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Context 1
... clinical assessment. The clinical presentation of ALI depends on the location and duration of the arterial occlusion, the presence of collateral circulation, and the metabolic changes related to tissue ischaemia. Typically, after occlusion of a native artery, the signs of ischaemia are located one level / joint distal to the level of occlusion (Fig. ...
Context 2
... in long term damage by contracture, or even limb loss. Prophylactic fasciotomy is seldom indicated, but if the arm has been ischaemic for many hours and swells considerably after successful embolectomy, fasciotomy is indicated. If it is indicated, volar fasciotomy is suggested, but concurrent dorsal fasciotomy is also recomended by some authors (Fig. 13). 277 Advice and assistance from orthopaedic, hand, or plastic surgeons may be necessary. Recommendation ...
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Citations
... Los stents liberadores de fármacos autoexpansibles también muestran mayor permeabilidad a largo plazo en comparación con la angioplastia con balón con stent provisional. 16 En el caso de la revascularización quirúrgica, la precisa planificación preoperatoria es esencial. Se prefiere el uso de la vena safena autógena ipsilateral como conducto para los injertos de derivación infragenicular. ...
... La calidad del conducto es crucial para el éxito de la derivación y tiene repercusiones directas en los resultados de permeabilidad a corto y largo plazo. 16 Por otro lado, la normalización farmacológica de los cambios microcirculatorios puede mejorar los resultados de la revascularización y es la única opción en pacientes en los que la revascularización es imposible o ha fracasado. 15,16 Los prostanoides actúan impidiendo la activación de plaquetas y leucocitos y protegen el endotelio vascular. ...
... 16 Por otro lado, la normalización farmacológica de los cambios microcirculatorios puede mejorar los resultados de la revascularización y es la única opción en pacientes en los que la revascularización es imposible o ha fracasado. 15,16 Los prostanoides actúan impidiendo la activación de plaquetas y leucocitos y protegen el endotelio vascular. Una revisión sistemática y un metaanálisis recientes sobre el uso de prostanoides para ICE incluyeron 20 ECA con un total de 2724 participantes. ...
La isquemia crítica de las extremidades (ICE) es la forma más grave y avanzada de la enfermedad arterial periférica (EAP), conllevando a importantes niveles de morbilidad y mortalidad, así como a altos costos asociados a su tratamiento. Se asocia con un alto riesgo de amputación e infección local, y las complicaciones cardiovasculares siguen siendo motivo de preocupación. A pesar de los avances en diagnóstico y terapéutica, la ICE sigue siendo manejada de forma subóptima, especialmente en centros sin suficiente experiencia. Esta revisión tiene como objetivo ofrecer un resumen actualizado que aborde la complejidad de la ICE, incluyendo datos epidemiológicos, evaluación de factores de riesgo cardiovascular, diagnóstico, opciones de tratamiento, estratificación pronóstica y posibles estrategias en el manejo médico, endovascular y quirúrgico.
... The value of revascularization is no longer debated [10]. Depending on the indication (i.e., ALI or elective setting), patient characteristics, and the presence of an adequate saphenous vein, an open PAA repair (OPAR) is considered to be the gold standard of treatment, especially when compared with an endovascular PAA treatment (EPAR) [11]. However, in the emergency setting, additional endovascular procedures such as preoperative lysis and covered stenting have been performed more frequently in recent years [2,11,12]. ...
... Depending on the indication (i.e., ALI or elective setting), patient characteristics, and the presence of an adequate saphenous vein, an open PAA repair (OPAR) is considered to be the gold standard of treatment, especially when compared with an endovascular PAA treatment (EPAR) [11]. However, in the emergency setting, additional endovascular procedures such as preoperative lysis and covered stenting have been performed more frequently in recent years [2,11,12]. Additionally, upon good outflow vessels, EPAR can produce equal results, at least in terms of short-term patency [13]. However, comparative or event-randomized studies are missing and questions remain whether the promising short-and long-term results of OPAR, especially in emergent settings, are altered by the patient, aneurysm, or procedural characteristics, paving the way for EPAR [14]. ...
