Intravascular Ultrasound-Guided Revascularization of Chronic Juxtarenal Aortoiliac Occlusion.

Chronic juxtarenal aortoiliac occlusion (JRO) represents the most severe form of aortoiliac occlusive disease, classified under Trans-Atlantic Inter-Society Consensus (TASC II) as a TASC II D lesion with surgical treatment as the main recommendation. Although endovascular revascularization of other TASC II D lesions are routinely performed, JRO is often considered a contraindication for endovascular treatment due to the extensive nature, extending from the level of the renal arteries down to the iliac arteries. We hereby illustrate an intravascular ultrasound-guided re-entry based technique to facilitate endovascular reconstruction of a JRO. A 58-year-old man with JRO presented with an infected nonhealing forefoot ulcer. A transradial pigtail catheter was positioned at the level of the occlusion as an imaging catheter and landmark for re-entry. Subintimal wiring was performed through bilateral groin accesses to the level of the pigtail catheter. Intravascular-guided re-entry catheter was used to identify the true lumen guide firing of the needle catheter, allowing passage for a guidewire into the true lumen of the suprarenal aorta. The intimal fenestration was dilated using a 4-mm angioplasty balloon which allowed passage of the contralateral guidewire. Kissing stent grafts were deployed bilaterally, extending from the level of the infrarenal aorta down to the level of the distal external iliac arteries in overlapping fashion. Completion angiography showed brisk flow from the aorta through the stented portion into the femoral arteries. The patient underwent forefoot amputation 2 days later with successful wound healing and limb salvage at 6 months.

Evaluation of Peripheral Perfusion in the Presence of Plantar Heel Ulcerations Status After Transmetatarsal Amputation With Achilles Tendon Lengthening.

The objective of this study is to evaluate peripheral perfusion in patients who developed plantar heel ulcerations status after transmetatarsal amputation and Achilles tendon lengthening. Peripheral perfusion was assessed via contrast angiography of the 3 crural vessels (anterior tibial, posterior tibial, and peroneal arteries), as well as intact heel blush and plantar arch. The secondary objective is to correlate the arterial flow to time to develop heel ulceration and incidence of minor and major lower-extremity amputation. Diagnostic angiography without intervention was performed on 40% of patients (4/10), and interventional angiography was performed on 60% of patients (6/10). In-line flow was present in 0% (0/10) of the peroneal arteries, 60% (6/10) of the anterior tibial arteries, and 70% (7/10) of the posterior tibial arteries. Heel angiographic contrast blush was present in 60% (6/10), and intact plantar arch was present in 60% (6/10). Patients developed heel ulcerations at a mean time of 7.6 months (range 0.7 to 41.2) postoperatively. The incidence of major lower-extremity amputation was 30% (3/10), with a mean time of 5.2 months (range 3.5 to 8.3) from time of heel wound development. No amputation occurred in 6 patients (60%). Among them, intact anterior tibial inline arterial flow was present in 3, intact posterior tibial inline arterial flow was present in 6, and heel blush was present in 5. Our results demonstrate that an open calcaneal branch of the posterior tibial artery is sufficient to heal plantar heel ulcerations to potentially increase rates of limb salvage.

Competing Risk Analysis of the Impact of Pedal Arch Status and Angiosome-Targeted Revascularization in Chronic Limb-Threatening Ischemia.

