Optimal tactics for surgical revascularisation in diabetic angiopathy of the lower limbs.

OBJECTIVE: Aim: This study aims to compare the efficacy of conservative treatment methods versus advanced surgical interventions, including revascularising automyelotransplantation and stem cell therapy, in improving vascular patency and the quality of life in patients with diabetic angiopathy. PATIENTS AND METHODS: Materials and Methods: The research analyzed 68 patients with angiopathies under medical supervision from January 2007 to December 2017 at the National Scientific Center of Surgery named after A.N. Syzganov. Participants, aged 4 to 49, were divided into two groups based on angiographic blood flow characteristics: one with accelerated and another with delayed blood flow. A comprehensive participant selection process was implemented to ensure a representative sample. Sensitivity analysis was conducted to validate the findings' robustness. RESULTS: Results: The main group demonstrated notable success in limb salvage, with 90.9% avoiding high limb amputation post-revascularising automyelotransplantation. Moreover, 16.7% of patients experienced healing of trophic ulcers and toe necrosis. The use of stem cells from adipose tissue and fetal tissue progenitor cells showed promising results in reducing pain and increasing pain-free walking distance, alongside the formation of collateral vascular networks. CONCLUSION: Conclusions: The study concludes that advanced surgical interventions and stem cell therapies significantly enhance treatment outcomes in patients with diabetic angiopathy compared to conventional conservative treatments. These findings highlight the potential of personalized and innovative approaches in managing vascular complications associated with diabetes, offering new avenues for reducing disability and improving patient quality of life. Future research should focus on further refining these therapeutic strategies and exploring their integration into clinical practice.

[Correlation and predictive value analysis of iliac artery calcification score and restenosis of lower extremity arteries after drug-coated balloon combined with stent implantation in patients with lower extremity atherosclerotic occlusive disease].

Objective: To analyze the correlation between iliac artery calcification score and restenosis of lower extremity arteries in patients with lower extremity atherosclerotic occlusive disease (LEASO) who underwent drug-coated balloon (DCB) combined with stenting, and to assess the predictive value. Methods: A total of 105 patients with LEASO at Nanjing Drum Tower Hospital, Nanjing University Medicine School, from January 2018 to June 2023 were retrospectively included, and the patients were divided into 2 groups according to whether restenosis of the original lower limb arteries had occurred during follow-up after DCB combined stent implantation: the restenosis group (n=64) and the patency group (n=41). The clinical information of the study subjects was collected through the electronic case system, and all patients underwent CTA examination of both lower limb arteries before the operation, and the calcification scores of common iliac arteries and external iliac arteries of patients' bilateral and stenotic sides were calculated according to the results of the CTA examination. The follow-up time [M (Q1, Q3)] was 9.15 (5.67, 15.60) months in the patency group and 9.20 (6.85, 19.65) months in the restenosis group. Univariate and multivariate logistic regression models were used to analyze the factors associated with restenosis after DCB combined with stent implantation in LEASO patients. The predictive value of iliac artery calcification score for postoperative restenosis was assessed using the receiver operating characteristic (ROC) curves. Results: There were 44 males and 20 females in the restenosis group, aged (73±9) years; 31 males and 10 females in the patency group, aged (73±10) years. Compared with the patency group, the restenosis group had higher neutrophil counts, platelet counts, lymphocyte counts, neutrophil-to-lymphocyte ratios (NLR), platelet-to-lymphocyte ratios (PLR), C-reactive protein, fibrinogen, stent lengths, stent numbers, common iliac artery calcification scores (bilateral and stenotic side), and external iliac artery calcification scores (bilateral and stenotic side) (all P<0.05). Multifactorial logistic regression analysis showed that higher external iliac artery calcification score on the stenotic side (OR=1.480, 95%CI: 1.130-1.939, P=0.004) was an associated factor for restenosis of the lower extremity arteries after DCB combined with stenting.ROC curve analysis showed that the cut-off value of the external iliac artery calcification score on the stenotic side was 5.5 score, the area under the curve (AUC) for predicting restenosis of lower extremity arteries after DCB combined stent implantation in LEASO patients was 0.818 (95%CI: 0.731-0.904, P<0.001), with a sensitivity of 85.4% and a specificity of 68.8%. Conclusions: An elevated calcification score of the external iliac artery on the stenotic side is a correlate of restenosis of the lower extremity arteries after DCB combined stenting in patients with LEASO. With a cut-off value of 5.5 points, its sensitivity for predicting restenosis of the lower extremity arteries after DCB combined stenting is 85.4%, and its specificity is 68.8%.

