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Limb ischemia, acute [keywords]
- Overview of classification systems in peripheral artery disease. [Journal Article, Review]
- Semin Intervent Radiol 2014 Dec; 31(4):378-88.
Peripheral artery disease (PAD), secondary to atherosclerotic disease, is currently the leading cause of morbidity and mortality in the western world. While PAD is common, it is estimated that the majority of patients with PAD are undiagnosed and undertreated. The challenge to the treatment of PAD is to accurately diagnose the symptoms and determine treatment for each patient. The varied presentations of peripheral vascular disease have led to numerous classification schemes throughout the literature. Consistent grading of patients leads to both objective criteria for treating patients and a baseline for clinical follow-up. Reproducible classification systems are also important in clinical trials and when comparing medical, surgical, and endovascular treatment paradigms. This article reviews the various classification systems for PAD and advantages to each system.
- Clinical assessment of patients with peripheral arterial disease. [Journal Article, Review]
- Semin Intervent Radiol 2014 Dec; 31(4):292-9.
Peripheral arterial disease (PAD) describes the clinical manifestations of atherosclerosis affecting the circulation in the legs. The severity of PAD is classified according to symptom severity, time course, and anatomical distribution. The signs and symptoms of PAD reflect the degree of circulatory compromise and whether there has been a gradual reduction in the circulation or an abrupt, uncompensated decrease. Accurate clinical assessment underpins decisions on management strategy and should objectively assess the severity of the ischemia and need for revascularization. Clinical history should discriminate symptoms of PAD from other conditions presenting with leg pain, elucidate cardiovascular risk factors and the effect of symptoms on the patient's quality of life. Clinical examination includes signs of general cardiovascular disease and associated conditions before assessing the circulation and viability of the limb. Palpation of peripheral pulses must be augmented by determination of the ankle brachial pressure index using hand held Doppler. A whole patient approach to management is required and must include modification of cardiovascular risk status as well as dealing with the local circulatory manifestation of PAD.
- Hypothermic, initially oxygen-free, controlled limb reperfusion for acute limb ischemia. [JOURNAL ARTICLE]
- Ann Vasc Surg 2014 Nov 26.
Controlled limb reperfusion has been shown to prevent the deleterious effects of ischemia-reperfusion (IR) syndrome following revascularisation of acute limb ischemia (ALI). To reduce the production of cell-toxic oxygen free radicals, we have established a new initially oxygen-free, hypothermic, heparin-coated perfusion and hemofiltration system and report on our first results.In a retrospective single center study, controlled limb reperfusion was applied in 36 patients (64.7±15 years) with ALI of category IIA to III (33.7±20.7 hours ischemic time). 52.8% had central (aortic and bifurcation) and 47.2% had peripheral (common iliac artery and distal) vascular occlusions. The common femoral artery and vein were cannulated, and a hypothermic (22°C), initially oxygen-free, potassium-free ringer's solution was perfused using a heparin-coated extracorporeal membrane oxygenation (ECMO) and hemofiltration system with low-dose heparinization. 30-day mortality, clinical recovery of neurological dysfunction, limb amputation and fasciotomy rate were analysed. Laboratory parameters associated with ischemia and IR injury were determined.Average perfusion time was 94±35 minutes. 30-day mortality was 27.8%. 55.5% of patients showed complete recovery of motor and sensory dysfunction. 27.8% developed a compartment syndrome and required fasciotomy. Lower leg amputation was necessary in 11.1%. Lactate levels were reduced in ischemic limbs by 25.3% within 60 minutes (P<.05). Preoperative negative base excess of -1.96±0.96 mmol/L was equalized after 12 hours (P<.05) while pH stayed balanced at 7.4. Serum potassium stayed within normal limits throughout 24 hours and therefore, systemic hyperkalemia was prevented, and imminent metabolic acidosis was corrected.An initially oxygen-free, hypothermic, heparin-coated ECMO counteracts local and systemic effects of IR injury. Reduced mortality and morbidity might result from this new treatment, although this could not be conclusively proven in our study. A prospective, randomized controlled trial is needed to prove superiority of this new concept.
- Interval exercise, but not endurance exercise, prevents endothelial ischemia-reperfusion injury in healthy subjects. [JOURNAL ARTICLE]
- Am J Physiol Heart Circ Physiol 2014 Nov 21.:ajpheart.00647.2014.
Background:Endothelial ischemia-reperfusion injury (IR-injury) importantly contributes to the poor prognosis during ischemic (myocardial) events. Preconditioning, i.e. repeated exposure to short periods of ischemia, effectively reduces endothelial IR-injury. In this study, we examined the hypothesis that exercise has preconditioning effects on endothelial IR-injury. Therefore, we studied whether an acute bout of endurance or interval exercise is able to protect against endothelial IR-injury.
