Trends in Lower Limb Amputation in Patients with Diabetic Foot Based on Vascular Intervention of Peripheral Arterial Disease in Korea: a Population-based Nationwide Study

BACKGROUND: Peripheral arterial disease (PAD) is known as the greatest risk factor affecting the amputation of diabetic foot. Thus, it is crucial to understand the epidemiology of PAD associated with diabetic foot and the relationship between PTA and amputation in predicting prognosis. However, no such multi-year data are available in Korea. Thus, the purpose of this study was to investigate trends of amputation involving diabetic foot based on vascular interventions for PAD in Korea. METHODS: This study was conducted using six-year data obtained from Health Insurance Review and Assessment Service from January 1, 2011 to December 31, 2016. Our study included data pertaining to diabetic foot, PAD, and vascular intervention codes (percutaneous transluminal angioplasty [PTA, M6597], percutaneous intravascular installation of stent-graft [PIISG, M6605], and percutaneous intravascular atherectomy [PIA, M6620]). We analyzed the number of vascular interventions and minor and major amputations each year. The relationship between annual amputation and vascular intervention was analyzed using χ² test. RESULTS: The overall number of vascular interventions increased from 253 (PTA, 111; PIISG, 140; and PIA, 2) in 2011 to 1,230 (PTA, 745; PIISG, 470; and PIA, 15) in 2016. During the same period, the number of minor amputations increased from 2,534 to 3,319 while major amputations decreased from 980 to 956. The proportion of minor amputations among patients who underwent vascular intervention was significantly increased from 19.34% in 2011 to 21.45% in 2016 while the proportion of major amputations among these patients was significantly reduced from 9.88% to 4.27%. In addition, the association between vascular intervention and amputation increased from 0.56 (spearman correlation coefficient) in 2011 to 0.62 in 2016. CONCLUSION: In diabetic foot patients, increase in vascular intervention resulted in a change in amputation pattern, showing statistically significant correlation.

Revascularización mediante aterectomía direccional en isquemia crítica de miembro inferior. Primera experiencia ecuatoriana / Revascularization through directional atherectomy in critical inferior limb ischemia: first Ecuadorian experience

Introducción: La aterectomía direccional es una técnica mínimamente invasiva que puede ser utilizada para evitar la amputación de los miembros inferiores en caso de isquemia crítica. Caso: Se presenta la primera experiencia en Ecuador, realizada en una paciente diabética e insuficiente renal. Este procedimiento logró repermeabilizar el segmento femoropoplíteo izquierdo con éxito. Discusión: La aterectomía direccional es una alternativa eficaz, mínimamente invasiva, para evitar la amputación de miembros inferiores en pacientes isquemia crítica y múltiples comorbilidades. Palabras clave: Aterectomía, isquemia, miembro inferior, pie diabético.

Introduction: Directional atherectomy is a minimally invasive technique that can be used to avoid lower limb amputation due to critical ischemia. Case report: This is the first experience in Ecuador, using this technique in a diabetic patient with chronic renal failure. The procedure achieved successful recanalization of the left femoropopliteal artery. Discusion: Directional atherectomy seems to be an alternative to avoid limb amputation in patients with critical ischemia and several comorbidities.

Usefulness of intraopertive ultrasonography during directional atherectomy using SilverHawk/TurboHawk system

PURPOSE: Directional atherectomy (DA) was introduced for the management of infrainguinal arterial stenosis or occlusive lesions. The procedure success rate in the DEFINITIVE LE study was determined using radiologic imaging. The aim of our study was to determine the usefulness of intraoperative ultrasonography (USG) during DA for evaluating the early results of this procedure. METHODS: Patients who underwent DA from January to December 2014 were reviewed retrospectively. Twenty lesions from 14 patients with femoral artery stenosis (>70% stenosis) with short segment occlusive lesions (<2 cm in length) were treated. Among 20 lesions, 3 were treated with the TurboHawk system with a protective device due to lesion calcification. The percentage of stenosis during and after DA was determined with USG. RESULTS: Median follow-up was 5.1 months, and the procedural success rate (<30% stenosis at the end of the procedure) was 100% on angiography, but only 30% on intraoperative USG. On USG, median residual stenosis was 40% (range, 28%–42%) at the end of DA, 40% (range, 30%–55%) at 1 month, 55% (range, 35%–85%) at 6 months, and 64% (range, 60%–100%) at 1 year. There was one dissection, but no cases of perforation, pseudoaneurysm, or thrombosis. Primary patency, which was defined as a peak systolic velocity ratio ≤3.5 with no reintervention at 6 months, was found in 18 lesions (90%), and 11 of 14 patients (78.6%) were free of ischemic symptoms such as claudication at 6 months. CONCLUSION: Our results demonstrated that DA with intraoperative USG is an effective treatment option for short segment occlusive lesions of the femoral artery.

