Worth an Arm and a Leg: The Critical Importance of Limb Ischemia

Valle, Javier A.; Waldo, Stephen W.

doi:10.1161/jaha.118.010093

Cited by 6 publications

(8 citation statements)

References 22 publications

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“… 10 Without proper intervention, CLI represents a considerable burden on the US health care system and individual morbidity and mortality and causes reduced health-related quality of life, particularly as the overall life expectancy increases. 11 , 12 …”

Section: Discussionmentioning

confidence: 99%

Successful Revascularization of Infrapopliteal Chronic Total Occlusions Using the Plantar Arch as a Conduit and Retrograde Pedal Access

Bob‐Manuel

Obi²,

N’Dandu

2021

TOJ

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Background: With the rising prevalence of critical limb ischemia (CLI), the pedal-plantar loop technique and retrograde access may be needed to increase interventional success. Case Report: A 63-year-old female with severe peripheral artery disease presented with a 2-month nonhealing wound on the dorsum of her left foot despite wound care. We inserted a 65-cm Destination Guiding Sheath and crossed the right superficial femoral artery (SFA) chronic total occlusion (CTO) that we initially treated with a 4.0-mm Ultraverse balloon. We attempted unsuccessfully to cross the distal anterior tibial artery into the dorsalis pedis artery. We obtained antegrade access of the posterior tibial artery at the level of the ankle with a 2.9-French Cook pedal access kit. We inserted a 90-cm CXI catheter with a 0.014 Fielder XT wire and used the lateral plantar artery as a conduit to cross the dorsalis pedis artery and distal anterior tibial artery CTO with retrograde wire manipulation via lateral plantar artery. Finally, we performed distal anterior tibial and dorsalis pedis CTO balloon angioplasty with a 2.5 × 220-mm Ultraverse balloon and performed SFA percutaneous transluminal angioplasty and stenting with a 7.0 × 120-mm Zilver PTX stent, postdilated with a 6.0-mm Ultraverse balloon. We successfully established in-line flow to the foot with 3-vessel runoff. The patient's wound healed in a month. Conclusion: Retrograde pedal access can improve the success rate of recanalization of below-the-knee disease in patients with CLI.

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Section: Discussionmentioning

confidence: 99%

Successful Revascularization of Infrapopliteal Chronic Total Occlusions Using the Plantar Arch as a Conduit and Retrograde Pedal Access

Bob‐Manuel

Obi²,

N’Dandu

2021

TOJ

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“…However, 30-day endpoints remain of particular interest in the clinical setting of CLTI, as interventions are often performed to facilitate immediate limb salvage and wound healing in patients with severe underlying comorbidities. 18,19 In general, atherectomy provides a means of endovascular removal of soft and calcified atheromatous plaque typically adherent to the walls of chronically diseased arteries, often referred to as "debulking." Aside from luminal gain, atherectomy of predominantly calcific plaque has been shown to increase vascular compliance, as demonstrated by a decrease in maximal balloon inflation pressures.…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Atherectomy with balloon angioplasty compared to balloon angioplasty alone for the treatment of chronic limb threatening ischemia: A national surgical quality improvement program database analysis