Predictive utility of a combination of the modified caprini risk assessment score and D-dimer for the evaluation and management of lower extremity venous thrombosis after lung cancer surgery.

OBJECTIVE: The objective of this study was to examine the utility of a combination of the modified Caprini score and D-dimer levels for the evaluation and management of lower extremity venous thrombosis following lung cancer surgery. The purpose was to offer insights for developing clinical intervention programs. METHODS: The study sample consisted of 224 patients who underwent surgery for lung cancer at the First Central Hospital of Baoding City. General patient data and D-dimer levels on the first day post-surgery were collected. The modified Caprini risk assessment score was calculated. All patients underwent ultrasonography of the lower limb veins before and after surgery to identify venous thrombosis in the lower limb veins. Differences in lower extremity venous thrombosis and D-dimer levels among patients in various modified Caprini score groups were compared and analyzed. RESULTS: Based on the modified Caprini risk assessment score, all patients were categorized into three groups: the low-risk, medium-risk, and high-risk groups. The groups did not differ significantly in terms of age, but the differences in the rates of lower extremity venous thrombosis in the low, intermediate, and high-risk Caprini risk groups (16.5%, 19.2%, and 37.1%, respectively) were statistically significant. Out of the total 224 patients, 47 (21%) were diagnosed with venous thromboembolisms post-surgery, and all of them had thrombosis of the intermuscular veins of the lower extremity. The difference in the modified Caprini risk assessment score between patients with and without lower extremity venous thrombosis was statistically significant (P = 0.035), as were the postoperative D-dimer levels (1.28 ± 1.64 vs. 2.69 ± 2.77, respectively; P < 0.05) between these two groups of patients. The modified Caprini risk assessment score showed an association with lower extremity venous thrombosis (r = 0.15, P = 0.56) with an area under the receiver operating characteristic curve (AUC) of 0.59. CONCLUSION: In this study, we found that combining the modified Caprini risk assessment score with D-dimer measurements enhanced the accuracy of assessing the severity of deep vein thrombosis (DVT). This combination can be beneficial in evaluating thrombosis risk post-lung cancer surgery and holds significant clinical utility.

Mesenchymal stromal cell therapy (REGENACIP®), a promising treatment option in chronic limb threatening ischemia - a narrative review.

Chronic Limb Threatening Ischemia (CLTI) is a challenging clinical problem associated with high morbidity and mortality. Endovascular interventions have been the cornerstone of treatment whenever possible. It is estimated that CLTI represents < 10% of all Peripheral Artery Disease patients, yet 50% of the patients end up either with a major amputation of the lower limbs or die of cardiovascular causes within one year period, especially in those with unsuccessful revascularization or "no-option" CLTI. Cell-based therapeutics, especially bone marrow-derived mesenchymal stromal cells have emerged as a potential, promising, and novel alternate therapeutic modality in the management of CLTI, bolstered with positive results in numerous research, including randomized and nonrandomized trials. REGENACIP® is one such BM-MSC therapy approved by Central Drugs Standard Control Organization in India for the management of "no-option" Atherosclerotic Peripheral Arterial disease / Buerger's disease patients with established critical limb ischemia in Rutherford Grade III-5 or III-6, not eligible for or have failed traditional revascularization treatment, with rest pain and / or ulcers in the affected limb. The current review aims to deliberate upon the various aspects of CLTI and clinical benefits of REGENACIP® therein.

Evaluation of the effects of thymoquinone on red blood cell deformability, morphology, and endothelial nitric oxide synthase (eNOS) synthesis in rat lower extremity ischemia-reperfusion injury.

BACKGROUND: Erythrocyte deformability refers to the ability of erythrocytes to bend and twist as they pass through capillaries, which is crucial for tissue perfusion. This study aims to investigate the effects of Thymoquinone treatment on erythrocyte deformability in rats subjected to lower extremity ischemia-reperfusion injury. METHODS: The study was conducted on Wistar albino rats weighing 400-450 g. The rats were randomly divided into five groups: the control group (C), in which no treatment was applied; the group that received dimethyl sulfoxide (DMSO) as a solvent; the group subjected to 90 minutes of ischemia followed by 90 minutes of reperfusion in the main femoral artery of the lower extremity (IR); the Thymoquinone control group (TQ-C), in which the effects of Thymoquinone alone were examined; and the group that received intraperitoneal Thymoquinone one hour before the ischemia-reperfusion procedure (IR+TQ). At the end of the procedure, intracardiac blood was collected from the rats, and May-Grunwald and Giemsa (MGG) staining, endothelial nitric oxide synthase (eNOS), and erythrocyte deformability indexes were measured. RESULTS: The study results showed significant differences. Erythrocyte deformability was statistically significantly improved in the group that received Thymoquinone before ischemia-reperfusion compared to the group subjected to ischemia-reperfusion only. Mor-phological changes in erythrocytes were also statistically significantly better in the IR+TQ group than in the IR group. Immunohisto-chemical eNOS staining revealed that eNOS activity in the IR group was lower than in the IR+TQ group. CONCLUSION: Our study demonstrates that Thymoquinone treatment administered before ischemia exerts protective effects against erythrocyte deformation and morphological deterioration by increasing eNOS activity.

