|
|
|
Critical Limb Ischemia
|
Critical Limb Ischemia or CLI is a severe obstruction of the arteries which seriously decreases blood flow to the extremities and has progressed to the point of severe pain and even skin ulcers or sores.
Excimer Laser-Assisted Angioplasty in Severe Infrapopliteal Disease and CLI: The CIS "LACI Equivalent" Experience
Background: 12-month major amputation rates in ?true limb salvage? (Rutherford class 5-6 with established tissue loss) are reported as > 90% if nonrevascularable and 25% if revascularable. Twenty-four month mortality rates of > 40-50% are reported post amputation and < 50% will ambulate with a prosthesis. The encouraging Laser Angioplasty for Critical Limb Ischemia (LACI) 6-month limb salvage (LS) rate of 93% prompted adoption of excimer laser assisted angioplasty as one of our primary infrapopliteal treatments for ?TLS.? Methods: Between October 2001 ? October 2003, 62 patients (62 limbs) with Rutherford class 5-6 symptoms presented with severe infrapopliteal disease without single vessel ?straight line flow? to the foot. Seventy infrapopliteal arteries (IA) were treated, including posterior tibial 21/70 (30%), peroneal 16/70 (23%), anterior tibial 8/70 (11%), tibioperoneal trunk 14/70 (20%), and multiple 11/70 (16%). Thirty out of 62 (48%) and 22/62 (35%) required superficial femoral artery (SFA) and popliteal artery (PA) laser assisted angioplasty respectively. Five out of 62 (8%) patients required the ?step-by-step? technique. Results: Procedural success 59/62 (95.2%) with 9/62 (14.5%) requiring a secondary reintervention [bypass 2/62 (3.2%) and repeat laser angioplasty 7/62 (11.2%)] at mean 7 months (range 1-23 months). No periprocedural deaths or major surgical vascular complications. Four out of 62 (6.4%) had minor (< 3cm) hematomas. Six- and 12-month mortality rates were 3/37 (8.1%) and 4/24 (16.6%) respectively. Six- and 12-month LS rates were 34/37 (91.8%) and 20/24 (83.3%) respectively. Arteries stented included SFA 15/23 (65%), PA 4/12 (33%), and IA 7/62 (11.2%). Conclusion: Excimer laser assisted angioplasty is safe and effective in achieving 6- and 12-month LS in patients with severe infrapopliteal disease and advanced limb ischemia, therefore warranting further investigation.
|
Dethrombosis of the Lower Extremities: Pharmacologic and Mechanical Techniques
Thrombus is widely present in the peripheral vasculature and its frequency depends on the patient?s clinical presentation. Thrombus is almost always present in acute critical limb ischemia (ALI) and is commonly found in patients with subacute presentations, chronic critical limb ischemia (CLI) and chronic occlusions. The approach to dethrombosing a vessel depends on multiple factors, including the age of the thrombus, but generally requires a combination therapy with chemical lysis and rheolytic thrombectomy, such as the use of Power-Pulse Spray (P-PS) technique, or atherectomy with dethrombosing capability such as the excimer laser. Surgery or chemical lysis as stand alone therapies carry very high rates of amputation and mortality. The role of embolic protection devices is still unclear but is promising, as embolization of atherothrombus continues to be a frequent occurrence during peripheral angioplasty. In this review, algorithms to treat thrombus in peripheral arterial disease are suggested.
|
Critical Limb Ischemia ? A Contemporary Review of Reperfusion Techniques
A Contemporary Review of Reperfusion Techniques Original Contribution: Critical Limb Ischemia ? Endoscopic vein harvest for infrainguinal vascular reconstruction and limb salvage in chronic critical limb ischemia. Limb salvage following laser-assisted angioplasty for critical limb ischemia: Results of the LACI multicenter trial.
|
First Clinical Application of Absorbable Metal Stents in the Treatment of Critical Limb Ischemia: 12-month results
Background. Biodegradable stents are discussed as a means to combine a mechanical prevention of vessel recoil with various advantages on the long-term perspective compared to permanent implants, including the possibility for late outward vessel remodelling, and improved re-intervention options. In the current communication, clinical results of a first application of the recently developed balloon expandable absorbable metal stent (AMS) on magnesium alloy basis for treatment of infrapopliteal lesions in patients with critical limb ischemia (CLI) is presented. Methods. Twenty patients with symptomatic CLI yielding rest pain or tissue loss, caused by peripheral arterial disease (PAD) in below-the-knee region, were treated. The stenosed area was stented by maximally 2 AMS implants of 15 mm in length. Results. Angiographic procedural success was achieved in all 20 patients and post-procedural intravascular ultrasound (IVUS) control confirmed a homogenous and complete stent inflation in all patients. According to the Kaplan Meier method, 12-month survival primary patency, secondary patency and limb salvage rates were calculated to be 85.0%, 73.3%, 78.9% and 94.7%, respectively. Analysis of blood sample parameters, as well as histological analysis of an explanted specimen did not reveal any toxic behavior of the implanted alloy, and former stent material had almost completely disappeared. Conclusions. After 6 months, the resulting values for primary clinical patency and limb salvage indicate a promising performance in the treatment of below-the-knee lesions in CLI patients using AMS.
|
Improving Critical Limb Ischemia Outcomes with Novel Anticoagulation Strategies
Improving Critical Limb Ischemia Outcomes with Novel Anticoagulation Strategies Original Contribution: Improving Critical Limb Ischemia Outcomes with Novel Anticoagulation Strategies - David E. Allie, MD I believe the authors are on the right track by exploring more optimal anticoagulation and antiplatelet strategies in treating patients with peripheral arterial disease (PAD), and especially critical limb ischemia (CLI). A safety and feasibility report of combined direct thrombin and GP IIb/...