BACKGROUND: In the context of chronic limb-threatening ischemia, the prognostic impact of angiosome-targeted revascularization and of the status of the pedal arch are debated. METHODS: This series includes 580 patients who underwent endovascular (n = 407) and surgical revascularization (n = 173) of the infrapopliteal arteries for chronic limb-threatening ischemia associated with foot ulcer or gangrene. The risk of major amputation after infrapopliteal revascularization was assessed by a competing risk approach. A subanalysis was made separately for patients who underwent endovascular or open surgical revascularization. RESULTS: At 2 years, survival was 65.1% and leg salvage was 76.1%. Multivariable competing risk analysis showed that C-reactive protein ≥10 mg/dL, diabetes, rheumatoid arthritis, increased number of affected angiosomes, and the incomplete or total absence of pedal arch compared with complete pedal arch (CPA) were independent predictors of major amputation after infrapopliteal revascularization. Multivariable analysis showed increasing risk estimates of major amputation in patients with incomplete (subdistribution hazard ratio [SHR], 2.131; 95% confidence interval [95% CI], 1.282-3.543) and no visualized pedal arch (SHR, 3.022; 95% CI, 1.553-5.883) compared with CPA. Pedal arch was important even if angiosome-targeted revascularization was achieved: Angiosome-directed revascularization in presence of CPA had a lower risk of major amputation (adjusted SHR, 0.463; 95% CI, 0.240-0.894) compared with angiosome-directed revascularization without CPA. In the subanalysis, among patients who underwent endovascular revascularization, CPA (SHR, 0.509; 95% CI, 0.286-0.905) and angiosome-targeted revascularization (SHR, 0.613; 95% CI, 0.394-0.956) were associated with a lower risk of major amputation. CONCLUSIONS: Competing risk analysis showed that a patent pedal arch had significant impact on leg salvage and that the subset of patients undergoing endovascular procedure may most benefit of an angiosome-targeted revascularization.

Vein Harvest Wound Healing after Bypass Surgery for Critical Limb Ischemia.

BACKGROUND: Lower-limb revascularization surgery, especially when performed using the great saphenous vein, predisposes patients to major surgical trauma on initially ischemic tissue. Vein harvest wounds (VHWs) after infrainguinal revascularization heal slowly. This study's aim was to assess the factors associated with VHW healing after infrainquinal bypass surgery for critical limb ischemia (CLI). METHODS: A retrospective patient record study was conducted. All patients with CLI who underwent infrainguinal bypass surgery with autologous vein graft between January 1, 2015, and December 31, 2017, in the Turku University Hospital, were included. Follow-up data were collected until February 28, 2018. The following data was collected from the patient files; risk factors, ankle-brachial indices (ABIs), systolic toe pressures (STPs), the presence of an ischemic ulcer, VHW dehiscence, and the time when the VHW was completely healed. Procedures with outflow vessels at either popliteal or tibial artery were analyzed separately. Descriptive and univariate statistical analyses were performed. RESULTS: Altogether, 195 patients were operated on for CLI, of whom 133 (68.2%) patients had ischemic ulcers. The mean follow-up time was 535.0 days (range 3.0-1143.0 days). The mean ABI improvement was 0.49 (P = 0.00), and STP improvement, 39.9 mm Hg (P = 0.00). The median time taken when VHW was healed was 48.0 days (95% confidence interval [CI], 39.4-56.6) in patients without ischemic ulcers and 82.0 days (95% CI, 59.7-104.3) in patients with ischemic ulcers, P = 0.03. VHW in patients who underwent popliteal artery bypass (62 days, 95% CI, 12.9-93.0) healed faster than VHW in those who underwent tibial artery bypass (132 days, 95% CI, 48.0-93.0), P = 0.02. Risk factors and the preoperative or postoperative ABIs or STPs had no effect on VHW healing time. CONCLUSIONS: VHW healing was remarkably slower after revascularization surgery in patients with an ischemic foot ulcer than in those without ischemic ulcers.

Ischemic Toe Ulceration Due to Foreign Body Embolus From Hydrophilic Polymer-Coated Intravascular Device.

Hydrophilic polymer coatings are now widely applied to catheters and other intravascular devices used in neurovascular, cardiovascular, and peripheral vascular procedures. Emboli consisting of these materials have been previously identified in biopsies and autopsies following pulmonary infarction, stroke, gangrene, or death. We report a case involving a nonhealing foot ulcer that appeared following cardiac catheterization, stenting, and automatic implanted cardiac defibrillator (AICD) implantation in a patient without other evidence of significant peripheral artery disease. An 85-year-old woman with chronic atrial fibrillation, aortic valve stenosis, and coronary artery disease underwent coronary stenting and AICD implantation for ventricular tachycardia and syncope. She developed a toe ulcer shortly thereafter, which did not respond to standard treatment. A histological examination following amputation of the toe found amorphous basophilic material in capillaries adjacent to the edge of the ulcer, which was similar to material associated with hydrophilic polymer coatings. Ischemia and infarcts following endovascular procedures should not be presumed to result from thrombus or vascular disease, even if intravascular devices appear intact or properly placed after the procedure. To help establish the incidence of ischemia caused by hydrophilic polymer device coatings, if excision of ischemic or infarcted tissue after endovascular procedures using coated devices becomes necessary, the tissue should be evaluated microscopically. Surgeons should also consider the tolerance of distal organs to infarct or ischemia when selecting coated intravascular devices.