... The PAA characteristics were the maximum transverse diameter and the number of patent crural outflow vessels before operation as well as asymptomatic and symptomatic disease. The symptoms were defined as a rupture, local pain (no concurrent origin), claudication, tissue loss, deep vein thrombosis (DVT), and an ALI based on the Rutherford classification (I, IIa/b, or III) [11]. All imaging was analyzed by at least two experienced vascular surgeons from the author list. ...
Background/Objectives: A popliteal artery aneurysm (PAA) is traditionally treated by an open PAA repair (OPAR) with a popliteo–popliteal venous graft interposition. Although excellent outcomes have been reported in elective cases, the results are much worse in cases of emergency presentation or with the necessity of adjunct procedures. This study aimed to identify the risk factors that might decrease amputation-free survival (efficacy endpoint) and lower graft patency (technical endpoint). Patients and Methods: A dual-center retrospective analysis was performed from 2000 to 2021 covering all consecutive PAA repairs stratified for elective vs. emergency repair, considering the patient (i.e., age and comorbidities), PAA (i.e., diameter and tibial runoff vessels), and procedural characteristics (i.e., procedure time, material, and bypass configuration). Descriptive, univariate, and multivariate statistics were used. Results: In 316 patients (69.8 ± 10.5 years), 395 PAAs (mean diameter 31.9 ± 12.9 mm) were operated, 67 as an emergency procedure (6× rupture; 93.8% severe acute limb ischemia). The majority had OPAR (366 procedures). Emergency patients had worse pre- and postoperative tibial runoff, longer procedure times, and more complex reconstructions harboring a variety of adjunct procedures as well as more medical and surgical complications (all p < 0.001). Overall, the in-hospital major amputation rate and mortality rate were 3.6% and 0.8%, respectively. The median follow-up was 49 months. Five-year primary and secondary patency rates were 80% and 94.7%. Patency for venous grafts outperformed alloplastic and composite reconstructions (p < 0.001), but prolonged the average procedure time by 51.4 (24.3–78.6) min (p < 0.001). Amputation-free survival was significantly better after elective procedures (p < 0.001), but only during the early (in-hospital) phase. An increase in patient age and any medical complications were significant negative predictors, regardless of the aneurysm size. Conclusions: A popliteo–popliteal vein interposition remains the gold standard for treatment despite a probably longer procedure time for both elective and emergency PAA repairs. To determine the most effective treatment strategies for older and probably frailer patients, factors such as the aneurysm size and the patient’s overall condition should be considered.
... Acute limb ischemia (ALI) is a potentially lethal condition in which the viability of the limb is threatened due to an acute decrease in limb perfusion [1]. Following the Rutherford classification for ALI [2], catheter directed thrombolysis (CDT) is generally the preferred treatment strategy in viable (Rutherford I) or marginally threatened (Rutherford IIa) ALI [1]. ...
... Acute limb ischemia (ALI) is a potentially lethal condition in which the viability of the limb is threatened due to an acute decrease in limb perfusion [1]. Following the Rutherford classification for ALI [2], catheter directed thrombolysis (CDT) is generally the preferred treatment strategy in viable (Rutherford I) or marginally threatened (Rutherford IIa) ALI [1]. The benefit of CDT should be counterbalanced with the inherent associated risk of bleeding complications which remain a major concern when applying CDT. ...
... Moreover, the role of PFL, in general, as predictor for haemorrhagic complications during CDT remains unproven [9]. Currently, the European Society for Vascular Surgery (ESVS) guidelines on ALI do not recommend routine monitoring of PFL during thrombolysis, mainly due to the lack of high quality evidence underlying its practice [1]. This finding advocates the necessity to prospectively investigate the predictive value of PFL, as well as a need for identification of other potential predictors. ...
Introduction
The risk of major bleeding complications in catheter directed thrombolysis (CDT) for acute limb ischemia (ALI) remains high, with reported major bleeding complication rates in up to 1 in every 10 treated patients. Fibrinogen was the only predictive marker used for bleeding complications in CDT, despite the lack of high quality evidence to support this. Therefore, recent international guidelines recommend against the use of fibrinogen during CDT. However, no alternative biomarkers exist to effectively predict CDT-related bleeding complications. The aim of the POCHET biobank is to prospectively assess the rate and etiology of bleeding complications during CDT and to provide a biobank of blood samples to investigate potential novel biomarkers to predict bleeding complications during CDT.
