Critical and subcritical ischaemia

Wolfe, John H.; Wyatt, Michael G.

doi:10.1016/s1078-5884(97)80067-6

Cited by 160 publications

(71 citation statements)

References 13 publications

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“…CLI has a 25% mortality rate at 12 months, and nearly half of all untreated CLI patients will progress to major amputation within this timeframe. 68,69 Major amputation of a limb (ie, above the ankle) is associated with loss of independence, diminished quality of life, and poor overall survival. 70 If the extent of the limb amputation can be minimized to only a minor amputation (defined as below the ankle including a digital, ray, or transmetatarsal amputation), limb function can be preserved without the need for prosthesis.…”

Section: Critical Limb Ischemiamentioning

confidence: 99%

Endovascular Intervention for Peripheral Artery Disease

Thukkani

Kinlay

2015

Circulation Research

220

158

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Advances in endovascular therapies during the past decade have broadened the options for treating peripheral vascular disease percutaneously. Endovascular treatment offers a lower risk alternative to open surgery in many patients with multiple comorbidities. Noninvasive physiological tests and arterial imaging precede an endovascular intervention and help localize the disease and plan the procedure. The timing and need for revascularization are broadly related to the 3 main clinical presentations of claudication, critical limb ischemia, and acute limb ischemia. Many patients with claudication can be treated by exercise and medical therapy. Endovascular procedures are considered when these fail to improve quality of life and function. In contrast, critical limb ischemia and acute limb ischemia threaten the limb and require more urgent revascularization. In general, endovascular treatments have greater long-term durability for aortoiliac disease than femoral popliteal disease. Infrapopliteal revascularization is generally reserved for critical and acute limb ischemia. Balloon angioplasty and stenting are the mainstays of endovascular therapy. New well-tested innovations include drug-eluting stents and drug-coated balloons. Adjunctive devices for crossing chronic total occlusions or debulking plaque with atherectomy are less rigorously studied and have niche roles. Patients receiving endovascular procedures need a structured surveillance plan for follow-up care. This includes intensive treatment of cardiovascular risk factors to prevent myocardial infarction and stroke, which are the main causes of death. Limb surveillance aims to identify restenosis and new disease beyond the intervened segments, both of which may jeopardize patency and lead to recurrent symptoms, functional impairment, or a threatened limb.

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Section: Critical Limb Ischemiamentioning

confidence: 99%

Endovascular Intervention for Peripheral Artery Disease

Thukkani

Kinlay

2015

Circulation Research

220

158

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“…1 Despite recent advances in interventional or surgical techniques, prognosis and amputationfree survival remains poor because a large number of patients with critical limb ischemia are not candidates for such revascularization procedures. 1,2 At present, no effective pharmacological therapy is available. 3 …”

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confidence: 99%

Intraarterial Administration of Bone Marrow Mononuclear Cells in Patients With Critical Limb Ischemia

Walter

Krankenberg

Balzer

et al. 2011

Circ: Cardiovascular Interventions

239

181

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Background— Critical limb ischemia due to peripheral arterial occlusive disease is associated with a severely increased morbidity and mortality. There is no effective pharmacological therapy available. Injection of autologous bone marrow-derived mononuclear cells (BM-MNC) is a promising therapeutic option in patients with critical limb ischemia, but double-blind, randomized trials are lacking. Methods and Results— Forty patients with critical limb ischemia were included in a multicenter, phase II, double-blind, randomized-start trial to receive either intraarterial administration of BM-MNC or placebo followed by active treatment with BM-MNC (open label) after 3 months. Intraarterial administration of BM-MNC did not significantly increase ankle-brachial index and, thus, the trial missed its primary end point. However, cell therapy was associated with significantly improved ulcer healing (ulcer area, 3.2±4.7 cm 2 to 1.89±3.5 cm 2 [ P =0.014] versus placebo, 2.92±3.5 cm 2 to 2.89±4.1 cm 2 [ P =0.5]) and reduced rest pain (5.2±1.8 to 2.2±1.3 [ P =0.009] versus placebo, 4.5±2.4 to 3.9±2.6 [ P =0.3]) within 3 months. Limb salvage and amputation-free survival rates did not differ between the groups. Repeated BM-MNC administration and higher BM-MNC numbers and functionality were the only independent predictors of improved ulcer healing. Ulcer healing induced by repeated BM-MNC administration significantly correlated with limb salvage ( r =0.8; P <0.001). Conclusions— Intraarterial administration of BM-MNC is safe and feasible and accelerates wound healing in patients without extensive gangrene and impending amputation. These exploratory findings of this pilot trial need to be confirmed in a larger randomized trial in patients with critical limb ischemia and stable ulcers. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00282646.

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“…Medically treated CLI patients undergo limb amputation in 95% of cases within a year, and surgical bypass treatment often fails because they are referred to the surgeon in a late phase of their pathology when coexisting diseases, mainly cardiovascular or renal, and vessel occlusions require difficult surgical management [2].…”

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confidence: 99%

The “Safari” Technique to Perform Difficult Subintimal Infragenicular Vessels

Gandini

Pipitone

Stefanini

et al. 2007

Cardiovasc Intervent Radiol

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The purpose of this study was to describe the efficacy of planned combined subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) to obtain the precise recanalization of the patent portion of a distal runoff vessel in critical limb ischemia (CLI) patients presenting long occlusions involving the popliteal trifurcation. Four patients at risk of limb loss due to long occlusions involving the leg vessel tree and not suitable for a surgical bypass were treated by the subintimal antegrade and retrograde (posterior tibial or anterior tibial artery) approach. The patent portion of the runoff vessel was previously assessed by magnetic resonance angiography (MRA) and directly punctured under Doppler ultrasound (US) guidance. A subintimal channel rendezvous was performed to allow snaring of the guidewires. Subsequently, a balloon dilatation was performed without stent deployment. All patients were successfully recanalized and had complete healing of the limb lesions. At the 12-month follow-up all patients showed clinical improvement with no major complications related to the procedure. This combined antegrade and retrograde subintimal approach is currently an excellent endovascular option in patients with long occlusions extending onto the leg vessels trifurcation and at risk of limb loss.

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Critical and subcritical ischaemia

Cited by 160 publications

References 13 publications

Endovascular Intervention for Peripheral Artery Disease

Endovascular Intervention for Peripheral Artery Disease

Intraarterial Administration of Bone Marrow Mononuclear Cells in Patients With Critical Limb Ischemia

The “Safari” Technique to Perform Difficult Subintimal Infragenicular Vessels

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