Upper- vs Lower-Extremity Secondary Access During Transcatheter Aortic Valve Implantation: A Randomized Clinical Trial.

Importance: An upper-extremity approach for secondary access during transfemoral transcatheter aortic valve implantation (TAVI) may reduce clinically relevant secondary access site-related bleeding. Objective: To investigate the safety and efficacy of an upper-extremity approach compared with a lower-extremity approach in patients undergoing TAVI. Design, Setting, and Participants: The TAVI XS trial was a randomized clinical trial performed between November 28, 2022, and November 15, 2023, with a 30-day follow-up, in 4 TAVI centers in the Netherlands. Eligibility was determined first, and only those patients with severe aortic stenosis and no contraindication for upper- or lower-extremity secondary access were informed about the study and asked to participate. Intervention: Participants were randomized 1:1 between the upper-extremity approach (radial artery diagnostic access and upper-arm vein for temporary pacing lead placement) and lower-extremity approach (femoral artery diagnostic access and femoral vein for temporary pacing lead placement) for secondary access during TAVI. Main Outcomes and Measures: Primary end point was clinically relevant bleeding (Bleeding Academic Research Consortium type 2, 3, or 5) of the randomized secondary access. Secondary end points included any clinically relevant bleeding, time to mobilization, duration of hospitalization, secondary access failure, and procedural time. Results: Of a total of 324 eligible patients, 238 patients undergoing transfemoral TAVI (mean [SD] age, 79.4 [6.5] years; 150 male [63.0%]; median European System for Cardiac Operative Risk Evaluation II score, 2.2% [IQR, 1.5%-3.5%]) were included. The primary end point occurred in 5 of 119 patients (4.2%) in the upper-extremity group and 16 of 119 (13.4%) in the lower-extremity group (odds ratio [OR], 0.28 [95% CI, 0.10-0.80]; P = .01). Incidence of any clinically relevant bleeding was decreased in the upper-extremity group (25 of 119 [21.0%] vs 41 of 119 [34.5%] patients; OR, 0.51 [95% CI, 0.28-0.91]; P = .02). There was no difference in time to mobilization or duration of hospitalization. Secondary access failure (14 of 119 [11.8%] vs 1 of 119 [0.8%] patients; OR, 15.73 [95% CI, 2.03-121.69]; P = .001) and procedural time (60.0 [IQR, 39.0-88.0; 95% CI, 53.0-70.0] vs 48.0 [IQR, 34.0-64.0; 95% CI, 40.0-55.0] minutes; P = .002) were higher in the upper-extremity cohort. Conclusion and Relevance: In this randomized clinical trial of patients undergoing transfemoral TAVI, the upper-extremity approach for secondary access was associated with less clinically relevant access site-related bleeding compared with the conventional lower-extremity approach and should be considered to reduce periprocedural bleeding complications. Trial Registration: ClinicalTrials.gov Identifier: NCT05672823.

Clinical significance and underlying mechanism of long non-coding RNA SNHG12 in lower extremity deep venous thrombosis.

D-dimer is widely used in the diagnosis of deep vein thrombosis (DVT), but the specificity is low. The study examined the diagnostic value of long non-coding RNA (lncRNA) SNHG12 in DVT, and preliminarily discussed its mechanism. SNHG12 levels were detected in 200 elderly fracture patients via RT-qPCR, including 38 DVTs. Logistic regression analysis and receiver operating characteristic (ROC) curve were applied for diagnostic value evaluation. HUVECs were used for function study. Cell proliferation, migration, apoptosis, release of inflammatory cytokines, and adhesion factors were detected. Student's t test and one-way ANOVA were applied for data comparison between two or among three or more groups. Correlation analysis of indicators was completed via Pearson's correlation analysis. Bioinformatics analysis predicted the target miRNAs and genes of SNHG12, with GO and KEGG for the function enrichment. It was found that SNHG12 was at low expression in DVT patients, and negatively correlated with D-dimer concentration (r = -0.535). SNHG12 and D-dimer were independent influence factors related to the development of DVT. SNHG12 and D-dimer combination had the best performance in DVT diagnosis. In HUVECs, SNHG12 promoted cell proliferation and migration and restricted the release of inflammatory cytokines and adhesion factors, but these influences were counteracted by miR-424-5p. A total of 208 overlapping target genes of miR-424-5p were identified, and their function was enriched in cellular cycle and senescence. PI3K-Akt signaling pathway was the most significant pathway based on KEGG results. In conclusion, SNHG12 had good diagnostic potential for DVT combined with D-dimer. SNHG12 maintains vascular endothelial cell function by acting as a competitive endogenous RNA (ceRNA) for miR-424-5p.

