Plasma thrombin-antithrombin complex evaluates hypercoagulable states and predicts revasenosis after revascularization in patients of atherosclerosis obliterans / 中华检验医学杂志

Objective:To study the changing characteristics of the levels of plasma thrombin-antithrombin complex (TAT) in atherosclerosis obliterans (ASO) patients with different conditions and the clinical value of predicting luminal restenosis after revascularization.Methods:A total of 386 ASO patients were collected, including 209 males and 177 females, aged 70 (44-97) years old, including 196 patients with intermittent claudication and 190 patients with critical limb ischemia. There were 172 patients with intermittent claudication and 185 patients with critical limb ischemia who received revascularization therapy. During the 30-day follow-up period, 23 patients with intermittent claudication and 49 patients with critical limb ischemia developed restenosis after surgery. Venous blood samples were collected before surgery, on the 3rd day after surgery, and on the 7th day after surgery. Plasma TAT levels were determined by Shine i2900-automatic chemiluminescence immunoassay analyzer; Kruskal-Wallis H test was used for comparison among multiple groups; Mann-Whitney U test was used for data comparison between the two groups; continuous comparison of patient data in the same group was done by using Friedman rank test; multivariate correlation analysis by Logistic regression was conducted to obtain odds ratio( OR). The diagnostic performance of TAT was evaluated by ROC analysis. Kaplan-Meier curve was used to analyze the survival curve, and the hazard ratio (HR) was obtained by Cox proportional hazard regression model. Results:Compared with the healthy control group, the level of plasma TAT in patients with intermittent claudication was significantly higher ( P<0.001); the level of plasma TAT in patients with critical limb ischemia was significantly higher than that in patients with intermittent claudication ( P<0.001). The plasma TAT of patients with Rutherford grade 3 >grade2, grade4 >grade3, and grade6 >grade5 ( P values were 0.038, <0.001, and 0.013, respectively).In the intermittent claudication group, the plasma TAT levels of the patients with restenosis on the 3rd and the 7th day after revascularization were both higher than that of the patients with unobstructed blood flow ( P values were 0.004 and <0.001, respectively); The plasma TAT level of patients with unobstructed blood flow on the 7th day after surgery was lower than that on the 3rd day after surgery and before surgery (both P values <0.001); the plasma TAT level of patients with restenosis on the 7th day after surgery was lower than that on the 3rd day after surgery and higher than before surgery (both P values < 0.001). In the critical limb ischemia group, before surgery, on the 3rd and the 7th day after surgery,the plasma TAT levels of the patients with restenosis were higher than that of the patients with unobstructed blood flow ( P values were 0.001, 0.013, and <0.001, respectively); The plasma TAT level of patients with unobstructed blood flow on the 7th day after surgery was lower than that on the 3rd day after surgery and before surgery (both P values <0.001); the plasma TAT level of patients with restenosis on the 7th day after surgery was lower than that on the 3rd day after surgery ( P<0.001), but was not significantly difference from that before surgery. The ROC analysis showed that the areas under the curve (AUC) of plasma TAT on the 7th day after surgery to predict postoperative restenosis in all the patients, patients with intermittent claudication and those with critical limb ischemia were 0.839, 0.783 and 0.853, respectively. Survival analysis indicated that in the critical limb ischemia group, patients with plasma TAT levels higher than the critical value (≥7.66 ng/ml) on the 7th day after surgery showed significantly higher cumulative risk of restenosis events within 30 days after surgery (Log-rank χ 2=93.674, P<0.001). Cox regression analysis showed that the plasma TAT level on the 7th day after the surgery could be used as an independent indicator to predict the occurrence of restenosis within 30 days after surgery in the critical limb ischemia group ( HR=2.259, P<0.001). Conclusion:Plasma TAT can reflect the hypercoagulable state of ASO patients in different conditions, which is helpful for stratification of disease severity. In addition, TAT is highly sensitive for luminal restenosis after revascularization and can be used as an independent marker for evaluating postoperative restenosis events in patients with critical limb ischemia.