Methods:In 17 healthy young subjects, we examined changes in brachial artery endothelial function using flow-mediated dilation (FMD) before- and after a bout of high-intensity interval exercise, moderate-intensity endurance exercise or a control intervention. Subsequently, IR-injury was induced by inflation of a blood pressure cuff around the upper arm to 220 mmHg for 20-min and 20-min of reperfusion, followed by another FMD measurement. Near infrared spectrometry was used in order to examine local tissue oxygenation during exercise.
Results:No differences in brachial artery FMD were found at baseline for the three conditions. IR induced a significant decline in FMD (7.1±2.3 to 4.3±2.3; P<0.001). When preceded by the interval exercise bout, no change in FMD was present after IR (7.7±3.1 to 7.2±3.1; P=0.56), whilst the decrease in FMD after IR could not be prevented by the endurance exercise bout (7.8±3.1 to 3.8±1.7; P<0.001).
Conclusions:A single bout of lower limb interval exercise, but not moderate-intensity endurance exercise, effectively prevents brachial artery endothelial IR-injury. This indicates the presence of a remote preconditioning effect of exercise, which is selectively present after short-term interval, but not continuous exercise in healthy young subjects.
- Popliteal artery thrombosis following total knee arthroplasty managed successfully with percutaneous intervention. [Journal Article]
- BMJ Case Rep 2014.
Acute popliteal artery thrombosis is a rare complication following total knee arthroplasty (TKA), with sequelae including critical limb ischaemia and amputation. We report the case of a 54-year-old woman who developed acute popliteal artery thrombosis following TKA, presenting 2 weeks after the initial symptoms. While such cases have been traditionally managed with surgical thrombectomy or bypass grafting, percutaneous aspiration thrombectomy is an emerging alternative management strategy in the early postoperative period. However, in patients in whom intervention is delayed, the efficacy of percutaneous aspiration thrombectomy is not known. Our patient had complete resolution of thrombus following percutaneous thrombus aspiration, angioplasty and tirofiban administration. Prompt diagnosis and early percutaneous intervention may avert critical limb ischaemia in patients presenting with popliteal artery thrombosis following TKA.
- Characterization of acute ischemia-related physiological responses associated with remote ischemic preconditioning: a randomized controlled, crossover human study. [Journal Article]
- Physiol Rep 2014 Nov 1; 2(11)
Remote Ischemic Preconditioning (RIPC) is emerging as a new noninvasive intervention that has the potential to protect a number of organs against ischemia-reperfusion (IR) injury. The standard protocols normally used to deliver RIPC involve a number of cycles of inflation of a blood pressure (BP) cuff on the arm and/or leg to an inflation pressure of 200 mmHg followed by cuff deflation for a short period of time. There is little evidence to support what limb (upper or lower) or cuff inflation pressures are most effective to deliver this intervention without causing undue discomfort/pain in nonanesthetized humans. In this preliminary study, a dose-response assessment was performed using a range of cuff inflation pressures (140, 160, and 180 mmHg) to induce limb ischemia in upper and lower limbs. Physiological changes in the occluded limb and any pain/discomfort associated with RIPC with each cuff inflation pressure were determined. Results showed that ischemia can be induced in the upper limb at much lower cuff inflation pressures compared with the standard 200 mmHg pressure generally used for RIPC, provided the cuff inflation pressure is ~30 mmHg higher than the resting systolic BP. In the lower limb, a higher inflation pressure, (~55 mmHg > resting systolic BP), is required to induce ischemia. Cyclical changes in capillary blood O2, CO2, and lactate levels during the RIPC stimulus were observed. RIPC at higher cuff inflation pressures of 160 and 180 mmHg was better tolerated in the upper limb. In summary, limb ischemia for RIPC can be more easily induced at lower pressures and is much better tolerated in the upper limb in young healthy individuals. However, whether benefits of RIPC can also be derived with protocols delivered to the upper limb using lower cuff inflation pressures and with lesser discomfort compared to the lower limb, remains to be investigated.
- Electrical injuries. Biological values measurements as a prediction factor of local evolution in electrocutions lesions. [Journal Article, Research Support, Non-U.S. Gov't]
- J Med Life 2014 Jun 15; 7(2):226-36.