Analysis of cause and treatment of acute limb ischemia complicated in peripheral endovascular interventions / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss the cause and treatment of acute limb ischemia in endovascular therapy of the lower extremity arterial occlusive disease.</p><p><b>METHODS</b>Clinical data of 54 cases of acute limb ischemia in the endovascular treatment of 685 cases of lower extremity arterial occlusive disease from June 2003 to April 2012 was analyzed retrospectively. There were 43 male and 11 female patients, with a mean age of 72.3 years (ranging from 56 to 82 years). The major causes which resulted in acute limb ischemia included: arterial embolization of 43 cases, arterial thrombosis of 8 cases, arterial dissection of 3 cases. The acute limb ischemia occurred in the process of balloon angioplasty/stent in 36 cases, catheter-directed thrombolysis in 17 cases, Silverhawk atherectomy in 1 cases. Thirty-two cases were treated by endovascular treatment, 9 cases by surgical procedures (bypass or embolectomy), 13 cases by the combination of endovascular therapy and surgical procedures.</p><p><b>RESULTS</b>Treatment were successfully accomplished in 50 of 54 cases, and failed in 4 cases which had surgical amputation. There were no deaths in all the patients. Forty-five of 54 cases were followed up for the average of 40.3 months. Six cases had ischemic symptoms recurrence in 43 artery embolization patients, in whom 4 cases were cured by endovascular treatment, 2 cases were cured by toe amputation. One case of bypass anastomotic stenosis and one case of stent restenosis were successfully cured by endovascular treatment in 8 arterial thrombosis patients. One cases of below-knee artery stent occlusion in 3 arterial dissection patients was cured by medical treatment. Four cases of amputation patients were followed up in good condition.</p><p><b>CONCLUSIONS</b>Most patients of acute limb ischemia complicated in endovascular therapy could be treated by endovascular therapy. Surgical procedures in time is still the best choice for the patients in whom the endovascular therapy was not satisfied.</p>

Below the Knee Intervention Using Multidisciplinary Methods Including an Antegrade, Retrograde Approach Without the Use of a Sheath but With a Plaque Excision Device

Below the knee (BTK) interventions are increasing in patients with rest pain or critical limb ischemia, and these interventions are frequently successful in facilitating limb salvage. New intervention techniques and devices allow successful recanalization of occluded BTK arteries. Here, we report a case of successful recanalization of BTK arteries using multidisciplinary methods, including an antegrade approach and retrograde approach without the use of a sheath, but with simple balloon angioplasty, and plaque excision using Silverhawk atherectomy device.

Intervention of the Dysfunctional and Thrombosed Autogenous Vascular Access / 한양의대학술지

In South Korea at the end of 2006, the total number of patients that had undergone renal replacement therapy was 46,730 (hemodialysis: 62.1%, peritoneal dialysis: 17.1%, functioning kidney transplantation: 20.8%). There were 9,197 new renal replacement therapy patients in 2006 and the incidence rate per million 185.3. In South Korea, the most common primary cause of end stage renal disease was diabetic nephropathy (42.3%), hypertensive nephrosclerosis (16.9%), and chronic glomerulonephritis (13.0%). The National Kidney Foundation Dialysis Outcomes Quality Initiative (K/DOQI) has recommended placement of autogenous arteriovenous fistulas over alternatives including the use of arteriovenous grafts and central venous catheters to improve the overall outcome of patients undergoing hemodialysis. However, autogenous arteriovenous fistulas, like polytetrafluoroethylene grafts, are also subject to dysfunction and eventual failure. Since first described in 1982, percutaneous transluminal balloon angioplasty has become the mainstay of treatment for accesses failing because of underlying central or peripheral venous stenoses. When angioplasty alone fails, alternative treatment modalities, including stent placement and atherectomy, allow immediate salvage in most cases. Consequently, interventional treatment should be attempted first for dysfunctional and thrombosed autogenous vascular access and should be initiated in all dialysis centers so long as the local radiologists are trained and enthusiastic.