Changes in Blood Volume and Oxygenation in Lower Limb Tissue in Patients Maintaining the Lithotomy Position Under General Anaesthesia.

To investigate the effect of the lithotomy position on lower limb circulation under general anaesthesia, near-infrared spectroscopy (NIRS) was used to measure changes in blood volume and oxygenation in thigh tissue in patients (n = 35) under general anaesthesia in the lithotomy position. The NIRS measurement items, including total haemoglobin concentration (total-Hb), tissue haemoglobin index (nTHI), and tissue oxygenation index (TOI) in the thigh, were recorded for 60 min, while the patients were in the lithotomy position. The correlation between changes in each measurement item and patient characteristics, elevation of the lower extremities, and cardiorespiratory indices were evaluated. Data obtained from 24 patients were analysed. The median values (quartile deviation) of changes in total-Hb, nTHI, and TOI during the 60-min period from baseline were + 3.09 (1.99) µmol/L, +0.08 (0.03) a.u., and + 2.25 (1.75) %, respectively, all of which were significantly increased (p < 0.05). Regression analysis showed that no factor was significantly associated with the increase in any measurement item. The present results suggest that circulation in thigh tissue tends to shift towards hyperaemia during 60 min of general anaesthesia in the lithotomy position, regardless of patient background factors or changes in cardiorespiratory conditions.

Optimizing Lower Extremity Local Flap Reconstruction in Peripheral Vascular Disease.

BACKGROUND: Local flaps remain a valuable reconstructive tool as a means for limb salvage for patients with advanced arterial disease. Our single-center, retrospective cohort study aims to compare the outcomes of different patterns of blood flow affected by vascular disease to pedicles in local flap reconstruction of the foot and ankle. METHODS: A retrospective review of 92 patients and 103 flaps was performed. On angiograms, pattern of blood flow to the flap pedicle was determined to be direct inline flow (DF) or indirect flow (IF). Patterns of IF were either by arterial-arterial connections (AC) or unnamed randomized collaterals (RC). Primary outcomes were immediate flap success and limb salvage. Comparative analyses were performed using the χ2 and Fisher tests for categorical variables. RESULTS: Among all flaps, 73.8% (n = 76/103) had DF and 26.2% (n = 27/103) had IF. Both groups experienced similar rates of immediate flap success (DF = 97.3% vs IF = 92.6%, P = 0.281) and limb salvage (DF = 75.% vs IF = 66.7%, P = 0.403). However, the rate of contralateral amputation was significantly higher in the IF group (26.9% vs 5.3%, P = 0.006). When comparing the 3 distinct patterns of blood flow (DF vs AC vs RC), pedicled flaps were more commonly supplied by DF and AC, while random pattern flaps were more commonly supplied by RC (P = 0.042). CONCLUSIONS: Alternative routes of revascularization can maintain local flap viability and achieve similar rates of limb salvage but risks contralateral amputation. We found that pedicled and local muscle flaps require inline blood flow or blood supply by ACs. Meanwhile, random pattern flap can be supported by random collaterals.

Using Wavelet Analysis of Blood Flow Oscillations to Investigate Differences in Skin Blood Flow Regulations Between the Upper and Lower Limbs.

BACKGROUND: The objective of this study was to investigate the differences in skin blood flow regulations between the upper and lower limbs in healthy adults using wavelet analysis of skin blood oscillations. To the best of our knowledge, this is the first study investigating the dominant skin blood flow control of the upper and lower limbs in healthy adults. METHODS: Skin blood flow of the forearm and leg was simultaneously measured by laser Doppler flowmetry (LDF) in 17 healthy adults. Skin blood flow oscillations were analyzed using wavelet analysis to assess the dominant control among the metabolic endothelial (0.0095-0.02 Hz), neurogenic (0.02-0.05 Hz), myogenic (0.05-0.15 Hz), respiratory (0.15-0.4 Hz), and cardiac (0.4-2 Hz) origins. RESULTS: Skin blood flow in the leg (11.13 ± 4.90 perfusion unit) was significantly higher than in the forearm (6.90 ± 2.50 perfusion unit, p < 0.001). The metabolic endothelial control is more dominant in the forearm (1.19 ±0.51 au) compared to the leg (0.73 ± 0.41 au, p < 0.01). The myogenic control is more dominant in the leg (1.18 ± 0.28 au) compared to the forearm (0.96±0.18 au, p < 0.05). CONCLUSION: Through wavelet analysis of skin blood flow oscillations, the results indicate that metabolic endothelial control is more dominant in the forearm (upper limbs) and myogenic control is more dominant in the leg (lower limbs).

