1. A Concept of "Total Vascular Care" for Critical Limb Ischemia:
The Importance of Aggressive Below-the-knee Interventions
and a Multi-disciplinary Team Approach
Department of Radiology, Toho University Sakura Medical Center
Shusuke Kasuya, Noriko Kitamura, Rumiko Kasai, Hitoshi Terada
Department of Radiology, Tokai University Hachioji Hospital / Tokai University School of Medicine
Kazunobu Hashida, Jun Endo, Terumitsu Hasebe*
*Corresponding Author: Terumitsu Hasebe
In the management of critical limb ischemia (CLI)-limb salvage, it is very important to understand the paradigm shift of “total vascular care” and new therapeutic strategies in collaboration with multidisciplinary specialists, including vascular surgeons, cardiologists, plastic surgeons, and nurses. The purpose of this paper is: 1. To review the recent therapeutic strategies of “total vascular care” for CLI, 2. To explain the conventional antegrade approach in below-the-knee (BTK) interventions for CLI, 3. To highlight utilization of the percutaneous retrograde tibial approach, which is particularly valuable in difficult cases where a conventional approach has failed. The major teaching points of this paper are: 1. The availability of multiple interventional devices and techniques can offer patients treatment options in diseased arterial territories that have traditionally not been amenable to treatment, particularly in tibial and pedal interventions. 2. Management of CLI requires a multidisciplinary approach rather than a turf battle to preserve radiologists' critical role in vascular interventions.
- Critical limb ischemia（CLI）
- Percutaneous transluminal angioplasty（PTA）
- Below-the-knee interventions
- Controlled antegrade and retrograde subintimal tracking（CART）
2. Endovascular Therapy for Patients with Critical Limb Ischemia
Kansai Rosai Hospital Cardiovascular Center
Shin Okamoto, Osamu Iida
EVT has emerged as an attractive alternative to bypass surgery for patients with critical limbs ischemia (CLI), achieving similar limb salvage rates as well as mortality to bypass surgery. Many reports suggest good results of endovascular therapy (EVT) for femoro-popliteal and infrapopliteal lesion as well as iliac ones. EVT should be conducted for limb salvage under familiarity with these data and our-own skills.
- Endovascular therapy
- Critical limb ischemia
- Superficial femoral artery
- Infrapopliteal artery
3. Endovascular Therapy in Patients with Critical Limb Ischemia
Department of Interventional and Diagnostic Radiology, Tsuchiya General Hospital
Endovascular therapy (EVT) has been recognized as a useful and low invasive technique for treating the patients with critical limb ischemia. Antegrade ipsilateral approach is needed to recanalize chronic total occlusions of the superficial femoral artery and lower leg arteries. Ipsilateral approach is not difficult and not troublesome if the operator is familiar with this procedure. To recanalize long chronic total occlusion, a bidirectional approach is quite useful. Additional distal puncture is needed in some cases. Trans-collateral wiring and catheterization can be done in some cases. Once the wires pass through the total occlusion, balloon angioplasty can be done without difficulty. Though the long-term patency of these recanalized arteries is not satisfactory, it is enough that those arteries are kept opened until wound healing is achieved. EVT has an important role in the treatment of critical limb ischemia.
- Endovascular therapy
4. Current Surgical Strategy for Critical Limb Ischemia
Department of Surgery, Tokyo Dental College Ichikawa General Hospital
Hirohisa Harada, Takahiro Shoji, Junichi Matsui
Among peripheral arterial disease (PAD) patients the proportion of the critical limb ischemia with below-the-knee (BK) lesions is markedly increasing in consequence of the growing number of diabetic patients. Although the indication of endovascular therapy for occlusive disease in iliac and superficial femoral arterial lesions has been established, such treatment for BK lesions still shows a poor long-term outcome in spite of its early benefits for limb salvage. Although endovascular therapy has surpassed surgical bypass in the iliac and even in the femoral area, the indication of distal bypass surgery in the BK area for critical ischemia has been established. For complex PAD cases involving multiple lesions from iliac to BK we are performing “hybrid surgery” in that vascular surgeons perform both EVT and bypass surgery simultaneously in the operating room and are achieving good results. The number of critical limb ischemia cases is likely to keep increasing in future, and thus we need to be engaged in multidisciplinary treatment therapies to improve outcomes.
- Critical limb ischemia
- Bypass surgery
- Peripheral arterial disease
5. Significance of the Angiosome Concept in Revascularization from the Viewpoint of a Microcirculation Specialist
Department of Plastic Surgery, Tojun Hospital
Emphasis has been placed on the angiosome concept in revascularization of limb salvage therapy. However, not all cases of revascularization apply this concept in the clinical setting. In fact, some cases can be healed without using angiosomes. We examined the significance of the current angiosome concept from the viewpoint of a microcirculation specialist. Endovascular treatment (EVT) and bypass surgery which can recover blood flow cannot save some ischemic limbs of diabetic patients receiving maintenance dialysis, most likely due to complications of macroangiopathy and impaired microcirculation. Though the collateral circulation to the lesions is essential as a route of blood flow for cases without using angiosomes, it is damaged due to impaired microcirculation, decreasing the blood flow to the site. An effective way to prevent this may be the application of EVT to below knee lesions to reconstruct or newly construct angiosomes in the leg and foot. A greater limb salvage rate is expected when EVT is aggressively applied from the leg to the foot in EVT only cases with insufficient blood flow volume or when EVT in the foot is applied to bypass surgery cases. However, further studies are needed to determine long-term results of revascularization of foot lesions.