Early Foot Structural Changes After Lateral Column Exostectomy in Patients With Charcot Foot.

Although exostectomy for chronic midfoot plantar ulcers in Charcot foot is apparently effective, with healing rates of nearly 75%, a subset of patients develop recurrent ulceration and show an unstable foot position, especially after undergoing exostectomy confined to the lateral column. The reasons for this failure have not been investigated. The main objective of this study was to evaluate the early changes in radiographic alignment after an exostectomy in patients with Charcot neuropathic osteoarthropathy (rocker bottom) and plantar ulcer located in the lateral column. The present study evaluated retrospectively changes in radiographic alignment after an exostectomy in 12 Charcot feet (rocker bottom) with plantar ulcer located in the lateral column. Indication for plantar exostectomy was the treatment of ulcer affected by osteomyelitis. We evaluated the early changes in the alignment of the foot on weight-bearing lateral radiographs 6 months after exostectomy. Paired sample Wilcoxon test was used to calculate the differences between preoperative and postoperative measurements. Furthermore, the relationship between revision surgery and early changes in radiographic angular measurements was determined by using the Mann-Whitney U test. After exostectomy, the inclination of the calcaneal bone decreased (P = .003; r = 0.849) and declination of talus bone increased (P = .041; r = 0.589). The change in calcaneal inclination was associated with revision surgery (P = .042; r = 0.586). The present case series demonstrates that exostectomy procedure for the lateral column in patients with Charcot foot results in radiological changes in the hindfoot over the sagittal plane. The inversion of the calcaneal pitch angle suggests the possibility of further adverse events and the need for revision surgery.

Peripheral Blood Mononuclear Cells Therapy for Treatment of Lower Limb Ischemia in Diabetic Patients: A Single-Center Experience.

BACKGROUND: The aim of this study is to analyze the effects of peripheral blood mononuclear cells (PBMNCs) therapy in diabetic patients with critical limb ischemia (CLI), with particular regard to its application, as adjuvant therapy in patients underwent endovascular revascularization. METHODS: Fifty diabetic patients affected by CLI were enrolled. All patients underwent PBMNCs therapy. Thirty-two patients underwent PBMNCs therapy associated with endovascular revascularization (adjuvant therapy group). In 18 patients, who were considered nonrevascularizable or underwent unsuccessful revascularization, regenerative therapy with PBMNCs was performed as the therapeutic choice (PBMNCs therapy group). RESULTS: The median follow-up period was 10 months. The baseline and end point results in adjuvant group were as follows. The mean transcutaneous partial pressure of oxygen (TcPO2) improved from 25 ± 9.2 mmHg to 45.6 ± 19.1 mmHg (P < 0.001), and visual analogue scale (VAS) score means decreased from 8.6 ± 2.1 to 3.8 ± 3.5 (P = 0.001). In PBMNCs therapy group, the mean TcPO2 improved from 16.2 ± 7.2 mmHg to 23.5 ± 8.4 mmHg (P < 0.001), and VAS score means decreased from 9 ± 1.1 to 4.1 ± 3.3 (P = 0.001). Major amputation was observed in 3 cases (9.4%), both in adjuvant therapy group and in PBMNCs therapy one (16.7%) (P = 0.6). CONCLUSIONS: The role of cellular therapy with PBMNCs is decisive in the patients that are not susceptible to revascularization. In diabetic patients with CLI and healing resistant ulcers, the adjuvant PBMNCs therapy could represent a valid therapeutic option.

Indocyanine Green Angiography to Prognosticate Healing of Foot Ulcer in Critical Limb Ischemia: A Novel Technique.