Resultados en el corto y mediano plazo del tratamiento endovascular en la enfermedad arterial obstructiva infrapoplítea en pacientes con isquemia crítica de una extremidad / Short to midterm results after endovascular approach in critical limb isquemia in patients with below-the-knee arterial disease

Resumen Objetivo: Mostrar los resultados en el corto y mediano plazo del tratamiento endovascular de angioplastia transluminal percutánea (ATP) con balón en pacientes en estado de isquemia crítica por enfermedad arterial obstructiva infrapoplítea. Materiales y Método: Estudio descriptivo, observacional, retrospectivo. Se incluyeron los pacientes hospitalizados entre 2009 y 2018 por isquemia crítica Fontaine III o IV sometidos a una ATP del territorio infrapoplíteo. Se observó como objetivos primarios la preservación de la extremidad afectada y la mortalidad posoperatoria a un año plazo, y como objetivos secundarios los procedimientos adicionales en pacientes con lesiones o necrosis distales, estadía hospitalaria, complicaciones posoperatorias y necesidad de reintervención. Resultados: Se incluyeron 42 pacientes con un promedio de edad de 66 años (46-82), con importantes comorbilidades. Un 83,3% ingresó en etapa Fontaine IV. En 16 casos se realizó una angioplastia percutánea en más de una arteria. No se colocó stents. Se presentaron complicaciones en 3 pacientes, 2 requirieron una amputación mayor y en otro se debió efectuar un nuevo procedimiento endovascular de rescate. La estadía hospitalaria promedio fue 22 días. No hubo mortalidad precoz posprocedimiento. La mortalidad global a un año fue 9,5%. A todos los pacientes en etapa Fontaine IV se les efectuó algún procedimiento adicional, a 31 una amputación menor, 3 cerraron sus lesiones por segunda intención y en otro se realizó un injerto dermo-epidérmico. De los 35 pacientes con seguimiento, 77% preservó su extremidad a un año. Conclusión: La reparación endovascular mediante una angioplastia percutánea en estos casos es un procedimiento seguro y tiene una alta tasa de preservación de la extremidad inicial a un año de seguimiento.

Aim: Show initial and midterms results of endovascular Percutaneous Transluminal Angioplasty (PTA) in critical limb isquemia (CLI) patients caused by below-the-knee arterial disease. Materials and Method: Observational, descriptive and retrospective study. 42 CLI patients admitted in our hospital from 2009 until 2018 with Fontaine III or IV treated by PTA in infrapopliteal arteries were analyzed, collecting demographic, clinical and surgical characteristics, additional procedures in Fontaine IV, hospital stay, postoperative complications, need of reintervention, limb preservation and mortality with one year follow-up after procedure. Results: 42 patients, average age 66 year-old (46-82), with significant comorbidities. Fontaine IV stage patients were 83.3%. In 16 cases more than one artery was intervened. No stent revascularization was performed. Complications occurred in 3 patients, 2 required major amputation and an urgent endovascular reintervention was required in another. Average hospital stay was 22 days with no post-operative mortality. One-year global mortality was 9.5 One-year follow-up in 35 patients shows that 77% preserved their limb. Conclusión: Percutaneous transluminal angioplasty procedure in this patients has a high rate of limb preservation in a one-year follow-up. There was no post-operative mortality.

Endovascular revascularization of chronic total arterial occlusion of the lower limb using the SAFARI technique / Revascularização endovascular utilizando a técnica SAFARI em casos de oclusão arterial total do membro inferior

Abstract The SAFARI technique or Subintimal Arterial Flossing with Antegrade-Retrograde Intervention is an endovascular procedure that allows recanalization of Chronic Total Occlusive (CTO) lesions when conventional subintimal angioplasty is unsuccessful. Retrograde access is usually obtained through the popliteal, anterior tibial, dorsalis pedis artery, or posterior tibial arteries and may potentially provide more options for endovascular interventions in limb salvage. The case of an 81-year-old man with a history of uncontrolled hypertension, diabetes mellitus, and dyslipidemia is presented. He presented with a cutaneous ulcer on the right lower limb with torpid evolution and poor healing. The Doppler ultrasound and arteriographic study revealed a CTO lesion of the popliteal artery that was not a candidate for antegrade endovascular revascularization, but was successfully treated using the SAFARI technique. The patient had no perioperative complications, the wound showed better healing, and he was discharged with an indication of daily dressings and control by an external outpatient clinic.

Resumo A técnica SAFARI, ou Subintimal Arterial Flossing with Antegrade-Retrograde Intervention, é um procedimento endovascular que permite a recanalização de lesões por oclusão total crônica (OTC) em caso de fracasso da angioplastia subintimal convencional. O acesso retrógrado é geralmente obtido através da artéria poplítea, tibial anterior, pediosa ou tibial posterior e pode fornecer mais alternativas de intervenções endovasculares para o salvamento do membro. É apresentado o caso de um homem de 81 anos com histórico de hipertenção não controlada, diabetes melito e dislipidemia. Ele apresentava uma lesão ulcerativa cutânea no membro inferior direito com evolução tórpida e má cicatrização. O ultrassom Doppler e o estudo arteriográfico revelaram uma lesão por OTC na artéria poplítea. O paciente não era candidato a revascularização endovascular anterógrada; sendo assim, esta foi realizada com successo utilizando a técnica SAFARI. O paciente não apresentou complicações perioperatórias e recebeu alta com indicação de cuidados diários com a ferida e controle em um ambulatório externo. Além disso, a ferida apresentou melhor cicatrização.