- Impaired microcirculation
6. Treatment of Critical Limb Ischemia Using Endothelial Stem and Progenitor Cells
Division of Vascular Regeneration, Unit of Regenerative Medicine, Institute of Biomedical Research and Innovation1)
Vascular Regeneration Research Group, Institute of Biomedical Research and Innovation2)
Department of Regenerative Medicine Science, Tokai University School of Medicine3)
Yasuyuki Fujita1,2), Atsuhiko Kawamoto1,2), Takayuki Asahara2,3)
Peripheral artery disease (PAD) is mainly caused by atherosclerosis and is associated with significant morbidity and mortality. Arteriosclerosis obliterans (ASO) is the most common cause of PAD affecting the lower limbs. Additional causes of PAD are Buerger’s disease and collagen diseases involving vasculitis. Currently, the standard treatment for CLI is medication, surgical or endovascular revascularization. However, such interventions can be performed in only 50% of CLI patients and the CLI-resolved ratio is only 25% one year after the initial treatment. Among the CLI patients in whom attempts at revascularization have failed, 30% lose their legs and 25% die within one year after treatment. Therefore, the development of novel therapeutic strategies is urgently needed to improve the poor prognosis of CLI patients. Bone marrow-derived endothelial progenitor cells (EPCs) have been identified as a potential new therapeutic option for neovascularization. The preclinical findings have encouraged clinical researchers to explore the safety, feasibility and efficacy of cell-based therapies including unselected bone marrow-derived mononuclear cells and EPCs in patients with CLI in several small clinical trials. The results of these clinical trials revealed that cell-based therapies for no-option CLI patients are relatively safe, feasible and possibly effective. Recently, large-scale, randomized, placebo-controlled, double-blind studies are in progress to further confirm this evidence.
- Autologous stem/progenitor cell transplantation
- Clinical trials
- Critical limb ischemia
7. Principles of Foot Care for Patients with Critical Limb Ischemia
Department of Gerontological Nursing, Division of Health Sciences and Nursing,
Graduate School of Medicine, The University of Tokyo
Makoto Oe, Hiromi Sanada
One of the causes of foot amputation is foot ulcers, making it important to prevent foot ulcers in patients with critical limb ischemia. Foot care of critical limb ischemia patients is based on control of peripheral vascular disease. Ischemic symptoms such as pain and claudication as well as blood flow such as the ankle brachial index and the toe brachial index need to be monitored, while smoking cessation, physical exercise and pharmacotherapy are also vital. Education regarding the importance of recognizing the risks of ulcers and the significance of treatment of peripheral arterial disease is also important. In addition, traumatic injury, which can cause ulcers, needs to be prevented. In addition to using appropriate footwear and loose socks, attention must be paid to skin injuries resulting from onychopathies and lesions caused during care for toenails.
If ulcers develop, even though the basics of topical treatment are the same as those for other chronic ulcers, removal of necrotic tissues and moist wound healing before revascularization should be avoided. Caution must be also exercised regarding compression therapy for venous ulcers and pressure reduction (excessive elevation of feet) applied to regions with pressure ulcers.
Recently, the wellbeing of patients with chronic wounds has been receiving increasing attention. Patients with critical limb ischemia may suffer a decline of mental wellbeing due to fear of foot amputation and pain. Care must also be improved for the mental wellbeing of patients suffering critical limb ischemia.
- Foot care
- Critical limb ischemia
- Wound management
Transcatheter Arterial Chemoembolization with Drug-eluting Superabsorbent Polymer Microsphere Loaded Epirubicin for Hepatocellular Carcinoma Refractory to Conventional Chemoembolization
Department of Radiology, GateTower Institute for Image Guided Therapy
Akihiko Seki, Shinich Hori, Atsushi Hori
The purpose of this retrospective study was to investigate the safety and clinical outcomes of transcatheter arterial chemoembolization (TACE) using drug-eluting superabsorbent polymer microsphere loaded epirubicin (DEM-TACE) for advanced hepatocellular carcinoma (HCC) patients refractory to TACE using epirubicin-Lipiodol mixture and gelatin sponge (Lip-TACE). Between March 2008 and February 2011, 59 patients with unresectable HCC refractory to Lip-TACE were enrolled to undergo DEM-TACE. The number of Lip-TACE sessions until judgment of resistance ranged from 2 to 13 (mean, 5.1). Tumor responses were evaluated by computed tomography according to the European Association for the Study of the Liver criteria. Overall survival and time to treatment failure were calculated using the Kaplan-Meier method. Toxicity was assessed according to CTCAE version 4.0 criteria. The mean number of DEM-TACE treatment sessions was 2.2 (range, 1-4), and the mean dose of epirubicin per session was 18 mg (range, 2-50). Response rates were 55.9 and 39.0% after 3 and 6 months, respectively. The median overall survival and time to treatment failure after initial DEM-TACE were 24.0 and 6.5 months, respectively. Overall, 10.2% of patients experienced grade 3 or 4 adverse events. Switching the drug carrier and the embolic agent from Lipiodol and gelatin sponge to superabsorbent polymer microsphere is a safe, well-tolerated, and efficacious treatment strategy for salvage TACE in HCC patients refractory to Lip-TACE.
- Hepatocellular carcinoma
- Drug-eluting microsphere