Background: We studied whether a 6‐month group‐mediated cognitive behavioral (GMCB) intervention for peripheral artery disease (PAD) participants, which promoted home‐based walking exercise, improved 6‐minute walk and other outcomes at 12‐month follow‐up, 6 months after completing the intervention, compared to a control group.
Purpose: To describe the use of transvascular autonomic modulation (TVAM) to improve cardiovascular autonomic nervous system (ANS) dysfunction in multiple sclerosis (MS) patients, comparing the safety and efficacy of this modified technique with traditional balloon angioplasty.
Although it is a relatively rare complication of endovascular therapy for patients with critical limb ischemia (CLI),1-3 distal embolization from atherothrombotic debris still remains a concern due to the major adverse events that may follow. These complications can in turn lead to additional procedures, increased limb amputation and mortality rates, as well as extended hospital stays and escalating hospitalization costs. The amount of dislodged thromboembolic material relies on many factors, ranging from lesion characteristics to revascularization techniques and the devices used.3,4 It has been documented that atherectomy and stent deployment induce dislodgement of more atherothrombotic material compared to percutaneous transluminal angioplasty (PTA) alone, and as expected, Transatlantic Inter-Society Consensus (TASC) C and D lesions tend to embolize more debris than lower-grade lesions.5
During the past 15 years, the number of major dysvascular amputations (defined as amputations above the ankle) performed annually has decreased. However, major amputation (MA) continues to be a primary therapy and is frequently the only treatment offered for critical limb ischemia (CLI).1,2
Critical limb ischemia (CLI) (characterized by rest pain and/or nonhealing ulcers) is a worldwide emergency because it frequently results in major limb amputation, which is a devastating event with profound physical, psychological, and work-related implications.1 Often, CLI appears along with “diabetic foot,” a chronic affliction of the lower extremities, with a lifetime risk that is estimated at approximately 15% for diabetics.2,3 It is caused by micro- and/or macrovascular complications of diabetes (sensory neuropathy, atherosclerosis, and motor, autonomic, or proprioceptive alterations) and by the altered response and resistance to infection.4 The macroangiopathy can also affect the coronary and cerebral anatomy.5
Multiple authors have published data on outcomes after endovascular therapy for complex tibioperoneal disease, demonstrating a staggering 20% to 40% technical failure rate with the antegrade approach.1,2 Unfortunately, due to the high morbidity in the population with critical limb ischemia, it is not rare that they are deemed unfit for open surgery. However, advancements in device technology and technical skills have resulted in higher technical success rates. This article describes the steps of and technical tips for one such technique: retrograde access.
Historically, the initial treatment of choice for revascularization of patients with critical limb ischemia (CLI) was lower extremity bypass grafting with autologous vein.1 With the publication of the randomized PREVENT III trial, it became apparent that real-world open revascularization for CLI patients carried 30-day rates of graft failure, perioperative mortality, and myocardial infarction of 5.2%, 2.7%, and 4.7%, respectively, as well as an overall primary graft patency rate of 61% at 1 year.2 As endovascular techniques and technologies have evolved, the paradigm of lower extremity revascularization has shifted. The BASIL (Bypass Versus Angioplasty in Severe Ischemia of the Leg) trial was the first randomized study of patients with CLI and infrainguinal disease; however, it failed to show a significant difference in amputation-free survival (AFS) between revascularization modalities.3 With the advent of newer approaches, it has been found that octogenarian CLI patients and those with high operative risk, such as patients with advanced kidney failure or end-stage renal disease, benefit from revascularization and should therefore be considered for an endovascular-first approach.4,5
By definition, critical limb ischemia (CLI) is the presence of ischemic rest pain or nonhealing wounds for > 2 weeks in the presence of reduced perfusion to the affected limb.1 The thresholds to define reduced perfusion commonly include an ankle pressure < 50 to 70 mm Hg or a first toe pressure < 30 to 50 mm Hg.2 Clinically, it can at times be difficult to attribute ischemia as the sole cause of a wound; however, ischemia may still contribute to poor healing. There is a strong association between CLI and amputation and death.3 Revascularization is often pursued to avoid amputation or to limit the extent of amputation with the goal of improving quality of life.
Critical limb ischemia is a major cause of morbidity and mortality worldwide and is characterized by multilevel disease, often involving the tibiopedal vessels. There are some reports that the atherosclerotic pattern in diabetic patients affects the tibial vessels yet tends to spare the pedal vasculature.1,2 Although this may be true in many cases, our experience has demonstrated frequent involvement of the pedal vessels, including the pedal arch. In a subset of patients with critical limb ischemia, particularly in longstanding type 1 diabetic patients and patients on dialysis, a predominance of disease involving the pedal vessels can exist with relative sparing of the tibial vessels.3
Today, critical limb ischemia (CLI) due to diabetic arterial disease is a major worldwide cause of morbidity and mortality,1,2 affecting a large number of patients and can lead to severe disabilities. In fact, major amputations are usually associated with significant increases in mortality risk, and every effort should be pursued to minimize amputations and ensure limb salvage.3
Critical limb ischemia (CLI) occurs as an arterial stenosis approaches a critical point, compromising blood flow to the distal extremity and thus falling short of the basal tissue oxygen demand.1,2 As a result, patients present with rest pain and/or nonhealing ulceration and comprise approximately 1% to 2% of the peripheral arterial disease (PAD) population.3 Nearly 40% of patients with CLI require amputation, and roughly 150,000 amputations occur annually.4,5
Lower extremity peripheral artery disease (PAD) affects more than 8 million people in the United States and in excess of 202 million people globally. PAD is associated with a high prevalence of coincident coronary artery disease and cerebrovascular disease, which serves to increase morbidity and mortality in this population.1-5 For patients with symptomatic lower extremity PAD, assuagement of pain, prevention of amputation, preservation of ambulatory/functional status, cardiovascular protection, and containment of health care cost are important.6 The safety, efficacy, and lower cost of endovascular interventions compared to surgical revascularization for the treatment of PAD have been previously demonstrated.7,8
Existing endovascular options for lower extremity and visceral arterial thromboembolism face the challenges of limited trackability, vessel injury, and incomplete revascularization. At the forefront of advances in catheter materials and technology, Penumbra, Inc. recently introduced the Indigo™ System for mechanical thrombectomy in the periphery. The Indigo System is designed to address the limitations of conventional technology, bringing greater trackability and the power of large-bore catheters and the Indigo pump to the peripheral vasculature.
Background Current guidelines recommend that patients with peripheral arterial disease (PAD) cease smoking and be treated with aspirin, statin medications, and angiotensin‐converting enzyme (ACE) inhibitors. The combined effects of multiple guideline‐recommended therapies in patients with symptomatic PAD have not been well characterized.
Background: Vorapaxar is a novel antagonist of protease-activated receptor-1, the primary receptor for thrombin on human platelets that is also present on vascular endothelium and smooth muscle. Patients with peripheral artery disease are at risk of systemic atherothrombotic events, as well as acute and chronic limb ischemia and the need for peripheral revascularization.
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