Fístula coronaria a ventrículo derecho en paciente con ateroesclerosis sistémica / Coronary artery fistula to the right ventricle in a patient with systemic atherosclerosis

RESUMEN La ateroesclerosis es una enfermedad sistémica que afecta múltiples lechos vasculares. Después de períodos prolongados de progresión comienzan las manifestaciones clínicas, de forma aguda o crónica (infarto agudo de miocardio, angina estable, claudicación intermitente, enfermedad cerebrovascular, entre otras); por lo que puede cursar de manera subclínica en pacientes con enfermedad arterial coronaria. Lo interesante de esta forma de presentación es que dentro de una serie de casos con enfermedad multivaso, asociado a un índice tobillo-brazo (ITB) < 0,9, después de un síndrome coronario agudo, hemos encontrado, como hallazgo angiográfico, la presencia de una fístula coronaria a ventrículo derecho en un paciente con ITB muy bajo y clínica de claudicación intermitente. Esta fístula es la causa de los síntomas que interrumpieron la rehabilitación cardiovascular; es una enfermedad poco frecuente y causa de dolor torácico, que se informa solo de 0,3 a 0,8%, como hallazgo incidental en angiografías coronarias.

ABSTRACT Atherosclerosis is a systemic disease that affects a number of vascular beds. Clinical manifestations whether acute or chronic (acute myocardial infarction, stable angina, intermittent claudication, cerebrovascular disease, among others) start after long periods of progression; so it may present subclinically in patients with coronary artery disease. What is particularly interesting about this form of presentation is that within a series of cases with multivessel disease, associated with an ankle-brachial index (ABI)<0.9, after an acute coronary syndrome, we have identified, as an angiographic finding, the presence of a coronary artery fistula to the right ventricle in a patient with very low ABI and clinical intermittent claudication. This fistula led to the symptoms that hampered cardiovascular rehabilitation. It is an infrequent disease characterized by chest pain; with low reporting (0.3 to 0.8%), as an incidental finding in coronary angiographies.

COVID-19 diagnosis in a patient with critical limb ischemia: complications and clinical outcomes / Diagnóstico de COVID-19 em paciente com isquemia crítica do membro: complicações e desfechos clínicos

Abstract A 67-year-old male diabetic patient with systemic arterial hypertension was admitted to the emergency department with a necrotic ulcer in the left external malleolus and no palpable popliteal or pedal pulses. Arterial Duplex ultrasound identified femoropopliteal occlusion, with popliteal refilling below the knee and a patent peroneal artery. An endovascular procedure was performed, requiring retrograde access to the popliteal artery to re-establish blood flow and deploy a popliteal stent. Technical success was achieved and the patient underwent debridement of the wound. Two days later, about 48 hours after the operation, the patient began to exhibit respiratory symptoms, with coughing and dyspnea. He immediately underwent a chest CT that identified ground glass opacities, the crazy-paving pattern, and bilateral air bronchogram in the lungs. A reverse transcription - polymerase chain reaction (RT-PCR) test was positive for SARS-Cov-2. The patient was moved to an intensive care unit and put on mechanical ventilation. Both hydroxychloroquine and azithromycin were administered. Despite appropriate treatment, the patient died 4 days after he was diagnosed with COVID-19.

Resumo Paciente do sexo masculino, 67 anos, diabético, hipertenso, foi admitido no pronto-socorro com histórico de úlcera necrótica no maléolo externo esquerdo, sem pulsos poplíteos e distais palpáveis. A ultrassonografia Doppler arterial identificou oclusão femoropoplítea, com reenchimento da artéria poplítea infragenicular e perviedade da artéria fibular. Foi realizado procedimento endovascular, com necessidade de acesso retrógrado na artéria poplítea para restabelecer o fluxo sanguíneo e realizar implante de stent poplíteo. O sucesso técnico foi alcançado e, em seguida, o paciente foi submetido ao desbridamento da ferida. No segundo dia, cerca de 48 horas de pós-operatório, o paciente apresentou quadro respiratório com tosse e dispneia. Foi submetido a uma tomografia computadorizada do tórax, que identificou opacidades em vidro fosco e broncograma aéreo bilateralmente nos pulmões, com teste de reverse transcription - polymerase chain reaction (RT-PCR) positivo para SARS-Cov-2. O paciente foi transferido para uma unidade de terapia intensiva, necessitando de ventilação mecânica. Recebeu hidroxicloroquina e azitromicina. Apesar do tratamento em suporte intensivo, o paciente morreu 4 dias após o diagnóstico de COVID-19.