Methods
The POCHET biobank is a multicentre prospective biobank. After informed consent, all consecutive patients with lower extremity ALI eligible for CDT are included. All patients are treated according to a predefined standard operating procedure which is aligned in all participating centres. Baseline and follow-up data are collected. Prior to CDT and subsequently every six hours, venous blood samples are obtained and stored in the biobank for future analyses. The primary outcome is the occurrence of non-access related major bleeding complications, which is assessed by an independent adjudication committee. Secondary outcomes are non-major bleeding complications and other CDT related complications. Proposed biomarkers to be investigated include fibrinogen, to end the debate on its usefulness, anti-plasmin and D-Dimer.
Discussion and conclusion
The POCHET biobank provides contemporary data and outcomes of patients during CDT for ALI, coupled with their blood samples taken prior and during CDT. Thereby, the POCHET biobank is a real world monitor on biomarkers during CDT, supporting a broad spectrum of future research for the identification of patients at high risk for bleeding complications during CDT and to identify new biomarkers to enhance safety in CDT treatment.
... According to the most recent European Society for Vascular Surgery (ESVS) Clinical Practice Guidelines on the Management of Acute Limb Ischemia [65]. ALI is a medical emergency, and it is essential that the diagnosis is established promptly, and appropriate treatment is started in order to prevent limb loss and other severe complication. ...
After the invention of the thromboembolectomy balloon catheter by Fogarty in 1963, surgical revascularization has been considered the gold standard treatment in patients with acute limb ischemia (ALI). ALI is a dramatic event, carrying a high risk of amputation and perioperative morbidity and mortality. The technological advancement of the endovascular era has resulted in the definition and development of a variety of therapeutic options to assure arterial patency. In the 1970s, Dotter first introduced the idea of clot lysis in the treatment of ALI, which was modified to catheter-directed thrombolysis. Nowadays percutaneous thrombectomy devices have widely emerged as excellent alternatives to surgical approaches. Different devices with different mechanisms of function (fragmentation, rheolytic thrombectomy, aspiration) have been developed to overcome the limits of the pre-existing techniques. Every device has peculiar characteristics, points of strength and weaknesses and their use have to be tailored to the patient’s clinical and anatomical setting. In this chapter, the treatment options for ALI are detailed from surgical thromboembolectomy to thrombolysis and current endovascular techniques.
... ALI is usually observed in patients with advanced age and a high number of comorbidities. If the symptoms occur <2 weeks before the patient seeks medical attention, it is considered ALI [2]. For the classification of ALI and determination of its clinical course, the Rutherford Classification System (RS) is used, which is based on the assessment of blood flow in the extremities via Doppler ultrasonography and the evaluation of tissue viability [3]. ...
... Especially in recent years, researchers have examined numerous hematologic and biochemical parameters to determine mortality and risk of amputation in patients who develop ALI. According to the guidelines of the European Society for Vascular Surgery (ESVS), there is no biochemical parameter to predict limb salvage or determine mortality in cases of ALI [2]. NLR is undoubtedly the most studied parameter. ...
Objective
This study aimed to investigate the causes of amputation and the associated biochemical parameters in patients with acute limb ischemia (ALI).
Methods
Patients who presented to our clinic with ALI between January 2012 and January 2022 were deemed eligible for participation. Patients who developed ALI owing to atherosclerosis or atrial fibrillation were included in the study. In contrast, patients who developed ALI owing to trauma, iatrogenic causes, or popliteal artery aneurysms were excluded. Patients' demographic data, biochemical parameters, and hemogram values at the time of admission were retrospectively analyzed.
Results
A total of 374 patients were included in the study. Of them, 57.82% (n = 218) were male and 42.18% (n= 156) were female. Amputation was required in 7.95% (n = 30) of the patients after presenting with ALI and receiving necessary surgical or medical intervention. Multivariate analysis revealed the symptom-to-door time to be the primary factor determining the need for amputation in patients. With each passing hour following the manifestation of symptoms, the risk of amputation increased by 1.3 times [odds ratio (OR): 1.289%, 95% confidence interval (CI): 1.079-1.540 p = 0.05]. The neutrophil-to-lymphocyte ratio (NLR) and other hematological parameters had no effect on amputation in both univariate and multivariate analyses (OR: 1.49%; 95% CI: 0.977-2.287 p = 0.512).
