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Assessing Therapeutic Angiogenesis in a Murine Model of Hindlimb Ischemia
Published on: June 8, 2019
Comparison of endovascular infrapopliteal revascularisation strategies based on the angiosome model in diabetics with
Hans-Ulrich Kreider-Stempfle1, Thomas Remp1, Sibylle Puntscher2
1Asklepios Hospital Bad Tölz, Germany.
Insights
Direct revascularization (DR) and complete revascularization (CR) strategies for diabetic patients with chronic limb-threatening ischemia (CLTI) showed similar positive outcomes. Successful revascularization is key, with collaterals improving outcomes when only indirect revascularization is possible.
Area of Science:
- Vascular Surgery
- Diabetic Limb Complications
- Endovascular Interventions
Background:
- Diabetic patients present unique challenges for infrapopliteal endovascular interventions (EVT) due to diffuse lesions and variable collateral patterns.
- The optimal EVT strategy for diabetic patients with chronic limb-threatening ischemia (CLTI) remains debated.
- This study compares angiosome-based direct revascularization (DR) versus complete revascularization (CR) in diabetic CLTI patients.
Purpose of the Study:
- To analyze and compare the clinical outcomes of DR versus CR infrapopliteal EVT strategies in diabetic CLTI patients.
- To evaluate outcomes when DR or CR strategies fail, necessitating indirect revascularization (IR) or no revascularization.
- To assess the impact of collateral status, defined by pedal arch patency, on clinical outcomes in both groups.
Main Methods:
- A retrospective analysis of 91 consecutive infrapopliteal EVT procedures in 68 diabetic patients (2013-2022).
- Patients were divided into two groups: Group I (DR) and Group II (CR).
- Positive clinical outcome was defined as wound healing and Rutherford category improvement to 0 or 1 at 6 months, compared using Fisher's exact test.
Main Results:
- Successful DR (59%) and CR (47%) strategies yielded similar positive clinical outcomes (92.6% vs. 90.5%, p=0.594).
- Indirect revascularization (IR) showed significantly lower positive outcomes compared to successful DR or CR (33.3% vs. 92.6%, p=0.0003; 40% vs. 90.5%, p=0.001).
- The presence of collaterals (intact pedal arch) significantly improved IR outcomes (66.7% vs. 30.8%).
Conclusions:
- Both DR and CR infrapopliteal EVT strategies achieve similarly high positive clinical outcomes in diabetic CLTI patients when successful.
- Successful revascularization is crucial for favorable outcomes.
- Collateral status and pedal arch patency are important predictors of success, particularly in cases requiring indirect revascularization.
Abstract:
Background: Infrapopliteal endovascular interventions (EVT) strategies in diabetic patients are still in debate because the lesions are more likely to be diffuse with a different pattern of collateral arteries ranging from reduced to normal caliber. The aim of this all-comers study was to analyse the outcome of two different infrapopliteal EVT strategies (Group I: angiosome-based direct revascularization - DR vs. Group II: complete (direct + indirect) revascularization strategy - CR) in diabetic patients with chronic limb-threatening ischemia (CLTI) in 2 time-periods. Furthermore we analysed the outcome if DR or CR failed and only indirect revascularization (IR) or no revascularization was possible. Both groups were differentiated in patients with collaterals, defined as an intact pedal arch (immediate or after pedal PTA). Patients and methods: The database includes 91 consecutive EVT with two intrapopliteal interventional strategies performed in 68 diabetic patients (pts. 24 female, 44 male, mean age 73±10 years) between 2013-2016 and 2017-2022. Positive clinical outcome was defined as wound healing with or w/o minor amputation, combined with a symptom improvement to Rutherford category 0 or 1 after 6 months. The clinical outcome proportions were compared using the Fisher's exact test. Results: Successful DR (59%) and successful CR (47%) strategy demonstrated a similar positive clinical outcome (92.6% vs. 90.5%; p=0.594). Indirect revascularization (Group I: 26%; Group II: 44%) showed a significantly lower positive outcome in comparison to a successful DR as well as CR strategy (33.3% vs. 92.6%, p=0.0003; 40% vs 90.5%, p=0.001). IR outcome improved by the presence of collaterals (66.7% vs. 30.8%). Conclusions: In case of successful intervention, both strategies (DR and CR) yielded a similarly high proportion of positive clinical outcome. The role of collaterals and the pedal arch on the clinical outcome are important in patients in whom only IR was possible.
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