BACKGROUND: To predict wound healing in patients with critical limb ischemia (CLI) is an ongoing issue. Current methods such as ankle-brachial index (ABI), color Doppler and transcutaneous oxygen pressure (TCPO2), and computed tomography angiography are lacking in demonstrating regional perfusion. Indocyanine green angiography (ICGA) has the potential to provide regional perfusion information lacking in other methods. This study was conducted to demonstrate successes of revascularization procedure in CLI patients based on ICGA data. METHODS: A total of 47 patients with grade 2 or grade 3 University of Texas Wound Classification System ischemic foot ulcer undergoing lower limb revascularization procedure were included in this study, from July 2014 to May 2016. ICGA with intravenous 0.1 mg/kg of 0.1% indocyanine green dye was performed before and after revascularization procedure. ICGA data maximum unit, blush time, and blush rate were compared between prerevascularization and postrevascularization data, along with ABI and TCPO2. RESULTS: Out of 47 patients (45 males and 2 females), 43 underwent endovascular revascularization and 4 underwent open procedure. Of all, 76.6% of patients were diabetic and 46.8% were hypertensive. Also, 31.9% had coronary artery disease, 21.2% had history of cerebrovascular disease, 23% had chronic kidney disease, and 74.4% were chronic smokers. A total of 37 patients' ulcer healed completely on follow-up with significant improvement (P < 0.05) in preoperative and postoperative ABI, TCPO2, and ICGA data. Ten patients' ulcer did not heal in the follow-up period. In those 10 patients, preoperative and postoperative ABI and TCPO2 improved, but ICGA data were not improved postoperatively (P > 0.05). CONCLUSIONS: ICGA is an evolving tool to quantify regional perfusion in CLI. ICGA parameters provide qualitative real-time visual images of perfusion in area of interest as well as quantitative information of perfusion.

The Ability of Fluorescence Angiography to Detect Local Ischemia in Patients With Heel Ulceration.

Heel ulcerations are a significant burden of care in both hospital and long-term care settings. The presence of peripheral arterial disease as a contributing factor to delayed healing is often not recognized, resulting in prolonged healing and high patient morbidity and mortality. Formal vascular evaluation and intervention is often not performed as these patients can have palpable pedal pulses while having localized ischemia of the heel. As routine noninvasive vascular studies can be affected by medial calcinosis and collateralization and do not specifically assess tissue perfusion to the heel, a false sense of security of adequate perfusion for healing can result. Indocyanine green fluorescence angiography (ICGFA) allows for real-time visualization and objective assessment of site specific tissue perfusion not limited by the factors that can make routine noninvasive vascular studies unreliable or unobtainable. A retrospective medical record review of a subset of patients with chronic heel ulceration from a prospective institutional review board-approved study in which serial ICGFA was performed during their treatment course was performed. ICGFA was able to identify local heel ischemia and expedite vascular intervention. ICGFA should be considered as an additional vascular study in patients presenting with chronic, nonhealing heel ulcerations. LEVELS OF EVIDENCE: Level IV: Diagnostic, Case series.

Squamous Cell Carcinoma Arising in a Chronic, Nonhealing Diabetic Foot Ulcer.

Diabetic foot ulcers (DFUs) are a severe and costly complication of diabetes and may result in foot amputation. CASE REPORT: A 69-year-old man with a 10-year history of type 2 diabetes, who was undergoing routine care for diabetes in the authors' clinic, developed a DFU of his right foot of 4 years' duration. The wound did not respond to conventional treatments, and imaging studies were normal. His 2 biopsies tested negative for malignancy. The DFU was fully removed surgically. Following surgical removal, squamous cell carcinoma (SCC) was diagnosed in the histologic study of the wound. CONCLUSION: Clinicians should consider a diagnosis of SCC in any chronic, nonhealing DFU. Early surgical resection of a chronic, nonhealing DFU may prevent development of SCC in an ulcer.

Relationship of Cuboid Height to Plantar Ulceration and Other Radiographic Parameters in Midfoot Charcot Neuroarthropathy.