Conclusions
Based on our findings, the main factor affecting the need for amputation in ALI patients was the symptom-to-door time. Biochemical and hematological parameters had no effect on amputation in ALI.
... As current guidelines have not covered evidence-based decision making for optimal revascularization procedure for traumatic artery injury [5,6], an increasing number of publications emerged reporting outcomes based on their center experience [2,[7][8][9] Open surgical repair (OSR) remained as the classic standard procedure for traumatic injuries to the lower extremity arteries with high limb salvage rates [9][10][11]. However, OSR is sometimes accompanied with larger surgical wounds, longer operating time and potentially higher wound complications [12]. ...
Objective
For traumatic lower extremity artery injury, it is unclear whether it is better to perform endovascular therapy (ET) or open surgical repair (OSR). This study aimed to compare the clinical outcomes of ET versus OSR for traumatic lower extremity artery injury.
Methods
The Medline, Embase, and Cochrane Databases were searched for studies. Cohort studies and case series reporting outcomes of ET or OSR were eligible for inclusion. Robins-I tool and an 18-item tool were used to assess the risk of bias. The primary outcome was amputation. The secondary outcomes included fasciotomy or compartment syndrome, mortality, length of stay and lower extremity nerve injury. We used the random effects model to calculate pooled estimates.
Results
A total of 32 studies with low or moderate risk of bias were included in the meta-analysis. The results showed that patients who underwent ET had a significantly decreased risk of major amputation (OR = 0.42, 95% CI 0.21–0.85; I²=34%) and fasciotomy or compartment syndrome (OR = 0.31, 95% CI 0.20–0.50, I² = 14%) than patients who underwent OSR. No significant difference was observed between the two groups regarding all-cause mortality (OR = 1.11, 95% CI 0.75–1.64, I² = 31%). Patients with ET repair had a shorter length of stay than patients with OSR repair (MD=-5.06, 95% CI -6.76 to -3.36, I² = 65%). Intraoperative nerve injury was just reported in OSR patients with a pooled incidence of 15% (95% CI 6%–27%).
Conclusion
Endovascular therapy may represent a better choice for patients with traumatic lower extremity arterial injury, because it can provide lower risks of amputation, fasciotomy or compartment syndrome, and nerve injury, as well as shorter length of stay.
... Therapeutic strategies for ALI may include different approaches on the basis of the severity of the ischemia, the patient's frailty, the presence of comorbidities, and the degree of vascular involvement. These include pharmacological treatments (i.e., IV administration of unfractionated heparins, fibrinolytic therapy), surgical procedures, and endovascular interventions [16,46]. Prompt intervention is essential to maintain limb function and prevent amputation, particularly in cases of severe reversible ALI (Grade IIa/IIb) [47]. ...
... In patients with severe ALI (Grade III), the adverse systemic sequelae associated with ischemia-reperfusion injury, combined with the reduced probability of successfully preserving a functional limb, often make primary amputation the only viable and beneficial strategy [46]. ...
Since the inception of the SARS-CoV-2 pandemic, healthcare systems around the world observed an increased rate of Acute Limb Ischemia (ALI) in patients with a COVID-19 infection. Despite several pieces of evidence suggesting that COVID-19 infection may also worsen the prognosis associated with ALI, only a small number of published studies include a direct comparison regarding the outcomes of both COVID-19 and non-COVID-19 ALI patients. Based on the above, a systematic review and a meta-analysis of the literature were conducted, evaluating differences in the incidence of two major outcomes (amputation and mortality rate) between patients concurrently affected by COVID-19 and negative ALI subjects. PubMed (MEDLINE), Web of Science, and Embase (OVID) databases were scrutinized from January 2020 up to 31 December 2023, and 7906 total articles were recovered. In total, 11 studies (n: 15,803 subjects) were included in the systematic review, and 10 of them (15,305 patients) were also included in the meta-analysis. Across all the studies, COVID-19-positive ALI patients experienced worse outcomes (mortality rates ranging from 6.7% to 47.2%; amputation rates ranging from 7.0% to 39.1%) compared to non-infected ALI patients (mortality rates ranging from 3.1% to 16.7%; amputation rates ranging from 2.7% to 18%). Similarly, our meta-analysis shows that both the amputation rate (OR: 2.31; 95% CI: 1.68–3.17; p < 0.00001) and mortality (OR: 3.64; 95% CI: 3.02–4.39; p < 0.00001) is significantly higher in COVID-19 ALI patients compared to ALI patients.
