A single center’s 15-year experience with palliative limb care for chronic limb threatening ischemia in frail patients

Sibona, Agustín; Bianchi, Christian; Leong, Beatriz V.; Caputo, Ben C.; Kohne, Courtney; Murga, Allen; Patel, Sheela T.; Abou-Zamzam, Ahmed M.; Teruya, Theodore H.

doi:10.1016/j.jvs.2021.09.032

Cited by 10 publications

(3 citation statements)

References 27 publications

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“…Furthermore, frailty is associated with higher mortality and amputation rates; in addition, frail patients are observed to have a mortality benefit with a less invasive approach [ 52 ]. Indeed, a comprehensive approach to the treatment of CLTI patients should include a palliative limb care option [ 53 ]. Revascularization as a palliative treatment should only be considered to improve inflow for a subsequent amputation and to relieve pain [ 54 ].…”

Section: Global Limb Anatomic Staging System (Glass)mentioning

confidence: 99%

Chronic Limb-Threatening Ischemia and the Need for Revascularization

Berchiolli

Bertagna

Adami

et al. 2023

JCM

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Background: Patients presenting with critical limb-threatening ischemia (CLTI) have been increasing in number over the years. They represent a high-risk population, especially in terms of major amputation and mortality. Despite multiple guidelines concerning their management, it continues to be challenging. Decision-making between surgical and endovascular procedures should be well established, but there is still a lack of consensus concerning the best treatment strategy. The aim of this manuscript is to offer an overview of the contemporary management of CLTI patients, with a focus on the concept that evidence-based revascularization (EBR) could help surgeons to provide more appropriate treatment, avoiding improper procedures, as well as too-high-risk ones. Methods: We performed a search on MEDLINE, Embase, and Scopus from 1 January 1995 to 31 December 2022 and reviewed Global and ESVS Guidelines. A total of 150 articles were screened, but only those of high quality were considered and included in a narrative synthesis. Results: Global Vascular Guidelines have improved and standardized the way to classify and manage CLTI patients with evidence-based revascularization (EBR). Nevertheless, considering that not all patients are suitable for revascularization, a key strategy could be to stratify unfit patients by considering both clinical and non-clinical risk factors, in accordance with the concept of individual residual risk for every patient. The recent BEST-CLI trial established the superiority of autologous vein bypass graft over endovascular therapy for the revascularization of CLTI patients. However, no-option CLTI patients still represent a critical issue. Conclusions: The surgeon’s experience and skillfulness are the cornerstones of treatment and of a multidisciplinary approach. The recent BEST-CLI trial established that open surgical peripheral vascular surgery could guarantee better outcomes than the less invasive endovascular approach.

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Section: Global Limb Anatomic Staging System (Glass)mentioning

confidence: 99%

Chronic Limb-Threatening Ischemia and the Need for Revascularization

Berchiolli

Bertagna

Adami

et al. 2023

JCM

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“…Endovascular revascularization is widely considered the first treatment option for femoropopliteal (FP) arteriosclerosis, due to reproducible and acceptable clinical results. [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] Recent guidelines recommend endovascular therapy as first line treatment for FP lesions <250 mm in length. 1,35,36 However, long-term clinical success of endovascular therapies may be complicated by early restenosis caused by neointimal hyperplasia necessitating redo procedures to maintain patency.…”

Section: Introductionmentioning

confidence: 99%

“…There is lack of knowledge and studies concerning the best endovascular treatment in CLTI and in particular treatment with DES in a cohort with only CLTI, and more complex FP lesions. 31,40,41 As a consequence of this, no fully relevant systematic reviews regarding this population yet appear in the literature. The aim of the current study was to determine any differences in treatment efficacy between BMS and DES treatment up to two years, in a parallel group trial with randomly allocated subjects.…”

Section: Introductionmentioning

confidence: 99%

Randomized clinical Trial Comparing drug Eluting Stent Zilver PTX® Versus Bare Metal Stent Zilver Flex® for Treatment of Lesions in Femoral and Popliteal Arteries in Chronic Limb Threatening Ischemia

Fransson

Gottsäter

Abdulrasak

et al. 2023

Vasc Endovascular Surg

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Objective Drug eluting stents (DES) might improve the results of stenting in the femoropopliteal (FP) segment, but randomized data between DES and BMS in the treatment of patients with chronic limb threatening ischemia (CLTI) is lacking. The aim of this study was to perform a randomized comparison, between DES and bare metal stent (BMS) implantation in a subgroup of CLTI patients with lesions in the superficial femoral artery (SFA) and the P1-P2 portion of the popliteal artery. Methods Patients presenting with CLTI scheduled for endovascular treatment of FP lesions were randomly assigned by blinded envelopes 1:1 in a single blinded, parallel group design to DES or BMS after lesion crossing. Primary endpoints were target lesion revascularization (TLR) at 12 and 24 months and primary patency at 12 and 24 months. Secondary endpoints were technical success (TS), clinical success, secondary patency at 12 and 24 months, limb salvage, serious adverse events (SAE) at 24 month and survival at five years. Results A total of 48 CLTI patients and 49 limbs, were enrolled, 22 in the BMS group and 27 in the DES group. Demographics, comorbidities, and Rutherford class were similar in both treatment arms. The overall rate of total occlusions was 96% and the corresponding overall median lesion length was 240 mm. No patients were lost to follow up. No significant differences were detected between groups regarding TLR and primary patency. The overall primary patency at 12 and 24 months was 42.9% and 36.7% respectively and the overall freedom from TLR was 67.3% and 61.2% respectively. The results in the two groups were also similar regarding secondary outcomes. Conclusions This single centre, randomized study could not demonstrate superiority of DES compared to BMS when treating long FP lesions in patients with CLTI but was limited by insufficient patient inclusion.

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Kritische extremitätenbedrohende Beinischämie bei geriatrischen Patienten – eine diagnostische und therapeutische Herausforderung

Ploenes¹

2022

Gefässchirurgie

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A single center’s 15-year experience with palliative limb care for chronic limb threatening ischemia in frail patients

Cited by 10 publications

References 27 publications

Chronic Limb-Threatening Ischemia and the Need for Revascularization

Chronic Limb-Threatening Ischemia and the Need for Revascularization

Randomized clinical Trial Comparing drug Eluting Stent Zilver PTX® Versus Bare Metal Stent Zilver Flex® for Treatment of Lesions in Femoral and Popliteal Arteries in Chronic Limb Threatening Ischemia

Kritische extremitätenbedrohende Beinischämie bei geriatrischen Patienten – eine diagnostische und therapeutische Herausforderung

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