et al. 2020

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Objectives To compare perioperative outcomes related to atherectomy with percutaneous transluminal angioplasty versus percutaneous transluminal angioplasty alone for the treatment of lower extremity chronic limb threatening ischemia using a national patient database. Methods Patients with chronic limb threatening ischemia treated with atherectomy and percutaneous transluminal angioplasty or percutaneous transluminal angioplasty alone from 2011 to 2016 in the National Surgical Quality Improvement Program database were identified. Primary outcomes were major adverse limb events (30-day untreated loss of patency, major reintervention, major amputation) and major adverse cardiac events (cardiac arrest, composite outcome of myocardial infarction or stroke). Secondary outcomes included 30-day mortality, length of stay, and any unplanned readmission within 30 days. Multivariate regression analyses were performed to determine independent predictors of outcome. Propensity score matched cohort analysis was performed. A p-value <0.05 was considered statistically significant. Subgroup analyses of femoropopliteal and infrapopliteal interventions were performed. Results In total, 2636 (77.2%) patients were treated with percutaneous transluminal angioplasty and 778 (22.8%) were treated with atherectomy and percutaneous transluminal angioplasty. Multivariate analyses of the unadjusted cohort revealed no significant differences in major adverse cardiac events or major adverse limb events between the two groups ( p-value >0.05). Subgroup analysis of femoropopliteal interventions demonstrated a significantly decreased likelihood of untreated loss of patency in 30 days in the atherectomy group compared to the percutaneous transluminal angioplasty group (1.1% vs. 2.7%, respectively; p-value = 0.034), which persisted on propensity score matched analysis (1.1% vs. 3.1%, respectively; p-value = 0.026). Conclusion Atherectomy with balloon angioplasty of femoropopliteal disease provides a significant decrease in untreated loss of patency compared to balloon angioplasty alone.

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“…9,[13][14][15] The consequences of amputation are dire. 9,14,15 For example, following an initial lower extremity amputation due to CLI, 27% of the patients will have one or more re-amputation(s) within 1 year, 16 35% will require proximal extension of the initial amputation site, 17 and 55% of those with PAD will require contralateral limb amputation within 2 to 3 years. 18 Mortality after nontraumatic amputation is also very high, with 1-year rates of 9% to 33% 16,17,19,20 rising to 26% to 82% at 5 years.…”

mentioning

confidence: 99%

“…16,[19][20][21] Despite the fact that rates of amputation in the general PAD population are declining, an estimated 150,000 amputations due to CLI occur annually in the United States, 2,22 and primary amputation continues to be firstline therapy for CLI at some institutions, with an average rate of ~20%. 9,[13][14][15]23 Surprisingly, of the patients who undergo primary amputation, 73% do not have diagnostic angiography 23 and 54% receive no revascularization attempts prior to the amputation. 24 This trend is also seen in Europe; researchers there have noted that 37% of the amputated CLI patients had not undergone angiography or revascularization during their index hospital stay or in the 2 years prior.…”

mentioning

confidence: 99%

Digital Subtraction Angiography Prior to an Amputation for Critical Limb Ischemia (CLI): An Expert Recommendation Statement From the CLI Global Society to Optimize Limb Salvage

Mustapha¹,

Saab²,

Martinsen

et al. 2020

J Endovasc Ther

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Despite recent guideline updates on peripheral artery disease (PAD) and critical limb ischemia (CLI) treatment, the optimal treatment for CLI is still being debated. As a result, care is inconsistent, with many CLI patients undergoing an amputation prior to what many consider to be mandatory: consultation with an interdisciplinary specialty care team and a comprehensive imaging assessment. More importantly, quality imaging is critical in CLI patients with below-the-knee disease. Therefore, the CLI Global Society has put forth an interdisciplinary expert recommendation for superselective digital subtraction angiography (DSA) that includes the ankle and foot in properly indicated CLI patients to optimize limb salvage. A recommended imaging algorithm for CLI patients is included.

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Worth an Arm and a Leg: The Critical Importance of Limb Ischemia

Cited by 6 publications

References 22 publications

Successful Revascularization of Infrapopliteal Chronic Total Occlusions Using the Plantar Arch as a Conduit and Retrograde Pedal Access

Successful Revascularization of Infrapopliteal Chronic Total Occlusions Using the Plantar Arch as a Conduit and Retrograde Pedal Access

Atherectomy with balloon angioplasty compared to balloon angioplasty alone for the treatment of chronic limb threatening ischemia: A national surgical quality improvement program database analysis

Digital Subtraction Angiography Prior to an Amputation for Critical Limb Ischemia (CLI): An Expert Recommendation Statement From the CLI Global Society to Optimize Limb Salvage

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