Impact of lower limb movements on iliac vein stenting in iliac vein compression syndrome patients: insights from computational modeling.

Purpose: Iliac vein stenting is the primary treatment for patients with iliac vein compression syndrome (IVCS). However, post-stent placement, patients often experience in-stent restenosis and thrombosis. Despite this, the role of lower limb movements in the functioning of stents and veins in IVCS patients remains unclear. This study aimed to address this knowledge gap by developing a computational model using medical imaging techniques to simulate IVCS after stent placement. Methods: This research used a patient-specific model to analyze the effects of lower extremity exercises on hemodynamics post-stent placement. We conducted a comprehensive analysis to evaluate the impact of specific lower limb movements, including hip flexion, ankle movement and pneumatic compression on the hemo-dynamic characteristics within the treated vein. The analysis assessed parameters such as wall shear stress (WSS), oscillatory shear index (OSI), and residence time (RRT). Results: The results demonstrated that hip flexion significantly disrupts blood flow dynamics at the iliac vein bifurcation after stenting. Bilateral and left hip flexion were associated with pronounced regions of low WSS and high OSI at the iliac-vena junction and the stent segment. Additionally, active ankle exercise (AAE) and intermittent pump compression (IPC) therapy were found to enhance the occurrence of low WSS regions along the venous wall, potentially reducing the risk of thrombosis post-stent placement. Consequently, both active joint movements (hip and ankle) and passive movements have the potential to influence the local blood flow environment within the iliac vein after stenting. Conclusions: The exploration of the impact of lower limb movements on hemodynamics provides valuable insights for mitigating adverse effects associated with lower limb movements post iliac-stenting. Bilateral and left hip flexions negatively impacted blood flow, increasing thrombosis risk. However, active ankle exercise and intermittent pump compression therapies effectively improve the patency.

Comparison of the protective effects of vanillic and rosmarinic acid on cardiac tissue: Lower limb ischemia-reperfusion model in rats.

BACKGROUND: Ischemia/reperfusion injury is one of the most challenging postoperative situations in vascular surgery, both in elective procedures with prolonged clamping time and in delayed emergency cases with vascular occlusion. The inflammatory response that develops during ischemia and the oxygen-free radicals that proliferate during reperfusion have detrimental effects on the brain, heart, and kidneys. In this study, we aimed to compare the effects of vanillic and rosmarinic acid in preventing ischemia/reperfusion injury in a lower limb ischemia-reperfusion model in rats. METHODS: Thirty-two female Sprague-Dawley rats weighing 185-240 g were randomly divided into four groups of eight animals each. Group 1 was designated as the control, Group 2 as ischemia/reperfusion (I/R), Group 3 as ischemia/reperfusion + vanillic acid (I/R + VA), and Group 4 as ischemia/reperfusion + rosmarinic acid (I/R + RA). In all groups except the control, the infrarenal abdominal aorta was clamped, and 60 minutes of ischemia followed by 120 minutes of reperfusion was performed. Vanillic acid was administered intra-abdominally 15 minutes before the start of reperfusion in Group 3, and rosmarinic acid in Group 4. At the end of the reperfusion phase, blood samples and hearts were collected, and the rats were euthanized. Histopathologically, myofibrillar edema, myocytolysis, focal hemorrhages, and infiltration of polymorphonuclear leukocytes (PMNL) in cardiac tissue were examined. Total antioxidant capacity (TAC), total oxidative status (TOS), oxidative stress index (OSI), 8-OH-deoxyguanosine, lactonase, and arylesterase activity were measured in blood samples. RESULTS: Myofibrillar edema was most pronounced in the I/R group and less pronounced in the I/R + VA and I/R + RA groups (p=0.005 and p=0.066, respectively). There was no difference between the ischemia/reperfusion groups regarding myocytolysis, focal hemorrhage, and PMNL infiltration (p>0.99). Among all groups, TOS and OSI were lowest in the control group, while TAC was highest. TAC was similar in the I/R + VA and I/R + RA groups but was significantly higher in these two groups than in the I/R group. The lactonase activity in the I/R + VA group was similar to that in the control group but was significantly higher compared to the I/R and I/R + RA groups. CONCLUSION: Our study shows that vanillic and rosmarinic acids reduce myofibrillar edema in the heart after lower limb ischemia and increase TAC. However, vanillic acid increases the activity of lactonase, an enzyme known for its antioxidant effect, more than rosmarinic acid.