Factors associated with outcome of endovascular treatment of iliac occlusive disease: a single-center experience / Fatores associados com os desfechos clínicos do tratamento endovascular da doença oclusiva ilíaca: experiência de um único centro

Abstract Background Endovascular treatment (ET) of iliac occlusive disease (IOD) is well established in literature. Use of stents in IOD has achieved long-term limb salvage and patency rates similar to those of open surgery, with lower morbidity and mortality rates. Objectives To report the long-term outcomes, particularly limb salvage and patency rates, of ET for IOD and the factors associated with these outcomes. Methods This retrospective cohort study included patients with IOD who underwent iliac angioplasty (IA), between January 2009 and January 2015. Patients with critical limb ischemia or incapacitating claudication were included. Results In total, 48 IA procedures were performed in 46 patients, with an initial technical success rate of 95.83%. Failure occurred in two patients, who were excluded, leaving 44 patients and 46 IA. The primary patency, secondary patency, limb salvage, and survival rates at 1200 days were 88%, 95.3%, 86.3%, and 69.9%, respectively. Univariate and multivariate Cox regression revealed that the primary patency rate was significantly worse in patients with TASC type C/D than in patients with TASC type A/B (p = 0.044). Analysis of factors associated with major amputation using Cox regression showed that the rate of limb loss was greater in patients with TASC type C/D (p = 0.043). Male gender was associated with reduced survival (p = 0.011). Conclusions TASC type C/D was associated with a higher number of reinterventions and with worse limb loss and primary patency rates. Male gender was associated with a worse survival rate after ET of IOD.

Resumo Contexto O tratamento endovascular da doença oclusiva ilíaca (DOI) é bem estabelecido. O uso de stents nas angioplastias ilíacas (AI) alcançou estimativas de salvamento de membro e perviedade similares às de cirurgias abertas, porém com menor morbimortalidade. Objetivos Demonstrar os desfechos clínicos a longo prazo, principalmente as estimativas de salvamento de membro (ESM) e perviedade, do tratamento endovascular da DOI e os fatores associados. Método Estudo de coorte retrospectiva e consecutiva incluindo pacientes com DOI e isquemia crítica ou claudicação limitante submetidos a AI entre janeiro de 2009 a janeiro de 2015. Resultados Foram realizadas 48 AI em 46 pacientes, com uma taxa de sucesso técnico inicial de 95,83%. Ocorreu falha técnica em dois pacientes, os quais foram excluídos da análise, restando 44 pacientes e 46 AI. As estimativas de perviedade primária, perviedade secundária, ESM e sobrevida aos 1.200 dias foram de 88%, 95,3%, 86,3% e 69,9%, respectivamente. A regressão de Cox univariada e multivariada revelou que a perviedade primária foi pior em pacientes com classificação TASC C/D do que em pacientes TASC A/B (p = 0,044). Quando analisamos os fatores associados à amputação maior, verificou-se que lesões TASC tipo C/D (p = 0,043) apresentaram piores resultados. O sexo masculino foi associado com sobrevida reduzida (p = 0,011). Conclusões Classificação TASC tipo C/D foi associada a um maior número de reintervenções, maior perda de membro e piores estimativas de perviedade primária. O sexo masculino foi associado a uma pior sobrevida.

Effect of benefiting Qi and activating blood circulation on critical limb ischemia of lower extremity arterio-sclerosis obliterans after intervention / 实用医学杂志

Objective To discuss the clinical value of benefiting Qi and activating blood circulation on crit-ical limb ischemia(CLI)of lower extremity arteriosclerosis obliterans(ASO)after intervention. Methods Totally 43 patients with CLI were randomly divided into treatment group and control group. Patients in control group re-ceived basic treatment and interventional therapy,and those in treatment group additional benefiting Qi and activat-ing blood circulation for 6 months.The ankle brachial index(ABI),clinical symptoms and patency rate of vascular in 1 month,3 months and 6 months after angioplasty were analyzed and compared. Results ABI in treatment group 1 month,3 months and 6 months after angioplasty was increased when compared with that in control group (P<0.05),and the incidence rate of claudication and rest pain was significantly lower than that in control group 3 months and 6 months later(P<0.05).The patency rate of vessels in treatment group was higher than that of con-trol group and there was significant difference between the two groups(P < 0.05). Conclusions Benefiting Qi to activating blood circulation could improve the clinical efficacy and reduce the degree of restenosis in patients with CLI.