Taking into account the incidence and the severity of electrocutions, we consider it extremely necessary to find effective, appropriate and particularized therapeutic solutions aimed at improving the survival, decreasing the mortality, ensuring a superior functional and aesthetic effect and facilitating the social reintegration. Given the severity of the general condition of the electrically injured patient and the fact that any worsening of the lesions has a systemic echo, the selection of the timing for re-excision is very important. The postponement of the surgical timing can break the precarious metabolic equilibrium and can hasten the installation of the multisystem organ failure (MSOF).The study is intended to establish a possible connection between the clinical evolution of the electrically injured patient and the dynamics of three important biological parameters, able to provide data concerning the therapeutic attitude to be followed. The patients with a diagnostic of high-voltage electrocution, who will be admitted to the Clinic, will be followed for a period of 2 years. The parameters to be followed daily will be: - Creatin-kinase, as a marker of muscular damage. - Hemoglobin, as a marker of tissue oxygenation. - Leukocytes, as an indicator of a possible septic evolution. The therapeutic alternatives, including the administration of antiplatelet drugs will be studied.In the period October 2010-June 2013 a total of 12 cases of high-voltage electrocution were admitted in our clinic. Among these, some could be placed in the study of 7 cases, as the remaining patients died within the first 24 hours of hospitalization due to the endured lesions. All the patients were admitted to the ICU ward that supported the treatment and monitoring until their stabilization, at which time they were transferred to the ward. All the patients received anti-thromboxane treatment from their admission (injectable NSAIDs associated with antisecretory drugs). By mutual agreement with ICU service, Dipyridamole was not introduced because of the "steal effect" in the viable areas to the detriment of the already ischemic areas, the drug effect being obvious in vitro, but hard to be proven in the clinical case. The relationship between the CK level and the clinical appearance of the ischemic areas is relative. We cannot conclude that an increased level of CK is equivalent to an enlarged ischemic area and even less it does not provide us direct information concerning the best time for re-excision. The presence of a viable blood supply around the necrotic tissue will lead to an important resorption of degradation products in that area, a quasinormal level of CK having no value. The sealing of the necrosis areas and the lack of immediate resorption does not have a positive prognostic value. Taking into account that the electrocutions are mostly multiple injuries, the CK level can increase even after some muscular damages, fractures, independent of the actual electrocution lesion. In one case, the patient suffered from electrocution at both thoracic limbs. With the carbonization of the hands and grifa installed up to the level of the elbow fold, he stayed for 6 hours at the accident site until he had been recovered. At the moment of presentation to the hospital, his consciousness condition was satisfactory but the CK level was of over 20000 IU, becoming rapidly non-detectable, in combination with black urine. The patient's condition deteriorated quickly, and, although the bilateral shoulder disarticulation has been carried out, he died in the next 12 hours.As a conclusion, the CK level did not prove itself a prognostic for the surgical timing or the actual surgical attitude and could be influenced by a whole series of factors, dependent or not on the electrocution lesion. A radical attitude is to be preferred in cases with established ischemia; the prognostic being the more reserved the larger the damage and the longer the period of time from the event. The established treatment is of renal support and treatment of acute renal injury (AKI) subsequently installed. An increased level of leukocytes is always present as in any severe trauma, even if there are no immediate signs of infection of the electrocution lesions. Taking into account that the electrocution lesion as well as the one caused by burning destroys the natural defense barrier represented by the skin, the infection risk is major and that is why the therapeutic protocol stipulates the immediate establishment of a treatment with broad-spectrum antibiotics or with an association of antibiotics. The increase of the leukocytes level under antibiotics treatment involves either the contamination with a germ that is not sensitive to the respective antibiotic or the persistence of necrosis areas which secondarily infect, and where antibiotic penetration is very low. Therefore, the excision of the compromised tissues is an absolute necessity. In terms of prognostic, the increase of the leukocytes number signified an insufficient excision and indicated the resuming and deepening of the excisions. Taking into account that the patient has been admitted through the ICU service, the risk of contracting severe infections with selected germs is real. Another risk is that of infection with Clostridium difficile following the prolonged utilization of broad-spectrum antibiotics, especially in patients with associated diseases and reduced immunity per primam. The existence of completely separate circuits should solve the problem of contamination with bacteria of selected species; unfortunately, in our cases, we have faced this problem and the utilization of last choice antibiotics (Imipenem, Vancomycin, Targocid, etc.) as well as the association of immunoglobulins was necessary. All the patients admitted in the study received anti-thromboxane drugs in order to limit the ischemic process at tissue level. Despite the efforts we have made, the lack of blood and its derivatives or simply the negligence in patient monitoring, allowed the decrease, even transient of the Hb level, sometimes only for a few hours, but enough to allow the deepening of the ischemic lesions. Excisions were carried out in all the patients in emergency or even amputations of the extremities, with the wish to limit the extension of the ischemic lesions and the resorption of cell degradation products. The amputations performed in emergency did not always represent a saving solution; however, they remained the most effective measures when they were carried out immediately after the accident and obviously in viable tissue. The increase of CK is not an indicative factor itself in making re-excisions but orients the therapeutic approach, the utilization of the dialysis when the values do not decrease by treatment for renal support and the forcing of diuresis is required. The normalization of CK indicates the time when we can start the covering of the defects resulted as a consequence of the excisions. The level of the leukocytes represents both a prognostic factor and an indicative factor for the re-excision of the ischemic areas. An increased level under antibiotic therapy signifies either an incomplete excision or the contamination with flora resisting to the antibiotic that has been used. In the light of findings in the caring of the patients with electrocutions, I propose several caring/assessment protocols for the severe electrically injured patient.