Risk factors for deep vein thrombosis of the lower extremity after total hip arthroplasty.

OBJECTIVE: To investigate the risk factors for deep vein thrombosis (DVT) following total hip arthroplasty (THA). METHODS: Patients who underwent THA in the Department of Joint Surgery at the Sixth Affiliated Hospital of Xinjiang Medical University from September 2020 to December 2022 were retrospectively selected based on inclusion criteria. They were divided into the DVT group (n = 65) and the non-DVT group (n = 397) according to the occurrence of postoperative DVT. The following variables were reviewed for both groups: age, sex, Body Mass Index (BMI), affected limb, previous history (smoking and drinking), diabetes, hypertension, operation time, total cholesterol, triglycerides, fibrinogen, hemoglobin, albumin, platelets, D-dimer, International Normalized Ratio (INR), and fibrin degradation products. Univariate analysis was conducted on these factors, and those with statistical significance were further analyzed using a binary logistic regression model to assess their correlation with DVT after THA. RESULTS: A total of 462 patients were included in the study, with the DVT group representing approximately 14% and the non-DVT group approximately 86%. The DVT group had an average age of 67.27 ± 4.10 years, while the non-DVT group had an average age of 66.72 ± 8.69 years. Univariate analysis revealed significant differences in diabetes mellitus, preoperative fibrinogen, preoperative D-dimer, preoperative INR, and preoperative and postoperative fibrin degradation products between the DVT and non-DVT groups. Binary logistic regression analysis identified diabetes mellitus, elevated preoperative fibrinogen, preoperative D-dimer, and preoperative INR (p < 0.05) as risk factors for DVT after THA. CONCLUSION: This study found that diabetes mellitus, elevated preoperative fibrinogen, preoperative D-dimer, and preoperative INR are independent risk factors for DVT following THA. Surgeons should thoroughly assess these risk factors, implement timely and effective interventions, and guide patients to engage in functional exercises as early as possible to reduce the incidence of DVT, thereby improving the outcomes of THA and improving patient quality of life.

Exploring the causal relationship between plasma lipids and varicose veins of lower extremity: A comprehensive two-sample Mendelian randomization study.

Varicose veins of the lower extremities (VVs) is a common chronic vascular disease, with high prevalence rates in some countries; however, their pathogenesis remains unclear. Some studies have identified associations between changes in specific plasma lipid molecules, such as phosphatidylethanolamine (PE), phosphatidylcholine (PC), and sphingomyelin (SM), and the onset of VVs, but due to confounders and reverse causality, the causal relationship remains unclear. Meanwhile, studies on the potential link between other plasma lipids beyond PE, PC, and SM and the risk of VVs in the lower extremities are lacking. This study aimed to explore the potential causal relationship between VVs and plasma lipid levels to provide theoretical insights into the interrelation of plasma lipids and VVs in their occurrence and progression. We conducted a two-sample Mendelian randomization (MR) analysis to assess the potential connection between genetically predicted levels of individual plasma lipids and the risk of developing VVs. We utilized data from a large-scale genome-wide association study involving 7174 Finnish individuals for 179 plasma lipidomes along with VVs genome-wide association study data from 408,455 UK individuals. MR analysis employed methods, such as inverse-variance weighting, weighted median, Bayesian Weighted Mendelian Randomization, and MR-Egger regression. The inverse-variance weighting method was primarily used to assess causality. The validity of the results was demonstrated through sensitivity analysis. In total, 12 lipids were found to have their plasma levels associated with an increased risk of VVs. This includes 3 types of PE, 7 types of PC, and 2 types of phosphatidylinositol. However, no significant causal relationship was found between the plasma levels of 11 types of SM and VVs. These results support the existence of a potential causal relationship between specific types of lipid levels and the risk of VVs, which can provide clues for further studies on biological mechanisms and the exploration of potential therapeutic targets.

Update on the diagnosis of recurrence of lower limb deep vein thrombosis. A Consensus statement of the French Society for Vascular Medicine (SFMV).