Value of wound blush in predicting ulcer healing in patients with critical limb ischemia after endovascular revascularization / 国际外科学杂志

Objective To explore the value of wound blush in predicting patients' ulcer healing whom with critical limb ischemia after revascularization.Methods Retrospectively analyze the clinical data of 173 cases of critical limb ischemia with ischemic ulcers under thetreatment of endovascular therapy followed the concept of angiosome.According to the condition of wound blush after endovascular therapy,by compared the difference of limb salvage rate and ulcer healing time,and try to analyze the value of wound blush in predicting ulcer healing in patients.Results Included in the study with a total of 173 cases (173 limbs),group wound blush(+) 109 patients,group wound blush (-) 64 cases,the age,proportion of male patients,smoking history,diabetes,coronary heart disease,chronic renal insufficiency,pre and post operative ankle brachial index,were no statistical difference between the two groups.The ulcer healing time of group wound blush (+) was significantly shorter than that of group wound blush(-) (P ＜ 0.05).The rate of ulcer healing in group wound blush(+) was significantly higher than that in group wound blush(-) (P ＜ 0.05).In group wound blush(+),the cumulative rate of limb salvage was statisticallyhigher than group wound blush (-) (P ＜ 0.05).By logistic regression analysis,wound blush(-) (OR =4.5,P ＜ 0.05),IRc revascularization (OR =2.6,P ＜ 0.05) were independent risk factors of ulcer healing.Conclusions The resoult of wound blush(+) shows a good distal perfusion of foot.It can be used as a predictive factor for critical limb ischemia ischemic ulcer healing,and wound blush (-) was an independent risk factor for ulcer nonhealing.

<b>Three Hemodialysis Patients with Postoperative Amputation Wounds Due to Critical Limb Ischemia Successfully Treated with Juzentaihoto and </b><b>Keishibukuryogan</b> / 日本東洋医学雑誌

<p>Peripheral arterial disease is a serious complication that can arise in hemodialysis patients. Prognosis in critical limb ischemia (CLI) due to peripheral arterial disease is extremely poor. A dialysis patient may experience symptoms of both <i>qi </i>and <i>ketsu </i>deficiency and <i>ketsu </i>stagnation during the long-term treatment of CLI. Herein, we report three hemodialysis patients with refractory postoperative skin ulcers who were successfully treated with juzentaihoto and keishibukuryogan after limb amputation. Case 1 was a 68-year-old man who had skin ulcers of the right second, third, and fifth toes. After amputation of the third toe, juzentaihoto and keishibukuryogan were initiated. Case 2 was a 67-year-old man who had skin ulcers after amputation of the left fourth and fifth toes. Postoperatively, juzentaihoto and keishibukuryogan were initiated, and good granulation was observed. Case 3 was a 76-year-old man who had skin ulcers after left below-the-knee amputation. Because of the extremely poor tissue granulation, juzentaihoto and keishibukuryogan were initiated, and good granulation was gradually observed. After an operation for CLI, prompt return to activities of daily living is desirable. The appropriate addition of Kampo treatment to Western treatment may improve chronic refractory skin ulcers.</p>

Concomitant Valve Surgery and Long Distal Bypass for Severe Mitral Regurgitation and Critical Limb Ischemia / 日本心臓血管外科学会雑誌

<p>A 75-year-old man with underlying arteriosclerosis obliterans presented with acute heart failure secondary to rest pain of the right lower extremity. Echocardiogram showed severe mitral regurgitation, moderate tricuspid regurgitation and a low cardiac function (ejection fraction : 27%). Right toe gangrene developed in association with continuous acute heart failure. He underwent mitral valve replacement, tricuspid annuloplasty, right common femoral artery-posterior tibial artery bypass and amputation of the right toes in single-stage surgery. There were no major complications during his hospital stay. After surgery, his symptoms significantly improved.</p>

Transplantation of peripheral purified CD34+ cells in treatment of thromboangiitis obliterans / 中华普通外科杂志