The objective of the present investigation was to examine the effect of cuboid height on the presence of plantar midfoot ulceration and the relationship of cuboid height to other commonly performed radiographic parameters during evaluation of midfoot Charcot neuroarthropathy. A retrospective analysis was performed of 68 feet in 60 subjects who met the inclusion criteria. We did not observe statistically significant differences in the presence of a plantar midfoot ulceration when considering a cuboid height threshold of 0.0 mm, 2.0 mm, -2.0 mm, or -5.0 mm nor was the cuboid height a robust predictor for the presence of plantar midfoot ulceration when considering the positive predictive value, negative predictive value, sensitivity, or specificity. We observed a significant negative association between a negative cuboid height and the presence of Sanders Type 2 deformities (76.2% of those with negative height versus 50.0% of those with positive height had type 2 deformities; p = .0036), the absence of radiographic visualization of the lateral tarsometatarsal joint (71.4% of those with negative height versus 26.9% of those with positive height had an absence of radiographic visualization; p = .005), and lower calcaneal inclination angles (6.06° versus 15.08°; p < .001). We further observed significant positive correlations between the cuboid height and the calcaneal-fifth metatarsal angle (0.655; p < .000), calcaneal inclination angle (0.591; p < .001), calcaneal-cuboid angle (0.254; p = .038), medial column height (0.264; p = .029), and first metatarsal inclination angle (0.245; p = .047). We also observed negative correlations with Meary's angle (-0.475; p < .001) and the talar declination angle (-0.387; p < .001). These findings showed a general trend toward a decreasing cuboid height and increasing sagittal plane deformity involving both the medial and the lateral columns. The results of the present investigation provide evidence against a single radiographic parameter being associated with the presence of plantar midfoot ulceration.

The Feasibility of Angiosome-Targeted Endovascular Treatment in Patients with Critical Limb Ischemia and Foot Ulcer.

BACKGROUND: To determine wound location according to the angiosome concept and to investigate the feasibility and success of angiosome-based revascularization in below-the-knee (BTK) arteries. METHODS: This was a retrospective study of 161 patients (67.5 ± 25.5 years, 66.5% diabetics) with critical limb ischemia and a foot ulcer, stage Rutherford 5-6, who underwent percutaneous transluminal angioplasty on BTK arteries in 2012. We evaluated feasibility of angiosome-targeted revascularization and the number of angiosomes affected by a wound in each patient. Patients were divided into 3 groups depending on how many BTK vessels were suitable for revascularization. The feasibility was analyzed in each group and in relation to number of affected angiosomes. RESULTS: The wound(s) interfered with one angiosome in only 39 (24.0%) cases. Direct flow into affected angiosome was successfully achieved in 98 (60.9%) cases. If ulceration was limited in one angiosome, the targeted revascularisation was possible in 27 cases (69.2%), if ulceration was extended over 2 angiosomes it was possible in 65 cases (86.7%), if 3 angiosomes were affected it was possible in 36 cases (85.7%), when 4 angiosomes were affected the rate dropped to 25.0% and ulceration extended over 5 angiosomes had no possibility of revascularization. CONCLUSIONS: In critical limb ischemia, the tissue lesion affects several angiosomes in majority of the cases. In thus far published literature, there is existence of more approaches of angiosome-targeted revascularization when more than one angiosome is clinically involved and therefore consensus needs to be achieved for the accurate definition.

Radiographic analysis of diabetic midfoot charcot neuroarthropathy with and without midfoot ulceration.