An accurate diagnosis of lower limb deep vein thrombosis (DVT) recurrence is mandatory. The diagnosis is difficult and has not been well investigated. Our objective was to define the role of clinical probability assessment, D-dimer assay, venous ultrasound and other imaging methods in the diagnosis of this condition based on a review of published data. Our review did not find any clinical prediction rule (CPR) specific to the diagnosis of DVT recurrence. D-dimer assays have not been sufficiently validated or proved effective either alone or when combined with the assessment of clinical probability or with ultrasound. The only validated ultrasound criteria are a new non-compressible vein segment and a≥2mm or>4mm increase in diameter of the common femoral or popliteal vein under compression in the transverse plane between two examinations. Limitations of these criteria include poor inter-observer agreement, non-availability of previous ultrasound reports and measurements, a high percentage of non-diagnostic ultrasound results, lack of power in diagnostic accuracy and diagnostic management studies, and lack of external validation. The analysis of venous obstruction, thrombus appearance, vein diameter and blood flow based on colour Doppler ultrasound criteria has not yet been validated in studies. Magnetic resonance direct thrombus imaging (MRDTI) is a new promising diagnostic imaging method, but is hardly accessible, costly and needs large scale validation studies. Based on this review, an update of the guidance for clinical practice is proposed for the diagnostic management of patients with clinically suspected lower limb DVT recurrence.

Preoperative Vascular Imaging in Lower Extremity Free Flap Reconstruction: Comparison Between Imaging Modalities.

BACKGROUND: Adequate vascular anatomy and perfusion status are essential for successful lower extremity free tissue transfer. Computed tomography angiography (CTA) is widely available, minimally invasive, and enables visualization of soft tissues and bones. Angiography permits temporal evaluation of flow, identifies potential needs for concurrent endovascular interventions, and enhances visibility in the setting of hardware. Despite widespread availability of these imaging modalities, no standardized algorithm for preoperative imaging prior to lower extremity free flap reconstruction exists. METHODS: Current Procedural Terminology (CPT) codes identified patients undergoing free flap reconstruction of the lower extremity over an 18-year period (2002-2020). Electronic medical records were reviewed for patient, treatment, and imaging characteristics, and pre- and post-imaging laboratory values. Outcomes included imaging findings and related complications and surgical outcomes. RESULTS: In total, 405 patients were identified, with 59% (n = 238) undergoing preoperative imaging with angiography, 10% (n = 42) with CTA, 7.2% (n = 29) with both imaging modalities, and 24% (n = 96) with neither performed. Forty percent (122 of 309) of patients who underwent preoperative imaging had less than 3-vessel runoff. Four patients developed contrast-induced nephropathy (CIN) after angiography only and one after having both CTA and angiography. Vessel runoff on CTA and angiography demonstrated moderate correlation. CONCLUSION: Most patients undergoing lower extremity free tissue transfer underwent preoperative imaging with angiography and/or CTA, 40% of which had less than 3-vessel runoff. Both angiography and CTA had low complication rates, with no statistically significant risk factors identified. Specifically, the incidence of CIN was not found to be significant using either modality. We discuss our institutional algorithm to aid in decision-making for preoperative imaging prior to lower extremity free flap reconstruction. Specifically, we recommend angiography for patients with peripheral vascular disease, internal hardware, or distal defects secondary to trauma.

[The application of cell products for the treatment of critical limb ischemia in patients with diabetes mellitus: a review of the literature].

The number of patients with diabetes mellitus (DM) has been progressively increasing worldwide over the past decades, and many international organizations consider DM as a public health emergency of the 21st century.Critical limb ischemia (CLI) is the most severe stage of peripheral arterial disease (PAD) in DM and is characterized by a high risk of limb loss without revascularization. Traditional treatment tactics include open and endovascular revascularization surgical techniques. However, in patients not eligible for revascularization and in cases where performed surgical treatment performed has been ineffective, there are almost no therapeutic alternatives, often leading to amputations and death. As of today, one of the newest non-surgical treatment options is cell therapy. Among different cells, mesenchymal stromal cells (MSCs) are potentially one of the most prospective for use in this patient population.This article provides an overview of clinical trials using cell therapy in patients with CLI.To analyze publications, electronic databases PubMed, SCOPUS, ClinicalTrials, and ScienceDirect were searched to identify published data from clinical trials, research studies, and review articles on cell therapy for critical lower extremity ischemia. After the search, 489 results were received.As a result of systematic selection, 22 clinical trials were analyzed.According to the analyzed literature data, the use of cell products in this category of patients is effective and safe. Cell therapy can stimulate the formation of new vessels and enhances collateral circulation; it is also reported improved distal perfusion, increased pain-free walking distance, decreased amputation rates, and increased survival rates.Nevertheless, further study of the potential use of this category of drugs is needed.