|
Combined Glycoprotein IIb/IIIa and Direct Thrombin Inhibition with Eptifibatide and Bivalirudin in the Interventional Treatment of Critical Limb Ischemia: A Safety and Feasibility Report
Objective: To evaluate the safety and feasibility of optimizing platelet inhibition and thrombin inhibition anticoagulation during peripheral vascular interventions (PVI) for patients with critical limb ischemia (CLI). Background: Glycoprotein (GP) IIb/IIIa inhibition combined with direct thrombin inhibition (DTI) with bivalirudin (Angiomax, The Medicines Company, Cambridge, Massachusetts) has shown decreased bleeding and ischemic complications in percutaneous coronary interventions (PCI). PCI benefits potentially applicable to CLI treatment include improved efficacy in diabetes, small complex vessels, microembolism reduction, and clinical outcomes. PVI cases have higher complications, more frequent reinterventions, and poorer outcomes than PCI. In CLI, a high incidence of diabetes, renal insufficiency, platelet dysfunction, hypercoagulability, inflammation, diffuse disease, and thrombus make DTI and eptifibatide (Integrilin, Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts) an attractive combination treatment. Methods: Between July 1, 2001 and August 1, 2004, 162 CLI patients underwent PVI utilizing bivalirudin (0.75mg/kg bolus with 1.75mg/kg/hr infusion) and eptifibatide (180 mcq/kg IV bolus and 2 mcq/kg/min for 12 hours) (group A) and were compared to a contemporary clinically matched heparin (UFH) control group without IIb/IIIa?s (group B). Results: The bivalirudin/eptifibatide group exhibited a statistically significant improvement (p = < 0.0001) in the variables of sheath removal time < 2 hours and length of stay < 72 hours vs. the UFH group. Trends towards significance were also exhibited in less major (3.7% vs. 5.5%) access site complications, 30-day thrombosis (1.8% vs. 4.3%), 6-month duplex ultrasound > 50% restenosis (17.3% vs. 24.7%), secondary reinterventions (11.7% vs. 16.0%), and 6-month limb salvage (92.6% vs. 87.6%, p = 0.1363). Conclusion: Combined eptifibatide and bivalirudin is a safe, feasible, and theoretically advantageous antiplate
|
Cyroplasty in the Treatment of Infrainguinal Arterial Disease: An Interview with James Joye, DO
Director, Cardiac Catherization Laboratory, El Camino Hospital; Director of Peripheral Vascular Interventions, The Cardiovascular Institute; Mountain View, CA
|
Endoscopic Vein Harvest for Infrainguinal Vascular Reconstruction and Limb Salvage in Chronic Critical Limb Ischemia
Endoscopic Vein Harvest for Infrainguinal Vascular Reconstruction and Limb Salvage in Chronic Critical Limb Ischemia Original Contribution: Endoscopic Vein Harvest for Infrainguinal Vascular Reconstruction and Limb Salvage in Chronic Critical Limb Ischemia - Michael C. Trotter, MD, Charles L. Kock, PA-C, Craig M. Walker, MD Introduction Autogenous greater saphenous vein is the preferred conduit for infrainguinal vascular reconstruction, and the most commonly utilized venous conduit for ...
|
Endovascular-First Strategy in Patients with Critical Limb Ischemia
Purpose: To assess outcomes of percutaneous infrainguinal endovascular interventions as the initial therapeutic modality in patients with critical limb ischemia (CLI). Materials and Methods: We performed a retrospective review of 33 consecutive interventions in 29 patients over a period of 24 months at a single center. Mean follow-up was 11.4 months. Technical success was defined as the ability to obtain in-line arterial flow into the foot with less than a 20% residual stenosis using percutaneous techniques. Limb salvage was defined as the ability to avoid major level amputation (below or above knee). Follow-up included clinical examination and noninvasive vascular evaluation by color-flow duplex ultrasound. Results: Thirty-three limbs were treated for disabling claudication (n = 2), rest pain (n = 10) or ulceration/gangrene (n = 21). All patients were male. Technical success was achieved in 31 limbs (93.9%). Intra-procedural complications included clinically significant embolization (n = 2, successfully treated by thrombolysis) and acute respiratory failure (n = 1). Post-procedure complications included puncture site pseudoaneurysm necessitating operative repair (n = 1), and acute renal failure (n = 1). Two patients died within 30 days post-procedure of cardiac related events. Of those patients who had a technically successful procedure, 5 underwent a major level amputation during the follow-up period. The limb salvage rate was 83.9%. Conclusions: An ?endovascular-first? strategy can yield good limb salvage rates in patients with advanced lower extremity limb ischemia.
|
Adjunctive Bioengineered Bi-layered Cell Therapy (Apligraf®) With Excimer Laser Revascularization Improves Wound Healing and Limb Salvage in Critical Limb Ischemia
Little data exists on wound care recommendations in the CLI patient with severe arterial insufficiency and few reports exist combining revascularization with the novel class of bioengineered skin substitutes in CLI. 26 Those clinical reports, the reported WH attributes of Apligraf, and our experience in treating CVI and DFU with Apligraf resulted in the adoption of Apligraf as our primary wound treatment in patients with leg and sternal wound complications after CABG,27 and now for ...
|
|
|
|
|
