overall, 10.3% in above-knee amputation, and 19.5% in below-knee amputation. Multivariate analysis showed that the risk factors for wound complications were female sex (hazard ratio, 4.66; 95% confidence interval, 1.40-17.3; P = 0.01) and below-knee amputation (hazard ratio, 4.36; 95% confidence interval, 1.20-17.6; P = 0.03). The 30-day mortality rate was 7.6%, pneumonia comprised the most frequent cause of 30-day mortality, followed by sepsis and cardiac death. Multivariate analysis showed that a low serum albumin concentration (hazard ratio, 3.87; 95% confidence interval, 1.12-16.3; P = 0.03) was a risk factor for 30-day mortality. Conclusions Female sex and below-knee amputation were risk factors for wound complications. A low serum albumin concentration was a risk factor for 30-day mortality after major amputation in Japanese patients with peripheral arterial disease.