A case report of bilateral persistent sciatic artery: Bilateral aneurysm with thromboembolism of the right lower extremity.

RATIONALE: Persistent sciatic artery (PSA) is a rare congenital vascular anomaly. The sciatic artery, which normally regresses to become the inferior gluteal artery during fetal development, persists as a direct branch of the internal iliac artery. PATIENT CONCERN: We report a 78-year-old female who was admitted due to sudden pain, numbness, and loss of sensation in the right lower limb. DIAGNOSES: Acute thromboembolism in the right leg, bilateral PSA, and bilateral aneurysm. INTERVENTIONS: After the super-selective embolization, lower limb arterial thrombolysis treatment was performed. After symptom relief, a computed tomography angiography was conducted to clarify the vascular variations. OUTCOMES: After relief of lower limb embolism, long-term antiplatelet therapy was administered. LESSONS: When performing an ultrasound examination of PSA, careful identification of the arterial anatomy, evaluation of blood flow, assessment of surrounding structures, comparison between sides, and correlation with clinical symptoms are crucial to accurately diagnose this rare vascular anomaly.

Antithrombotic Therapy in Patients Undergoing Peripheral Artery Interventions.

Patients with peripheral artery disease (PAD) who undergo lower extremity revascularization (LER) are at high risk for cardiovascular and limb-related ischemic events. The role of antithrombotic therapy is to prevent thrombotic complications, but this requires balancing increased risk of bleeding events. The dual pathway inhibition (DPI) strategy including aspirin and low-dose rivaroxaban after LER has been shown to reduce major adverse cardiovascular and limb-related events without significant differences in major bleeding. There is now a need to implement the broad adoption of DPI therapy in PAD patients who have undergone LER in routine practice.

[Clinical application of iliac myocutaneous flap pedicled with deep circumflex iliac artery in repair of complex defect of lower limb with cavity].

Objective: To explore the effectiveness of iliac myocutaneous flap pedicled with deep circumflex iliac artery (DCIA) on the repair of lower limb composite defect wounds with cavity. Methods: A retrospective analysis of 7 patients with lower limb composite defect wounds treated between March 2017 and September 2020 was conducted, including 4 males and 3 females, aged 24-58 years, with a median age of 37 years. The causes of injury were machine twisting injury in 2 cases, fall from height injury in 2 cases, and traffic accident injury in 3 cases. According to Gustilo-Anderson classification, there were 1 case of type Ⅲa, 4 cases of type Ⅲb, and 2 cases of type Ⅲc (combined with anterior tibial artery rupture); according to AO/Orthopaedic Trauma Association (AO/OTA) classification, there were 2 cases of type 42-C3, 2 cases of type 43-A2, and 3 cases of type 43-B1. The time from injury to admission ranged from 2 to 10 hours, with an average of 6 hours. Tibial bone defect and surrounding soft tissue defect with deep cavity were left after primary emergency debridement. In the second stage, according to the characteristics of the wound, the three-dimensional repair of the composite defect was designed with DCIA embedded iliac myocutaneous flap. The size of the iliac flap was 2.0 cm×2.0 cm×2.0 cm to 7.0 cm×3.0 cm×2.5 cm, and the size of the flap was 12.0 cm×8.0 cm to 21.0 cm×13.0 cm. The internal oblique muscle flap was harvested in size of 3.0 cm×2.0 cm×2.0 cm to 5.5 cm×4.0 cm×4.0 cm. The donor site was primarily closed. Results: All the flaps survived after operation, except for 1 case of partial necrosis of the flap edge, which healed after secondary skin grafting, and the donor and recipient wounds healed by first intention. All patients were followed up 16-24 months, with an average of 18 months. The broken end of the bone defect healed well, and the healing time was 8-10 months, with an average of 7.3 months. At last follow-up, the shape of the flap was satisfactory, the texture was soft, and there was no abnormal hair growth, pigmentation, and so on. Only linear scar was left in the donor site, and no complication such as abdominal hernia occurred. According to Paley fracture healing scoring system, bone healing was rated as excellent in 5 cases and good in 2 cases. The limb function was satisfactory, and full weight bearing was achieved at 12-16 months after operation. According to the lower extremity functional scale (LEFS), 6 cases were excellent and 1 case was good. Conclusion: The iliac myocutaneous flap pedicled with DCIA is flexible in design and highly free in tissue composition, which can repair the composite defect wound of lower limbs with deep cavity in a three-dimensional way, and repair the limb shape and reconstruct weight-bearing function to the greatest extent.