... 1,2 ALI is characterized by a sudden blockage of arterial blood flow, which can cause pain, loss of function, and skin pallor. 1 CLTI is the final stage of peripheral arterial disease and is characterized by symptoms such as persistent pain, trophic disorders, and impaired mobility. 2 The inflammatory state that dominates ALI increases the number of neutrophils, which are the primary responders to the site of injury, and platelets that adhere to the activated endothelium. ...
Acute limb ischemia (ALI) and chronic limb-threatening ischemia (CLTI) are severe vascular conditions that can be lethal. The inflammatory response in these diseases, characterized by increased levels of neutrophils and platelets, highlights the importance of prompt management. The neutrophil-to-lymphocyte ratio (NLR) has emerged as a useful biomarker during the COVID-19 pandemic and high NLR levels were found to be associated with an increased risk of ALI and other thromboembolic events. The aim of this systematic review was to analyze the prognostic role of the NLR regarding the risk of amputation and mortality in patients diagnosed with ALI and CLTI. We included 12 studies (five for ALI, with 1,145 patients, and seven for CLTI, with 1,838 patients), following the PRISMA guidelines. Treatment results were evaluated, including amputation and mortality. We found that high NLR values were consistently associated with an increased risk of amputation and/or mortality, with pooled odds ratios ranging from 1.28 to 11.09 in patients with ALI and from 1.97 to 5.6 in patients with CLTI. The results suggest that NLR may represent an important tool for informed decision-making in the management of these patients.
... Known rheumatological disease, diseases affecting calcium and phosphorus metabolism, major lower limb traumas in the previous six months, severe osteoporosis, documented allergies to iodine or to iodine-derived medium of contrast, renal impairment with values <45 mL/min of glomerular filtration rate, and congestive heart failure were also considered as exclusion criteria. Other excluded cases were those with clear clinical symptoms of acute limb ischemia [41]. Furthermore, all patients who lacked imaging follow-up or were missing physical examinations performed in our institution were excluded. ...
(1) Background: Type 2 diabetes is a major cause of incidences and the progression of peripheral artery disease (PAD). Bone marrow edema (BME) is an important finding suggestive of underlying bone inflammation in non-traumatic diabetic patients with PAD. Our aim was to evaluate the presence, severity, and clinical implications of BME detected by virtual non-calcium application (VNCa) of dual-energy CT angiography (DE-CTA). (2) Methods: A consecutive series of 76 diabetic patients (55 men; mean age 71.6 ± 11.2 yrs) submitted to lower limb DE-CTA for PAD evaluation and revascularization planning, which were retrospectively analyzed. VNCa images were independently and blindly revised for the presence, location, and severity of BME by two radiologists with 10 years of experience. BME and non-BME groups were evaluated in terms of PAD clinical severity and 6-month secondary major amputation rate. (3) Results: BME was present in 17 (22%) cases, while 59 (78%) patients were non-BME. The BME group showed a significantly higher incidence of major amputation (p < 0.001) and a significantly higher number of patients with advanced clinical stages of PAD compared to the non-BME group (p = 0.024). (4) Conclusions: Lower limb DE-CTA with VNCa application is a useful tool in the detection of BME in diabetic patients with PAD, simultaneously enabling the evaluation of the severity and location of the arterial disease for revascularization planning. BME presence could be a marker of clinically severe PAD and a possible risk factor for revascularization failure.