BACKGROUND: The aim of this study was to evaluate weight-bearing radiographs in patients with and without foot ulcers diagnosed with midfoot Charcot neuroarthropathy (CN) secondary to diabetes mellitus. METHODS: One hundred fourteen patients with midfoot CN (50 with foot ulcers and 64 without ulcers) were identified and included in this study. Nine radiographic measurements were made (7 in the sagittal plane and 2 in the transverse plane). RESULTS: CN patients with foot ulcers had significantly greater deformity when assessing the lateral-talar first metatarsal angle, calcaneal pitch, cuboid height, medial column height, calcaneal-fifth metatarsal angle, talar declination, and lateral tibiotalar angle. Two measurements in the transverse plane (hindfoot-forefoot angle and AP talar first metatarsal angle) were not significantly different between the 2 groups. Of patients with foot ulcers, 24% had a lateral talar first metatarsal angle of less than -27 degrees and 80% had a negative cuboid height. CONCLUSION: Sagittal plane deformities were more likely to be associated with foot ulceration in patients with CN than transverse plane deformities. Lateral column involvement was associated with a worse prognosis than medial column involvement, thus we believe progressive deformity of the lateral column should be monitored closely to prevent foot ulceration. Lateral column involvement could be identified by a decrease in the cuboid height, decreased calcaneal pitch, and decreased lateral calcaneal fifth metatarsal angle. This study can assist physicians in stratifying the risk for both ulceration and need for surgery in patients with CN based on reproducible radiographic measurements. LEVEL OF EVIDENCE: Level III, comparative series.

Selective intra-arterial dual-energy CT angiography (s-CTA) in lower extremity arterial occlusive disease.

OBJECTIVE: In patients with peripheral arterial occlusive disease, renal impairment is a common contraindication to iodine and gadolinium contrast media, which limits the utility of conventional computed tomography angiography (CTA) and magnetic resonance angiography (MRA). It is proposed that selective intra-arterial dual-energy CT-angiography (s-CTA), that is CTA with intra-arterial injection of an ultra-low dose iodine contrast media, is a feasible, safe and accurate alternative imaging method to conventional non-invasive contrast enhanced vascular imaging in this patient group. The aim of this study was to report a preliminary experience of s-CTA in patients with critical limb ischemia and renal insufficiency with respect to safety, feasibility, and diagnostic accuracy. MATERIALS AND METHODS: Ten non-consecutive patients with ischemic foot ulcers underwent s-CTA of one leg. Procedure related complications were recorded and imaging results were compared with conventional digital subtraction angiography (DSA). RESULTS: A median 17 mL (range 10-19 mL) contrast media (400 mg I/mL) was used. The median baseline plasma creatinine was 163 µmol/L (range 105-569) pre s-CTA versus 153 µmol/L (range 105-562) post s-CTA (p = .24). There was no puncture site complication. Among the patients selected for intervention (n = 6 with 30 arterial segments) the s-CTA findings correlated well with the DSA findings; the diagnostic sensitivity was 100%, the specificity 89%, and the accuracy 93%. CONCLUSION: In this pilot study, a novel imaging method (s-CTA) is presented that provides high-quality arterial phase images with ultra-low dose iodine contrast media useful also for patients unsuitable for conventional contrast enhanced imaging methods because of renal insufficiency.

Solitary erythematous, tender plaque of the heel in a young infant.

Calcinosis cutis is a rare disorder resulting from the precipitation and deposition of insoluble calcium and phosphate salts (hydroxyapatite crystals) in the dermis and subcutaneous tissue. It is generally divided into four main groups on the basis of etiology and pathogenesis. Clinical presentation of cutaneous calcinosis cutis varies according to the diagnosis and the underlying process. We report a case of calcinosis cutis of the heel in which both the extravasation of a calcium gluconate infusion and renal failure could have promoted the development of calcinosis cutis.

Allogeneic lethally irradiated cord blood mononuclear cells in no-option critical limb ischemia: a "box of rain".

Critical limb ischemia (CLI) is burdened by a 40% major amputation rate, and a 5-year life expectancy <50%. We report the first in-human injection of lethally γ-irradiated non-human leukocyte antigen (HLA)-matched cord blood (CB)-derived mononuclear cells in a no-option CLI patient, to induce therapeutic neo-angiogenesis, with evidence of successful outcome supported by clinical findings (ulcer healing and pain relief), instrumental assessment (transcutaneous O2 pressure, ankle/brachial index, and contrast-enhanced ultrasonography), and histological demonstration of muscular tissue repair and capillary network expansion. If our approach will be confirmed, the huge number of CB units currently discarded might be redirected toward regenerative medicine purposes, leading to cutting-edge solutions for important unmet clinical needs, such as ischemic diseases, which remain the main cause of disability and mortality in western countries.