Objective To evaluate the safety and efficacy of transplantation of purified CD34 + cells (PCCs) in treatment of critical limb ischemia (CLI) caused by thromboangiitis obliterans (TAO).Methods From May 2009 to June 2015,34 TAO-induced-CLI cases underwent PCCs transplantation.None of these patients were eligible for surgical or endovascular revascularization.G-CSF was subcutaneously injected for 5 days before peripheral CD34 + cells were isolated,purified and intramuscularly injected in the limbs.Patients were regularly follow-up.Results Technical success was achieved in all cases.The mean number of transplanted cells was (7.5 ± 2.4) × 105/kg.The follow-up was accomplished in 32 cases,ranging from 6 to 79 months (mean 45 ±24 months),and two patients were lost.Wong-Baker FACES pain rating scale score significantly decreased from 8.0 ±2.0(4-10)to 2.2 ±3.1 (P ＜0.05) at 1 month.The Peak pain-free walking time improved from (4.0 ± 2.0) min to (13.5 ± 5.3) min (P ＜ 0.05) at 3 months and (19.0 ± 3.1) min (P ＜ 0.05) at 6 months.The ankle-brachial index increased from 0.42 ± 0.20 to 0.50 ± 0.10 (P ＜ 0.05) at 3 months and 0.52 ± 0.11 (P ＜ 0.05) at 6 months,respectively.Transcutaneous partial oxygen pressure rose from (25 ± 11) mmHg to (48 ± 11) mmHg(P ＜ 0.05) at 3 months and (58 ± 10) mmHg (P ＜ 0.001) at 6 months,respectively.Ulcers healed in 21 out of 22 patients at (5 ± 4) months.The overall amputation-free survival rate was 94.1％ at 6 months and 91.2％ at 48 months.No major adverse events were observed perioperatively or postoperatively.Conclusions Transplantation of PCCs could yield safe,satisfactory and durable treatment outcomes in patients with TAO-induced-CLI.

Increasing injection frequency enhances the survival of injected bone marrow derived mesenchymal stem cells in a critical limb ischemia animal model

Critical limb ischemia (CLI) is one of the most severe forms of peripheral artery diseases, but current treatment strategies do not guarantee complete recovery of vascular blood flow or reduce the risk of mortality. Recently, human bone marrow derived mesenchymal stem cells (MSCs) have been reported to have a paracrine influence on angiogenesis in several ischemic diseases. However, little evidence is available regarding optimal cell doses and injection frequencies. Thus, the authors undertook this study to investigate the effects of cell dose and injection frequency on cell survival and paracrine effects. MSCs were injected at 10⁶ or 10⁵ per injection (high and low doses) either once (single injection) or once in two consecutive weeks (double injection) into ischemic legs. Mice were sacrificed 4 weeks after first injection. Angiogenic effects were confirmed in vitro and in vivo, and M2 macrophage infiltration into ischemic tissues and rates of limb salvage were documented. MSCs were found to induce angiogenesis through a paracrine effect in vitro, and were found to survive in ischemic muscle for up to 4 weeks dependent on cell dose and injection frequency. In addition, double high dose and low dose of MSC injections increased vessel formation, and decreased fibrosis volumes and apoptotic cell numbers, whereas a single high dose did not. Our results showed MSCs protect against ischemic injury in a paracrine manner, and suggest that increasing injection frequency is more important than MSC dosage for the treatment CLI.

The Study of BD-MSC Therapy against Critical Limb Ischemia / 체질인류학회지

Critical limb ischemia (CLI) is the most severe peripheral artery disease and caused by thrombus formation in blood vessel. The current strategies for treating CLI does not protect limb amputation and reduction in the risk of mortality. Recently, human bone marrow derived mesenchymal stem cells (BD-MSC) were reported to have a paracrine effects on angiogenesis in several ischemic diseases. So, we validate to determine whether BD-MSC protect against ferric chloride treated CLI and induce angiogenesis. To characterized human bone marrow derived stem cell, BD-MSC differentiated to osteocytes and adipocytes and validated stemness using flow cytometry. Endothelial cell induced angiogenesis followed by mesenchymal stem cell cultured medium treatment in HUVEC in vitro. We also mimicked CLI patients condition using FeCl₃ treated CLI mouse and injected one hundred thousand of BD-MSC along the femoral artery to leg muscle. We validated stem cell survival, blood vessel formation, leg muscle condition and fibrosis compared by saline injected mice 28 days later. In this study, BD-MSC cultured medium treatment increased migration and tube formation of HUVEC and BD-MSC injection had an effective blood vessel formation in FeCl₃ treated CLI. As well as blood vessel formation, limb salvage rate also improved and fibrosis area statistically decreased in BD-MSC injected mice. In conclusion, bone marrow derived mesenchymal stem cell improved not only blood vessel formation but also reduction of fibrosis in FeCl₃ treated CLI mice and finally protected limb amputation.