... Acute limb ischemia (ALI) is a common vascular emergency associated with high mortality and limb loss rates. 1 Despite the widespread use of contemporary vascular imaging and implementation of new percutaneous techniques for revascularization (thrombolysis, mechanical and pharmaco-mechanical thrombectomy), the treatment outcomes of ALI have not improved significantly during the last decades. 2 The time interval from the onset of ischemia till the restoration of perfusion is critically important for the preservation of functional limb and the prevention of systemic complications caused by ischemia-reperfusion syndrome. ...
... It is augmented by evaluation of arterial and venous Doppler signals. 1,5 We hypothesized that severity of foot poikilothermy caused by ischemia could be quantified and used for differentiation of grades of ischemia. Thus, the study aim was an evaluation of the value of non-contact foot thermometry, performed using standard infrared medical thermometer, as an adjunct for clinical diagnosis of immediately threatened ALI. ...
... Audible arterial Doppler signal upon pedal arteries was interpreted as an indicator of non-immediately threatening ALI, and absence of venous signal -as a sign of irreversible ischemia. 1,5 In patients 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 R e v i e w C o p y 5 with audible arterial signal, the ankle-brachial index (ABI) value was calculated; two experienced vascular surgeons determined the ischemia's grade independently, and any discrepancies were resolved through consensus. Preoperative duplex ultrasound and/or computed tomography angiography were used on the discretion of operating surgeon and depending on availability. ...
Objective
We hypothesized that the severity of foot poikilothermy can be used for better differentiation of grades of acute limb ischemia. Thus, the study aim was evaluation of the value of non-contact foot thermometry, performed using a low-cost infrared medical thermometer, as an adjunct for clinical diagnosis of immediately threatened acute limb ischemia.
Methods
It was a single-center observational prospective study performed over 3 years. Patients with acute limb ischemia of lower limbs grade I–IIB Rutherford treated with urgent revascularization were included. Grade of ischemia was determined independently by two experienced vascular surgeons. Thermometry of the ischemic foot was performed using a medical digital infrared non-contact thermometer (CK-T1501, Cooligg, China) with measuring accuracy of ±0.2°C. Temperature was measured in three points: the dorsal surface of the foot, plantar surface of the foot (both in the metatarsal region), and forehead. The maximal temperature gradient between patient’s forehead and foot (∆T max F-F) was calculated. Measurements were repeated 6–12 h after revascularization.
Results
A total of 147 patients were included. Only 3 (2%) patients presented rest pain without sensory loss and motor deficit, while the majority were diagnosed with mild (63/147, 42.8%) or moderate (27/147, 18.3%) motor deficit. The temperature of the ischemic foot varied from 20 to 36.1°C, while median value of the temperature was 26.7 [24.5–29.9] °C on the dorsal surface and 26.8 [24.5–29.6] °C on the plantar surface of the foot ( p = 0.85). Patients with Grade IIB ischemia had significantly lower dorsal foot temperature, plantar foot temperature, and larger ∆T max F-F than the patients with grades I–IIA: 25.1 [23.9–26.8] °C versus 29.9 [27.6–30.8] °C; 25.2 [23.8–27.5] °C versus 29.6 [28–31.1] °C; and 11.6 [9.7–12.8] °C versus 7.2 [6–9] °C ( p < 0.0001). Areas under ROC curve for diagnosis of Grade IIB ischemia were similar for dorsal foot temperature (0.82), plantar temperature (0.81), and ∆T max F-F (0.82). The best cutoff value by Youden was ≥9.5°C for ∆T max F-F, ≤26.8°C for dorsal, and ≤27.7°C for plantar temperature. Criterion ∆T max F-F offered the highest specificity of 86% (95%CI 74.2–93.7) and positive predictive value of 89.2% (95%CI 79.5–93.2), while plantar temperature offered sensitivity of 82.5% (95%CI 70.1–91.3) and negative predictive value of 69.1% (95%CI 57.6–83.2). In multivariate analysis including age, gender, and etiology of arterial occlusion, the criterion ∆T max F-F of ≥9.5°C was a unique variable significantly associated with risk of amputation (adjusted OR 2.6, 95%CI 1.2–5.9, p = 0.01).
Conclusion
Current study demonstrated that patients with immediately threatening ALI have significantly lower foot temperature than those with viable and marginally threatened limbs. Severe foot poikilothermy at admission is associated with poor outcomes of revascularization, mostly with limb loss.