- Patient delay is the main cause of treatment delay in acute limb ischemia: an investigation of pre- and in-hospital time delay. [Journal Article]
- World J Emerg Surg 2014; 9(1):56.
The prognosis of acute limb ischemia is severe, with amputation rates of up to 25% and in-hospital mortality of 9-15%. Delay in treatment increases the risk of major amputation and may be present at different stages, including patient delay, doctors´ delay and waiting time in the emergency department. It is important to identify existing problems in order to reduce time delay. The aim of this study was to collect data for patients with acute limb ischemia and to evaluate the time delay between the different events from onset of symptoms to specialist evaluation and further treatment with focus on pre-hospital and in-hospital time delays.We conducted a prospective cross-sectional cohort study including all patients suspected with acute limb ischemia who were admitted to the emergency department of a community hospital in a six months period. Temporal delay in the different phases between the time of occurrence of symptoms and completion of treatment was recorded prospectively. All patients who underwent intervention had a 30 days follow-up with regard to major amputation of the leg and survival.A total of 42 patients (21 men and 21 women) age 73 (20-95) years (median (range)) was identified. From onset of symptoms to first contact with a doctor the time for all patients were 24 (0-1200) hours. Thirty patients needed immediate intervention. In the group of fourteen patients who had immediate operation, the median time from vascular evaluation to revascularization was 324.5 (122-873) minutes and in the group of eight patients that went through an imaging procedure before an operation the median delay was 822 (494-1185) minutes from specialist assessment to revascularization. The median time for revascularization among four patients, who were treated with arterial thrombolysis was 5621 (1686-8376) minutes. At 30 days follow up, six patients had had the ischemic limb amputated above the ankle and four patients had died.We found that the largest time delay was between onset of symptoms and first contact to a medical doctor. A greater public awareness is needed, so as to facilitate urgent revascularisation and improve outcomes.
- Impact of duplex arterial mapping on decision making in non-acute ischemic limb patients. [JOURNAL ARTICLE]
- Int Angiol 2014 Nov 14.
to demonstrate the impact of duplex arterial mapping on decision making in non--acute ischemic limb patient group reporting pain onset between 15 days and 3 months.We prospectively evaluated patients presented with critical limb ischemia who reported pain onset of duration between 15 days and 3 months in one--year period. Our series included thirty cases (mean age = 61.3 years old), as duplex arterial mapping was the sole preoperative imaging tool performed in all of them. All patients, in whom duplex indicated thrombosis in long occluded segments, were candidates for fluoroscopically guided thrombectomy. When duplex defined chronic arterial occlusions, patients underwent endovascular or bypass revascularisation procedures. Impact of duplex wall interrogation on decision--making between the 2 groups (subacute and chronic) was measured.Duplex arterial mapping categorised correctly all 30 patients into either subacute ischemia with removable clot (n=14) or chronic ischemia (n=16). Fluoroscopic guided thrombectomy was performed in 14 cases when duplex advised long occluded arterial segments as indicted by intact intima with echogenic thrombus inside. Bypass surgery was performed in 8 patients. PTA was done in 7 cases and thrombendartrectomy of common femoral artery in a single case. One--year patency rate in our series was 86.6%. It was 71.4% in thrombosis group. Limb salvage rate was 93.3%.Duplex arterial mapping could be used to differentiate the subacute ischemia with removable thrombus and chronic arterial occlusions guiding for the best revascularization procedure accordingly.
- Acute lower limb ischemia complicating pemetrexed and carboplatin combination chemotherapy for malignant pleural mesothelioma. [Journal Article]
- Ann Ital Chir 2014; 85(ePub)
Pemetrexed and Carboplatin are two well-known chemioterapic agents used for the treatment of many tumors, especially for lung cancer and mesothelioma. Peripheral ischemic events related to Pemetrexed and Carboplatin are rarely reported. We herein report a case of lower limb acute ischemia related to combined treatment of Pemetrexed and Carboplatin. A 68-year-old woman was given the chemiotherapic treatment with combination of Pemetrexed and Carboplatin after pleural resection for a malignant pleural mesothelioma. Immediately after the second cycle of treatment, the patient experienced sudden acute left lower limb ischemia. Symptoms resolved after an intra-operative thrombolytic and spasmolytic therapy.Acute ischemia, Chemotherapy, Endovascular treatment, Malignant Pleural Mesothelioma.