Post-treatment neutrophil-lymphocyte ratio independently predicts amputation in critical limb ischemia without operation

OBJECTIVES: Limited information is available concerning the post-treatment neutrophil-lymphocyte ratio in critical limb ischemia patients who receive conservative therapy. Accordingly, this study was designed to evaluate the predictive value of the post-treatment neutrophil-lymphocyte ratio in critical limb ischemia patients without surgery. METHOD: From January 2009 to January 2011, critical limb ischemia patients were admitted to a vascular center. The demographic data, patient histories, comorbidities and risk factors were documented, and the differential cell count was determined at admission and seven days later after conservative therapy. The cutoff value of the post-treatment neutrophil-lymphocyte ratio was determined by an ROC curve. Patients were divided into groups A and B according to the cutoff value. Amputation-free survival was compared between groups. Univariate and multivariate analyses were used to identify independent risk factors. RESULT: A total of 172 patients were identified with a mean age 71.98±10.09 years; among them, 122 were male. A value of 3.8 was identified as the cutoff value of the post-treatment neutrophil-lymphocyte ratio. Groups A (post-treatment neutrophil-lymphocyte ratio ≥3.8) and B (post-treatment neutrophil-lymphocyte ratio <3.8) showed a significant difference in amputation-free survival (P<0.001). The 1-year, 2-year and 3-year amputation-free survival rates were 79.6%, 55.6% and 46.3%, respectively, in group A; however, in group B, these values were 89.7%, 79.3% and 75.9%, respectively. The post-treatment neutrophil-lymphocyte ratio was identified as an independent predictive factor for amputation in critical limb ischemia patients (P<0.001). CONCLUSION: The post-treatment neutrophil-lymphocyte ratio is an independent predictive factor for amputation in critical limb ischemia patients. Patients with a post-treatment neutrophil-lymphocyte ratio ≥3.8 are likely to suffer from ...

Pedal-plantar Loop Technique for Below-the-ankle Arterial Occlusion / 中国微创外科杂志

Objective To assess the feasibility and efficiency of pedal-plantar loop technique in the treatment of below-the-ankle arterial occlusion . Methods A retrospective analysis was undertaken on 12 cases ( 14 legs ) of below-the-ankle arterial occlusion.The pedal-plantar loop angioplasty was performed in all the cases .Balloon angioplasty was performed after traversing through the arterial obstruction sites using antegrade or retrograde technique .After 6 months of the surgery , the results of visual analogue scale , dorsal or plantar arterial pulse volume scores , ankle brachial index , TcPO2 , and healing of the ulcer were compared to preoperative measures. Results Technical success was achieved in 9 cases (11 legs).During follow-up, 1 patient died of cerebrovascular events 2 months after the therapy .The other 8 cases (10 legs) were followed up for 6 months and no one had recurrent ischemic symptoms . The results of visual analogue scale , ankle brachial index, and TcPO2 before the surgery were (5.68 ±1.09) points, 0.60 ±0.04, and (25.71 ±5.25) mm Hg, which were improved to (0.44 ±0.27) points, 0.87 ±0.05, and (35.90 ±5.28) mm Hg (P<0.05).Dorsal or plantar arterial pulse volume scores were also enhanced markedly (P=0.004).Complete ulcer healing was observed in 8 limbs.No related complication was observed in other patients after the surgery .One technical unsuccessful patient who suffered infection and severe rest pain was given leg amputation . Conclusion Pedal-plantar loop technique is an effective therapy for below-the-ankle arterial occlusion while long term follow-up data need to be collected .

RE: Percutaneous Angioplasty in Diabetic Patients with Critical Limb Ischemia

No abstract available.

Prognostic Usefulness of Metabolic Syndrome Compared with Diabetes in Korean Patients with Critical Lower Limb Ischemia Treated with Percutaneous Transluminal Angioplasty

PURPOSE: Metabolic syndrome (MS) is a clinical condition that shares many common characteristics with diabetes. However, unlike diabetes, the usefulness of MS as a prognostic entity in peripheral arterial disease is uncertain. This study evaluated the prognostic usefulness of MS in critical lower limb ischemia (CLI) patients. MATERIALS AND METHODS: We compared the 2-year clinical outcomes in 101 consecutive CLI patients (66+/-14 years; 78% men) with 118 affected limbs treated with percutaneous transluminal angioplasty (PTA) according to the presence of MS and diabetes. RESULTS: The number of MS patients was 53 (52%), of which 45 (85%) had diabetes. During a 2-year follow-up, the incidence of clinical outcomes, including reintervention, major amputation, minor amputation, and survival, was not significantly different between MS and non-MS patients; however, the incidence of minor amputation was significantly higher in diabetic than in non-diabetic patients (42% vs. 17%; p=0.011). Cox regression analysis for the 2-year primary patency demonstrated no association between MS and 2-year primary patency [hazard ratio (HR), 1.02; 95% confidence interval (CI), 0.45-2.30; p=0.961], whereas there was a significant association between diabetes and 2-year primary patency (HR, 2.81; 95% CI, 1.02-7.72; p=0.046). Kaplan-Meier analysis revealed no significant difference in the 2-year primary patency between MS and non-MS patients; however, the 2-year primary patency was lower in diabetic than in non-diabetic patients (p=0.038). CONCLUSION: As a prognostic concept, MS might conceal the adverse impact of diabetes on the prognosis of CLI patients treated with PTA.

Endovascular Revascularization for Patients with Critical Limb Ischemia: Impact on Wound Healing and Long Term Clinical Results in 189 Limbs

OBJECTIVE: To evaluate the impact on wound healing and long-term clinical outcomes of endovascular revascularization in patients with critical limb ischemia (CLI). MATERIALS AND METHODS: This is a retrospective study on 189 limbs with CLI treated with endovascular revascularization between 2008 and 2010 and followed for a mean 21 months. Angiographic outcome was graded to technical success (TS), partial failure (PF) and complete technical failure. The impact on wound healing of revascularization was assessed with univariate analysis and multivariate logistic regression models. Analysis of long-term event-free limb survival, and limb salvage rate (LSR) was performed by Kaplan-Meier method. RESULTS: TS was achieved in 89% of treated limbs, whereas PF and CF were achieved in 9% and 2% of the limbs, respectively. Major complications occurred in 6% of treated limbs. The 30-day mortality was 2%. Wound healing was successful in 85% and failed in 15%. Impact of angiographic outcome on wound healing was statistically significant. The event-free limb survival was 79.3% and 69.5% at 1- and 3-years, respectively. The LSR was 94.8% and 92.0% at 1- and 3-years, respectively. CONCLUSION: Endovascular revascularization improve wound healing rate and provide good long-term LSRs in CLI.

Tratamiento endovascular de las arterias distales del miembro inferior / Endovascular treatment of distal lower limb arteries / Tratamento endovascular das artérias distais do membro inferior

La angioplastía es un procedimiento que se ha introducido en el tratamiento de las lesiones oclusivas de los miembros inferiores con resultados prometedores. No obstante, son importantes los nuevos aportes de datos sobre los resultados obtenidos, teniendo en cuenta la falta de homogeneidad de los pacientes tratados afectados por diferentes procesos obstructivos arteriales, tratados en diferentes situaciones clínicas y con una muy variada extensión de las lesiones. Se realiza un análisis de 239 casos incluidos en un estudio prospectivo con el objetivo de analizar los resultados en relación a los diversos factores que afectan a los pacientes. Se analizan los resultados y se valoran los mismos.

A angioplastia é um procedimento que foi introduzido no tratamento das lesões oclusivas dos membros inferiores com resultados prometedores. Entretanto, são importantes as novas contribuições de dados sobre os resultados obtidos, levando em consideração a falta de homogeneidade dos pacientes tratados afetados por diferentes processos obstrutivos arteriais, tratados em diferentes situações clínicas e com uma muito variada extensão das lesões. Realiza-se uma análise de 239 casos incluídos em um estudo prospectivo com o objetivo de analisar os resultados com relação aos diversos fatores que afetam os pacientes. Analisam-se os resultados e se valorizam os mesmos.

Angioplasty is a procedure that has been introduced with promising results in the treatment of occlusive lesions of the lower limbs. However, it is necessary further input of data on the results obtained taking into account the lack of homogeneity of patients suffering from obstructive arterial different processes, treated in different clinical situations and with a very wide extent of the injury. An analysis of 239 cases in a prospective study to analyze the results in relation to the various factors that affect patients. The results are analyzed and valued the same.

Endovascular treatment of long femoro-popliteal arterial occlusions of lower extremities / 国际外科学杂志

Objective To explore the feasibility and outcome of percutaneous transluminal angioplasty (PTA) as a primary treatment modality long femoro-popliteal arterial occlusions in critical limb ischemia.Methods Ten cases with 10 lesions in their femoro-popliteal arterial occlusions were treated with PTA, and the symptoms, intraoperative and postoperative DSA characteristics were retrospectively analyzed. Short-term follow-up were obtained in 8 cases. Results The technical success rate related to procedure was 90% and 12 stents were placed after PTA in femoro-popliteal arterial occlusions. One case was suffered fromamputa-lion due to development of compartment syndrome. The primary patency rate and recurrence rate of 12 months after procedure were 70% and 30% respectively. Conclusion Patients with critical limb ischemia could be beneficial from PTA in long femoro-popliteal arterial occlusions.