Current Role of Endovascular Therapy in Leg Arteries

Lower extremity peripheral arterial occlusive disease poses a unique challenge to traditional angioplasty based endovascular therapies. The diffuse nature of lower extremity atherosclerotic disease, the presence of chronic total occlusions, poor distal runoff, and the presence of critical limb ischemia have all contributed to the disappointing results of balloon angioplasty of complex infrainguinal arterial disease. These challenges have spawned the development of new technologies in an attempt to improve the safety and effectiveness of percutaneous revascularization for lower extremity peripheral arterial occlusive disease. This review summarizes the advances in available technologies including conventional angioplasty balloons, nitinol stents, stent graft, drug-eluting stents, excisional atherectomy devices, devices for crossing total occlusions, and true lumen reentry devices.

Experience with Directional Atherectomy in Infrainguinal Peripheral Arterial Disease with Using a Silverhawk Plaque Excision Device

PURPOSE: This study was conducted to report our single center experience with performing directional atherectomy in patients with infra-inguinal arterial disease by using the Silverhawk plaque excision device. This procedure was performed at Washington University Hospital in St. Louis, USA (WASH). METHODS: Fifty-six patients with 102 lesions and who were classified into the Rutherford categories 2 to 6 underwent 66 procedures using the Silverhawk device from November 2004 to July 2007 in WASH. The patients' medical records were retrospectively reviewed. RESULTS: The initial technical success rate was 86.4%. The primary patency rate and limb salvage rate at 1 year was 48.5% and 80.3%, respectively. After 2 year' s follow-up, there was no occlusion or limb loss, and the overall primary patency rate and limb salvage was 45.5% and 75.8%, respectively. The mean preoperative ABI was 0.52+/-0.24 and the postoperative ABI was 0.73+/-0.22 (P=0.001). The one-year primary patency rate in the TASC II A and B group was 56.4% and that in the C and D group was 29.6% (P=0.003, P=0.007), respectively. There was a significantly different between both groups. However, the location, nature and length of the lesion, the Rutherford category and the adjunctive procedures did not statistically affect the primary patency rate. CONCLUSION: In this study, the Silverhawk plaque excision device was a feasible treatment modality for infra-inguinal peripheral arterial disease because of its high technical success rate, the primary patency rate and the limb salvage rate. However, it had an obstacle for being accepted for widespread use because secondary endovascular techniques are frequently required for restenosis after plaque excision. The practical use of the Silverhawk is controversial and further studies will be needed.

A Morphometric Study on Cadaveric Aortic Arch and Its Major Branches in 25 Korean Adults : The Perspective of Endovascular Surgery

Objective: To understand the anatomic characteristics of the aortic arch (AA) and its major branches to build a foundation toward performing endovascular surgery safely. Methods: A total of 25 formalin fixed Korean adult cadavers were used. The authors investigated : anatomical variations of the AA and its major branches; curvature of the AA; distance from the mid-vertebrae line to the origin of the major branches; distances from the origin of the major branches of AA to the origin of its distal branches; and the angle of the three major branches, the brachiocephalic trunk (BCT), the left common carotid artery (LCCA) and the left subclavian artery (LSCA) arising from AA. Results: The three major branches directly originated from AA in 21 (84%) of the cadavers. In two (8%) of remaining four cadavers, orifice of LCCA was slightly above the stem of BCT. In remaining two (8%) cadavers, the left vertebral artery (LVA) was directly originated from AA. Average angle of AA curvature to the coronal plane was 62.2 degrees. BCT originated 0.92 mm on the right of the mid-vertebrae line. LCCA and LSCA originated from 12.3 mm and 22.8 mm on the left of the mid-vertebrae line. Mean distance from the origin of the BCT to the origin of the RCCA was 32.5 mm. Mean distance from the origin of the LSCA to the origin of the LVA was 33.8 mm. Average angles at which the major branches arise from the AA were 65.3, 46.9 and 63.8 degrees. Conclusion: This study may provides a basic anatomical information to catheterize AA and its branches for safely performing endovascular surgery.

Intervenção percutânea das lesões de bifurcação coronária / Coronary bifurcation lesion treatment: a review

As lesões em bifurcação representam um grande desafio no tratamento percutâneo da insuficiência coronária. Os resultados imediatos e a médio prazo obtidos com a angioplastia convencional por balão mostraram-se desapontadores. O desenvolvimento de novos dispositivos, como aterectomia e stents, cateteres-guia, balões de baixo perfil e cordas-guia, e a associação de tienopiridínicos-aspirina trouxeram gradativa e substancial melhora nos resultados clínicos e angiográficos desses procedimentos. O implante de stents em bifurcação tornou-se o procedimento de escolha, com resultados seguros e previsíveis na maioria dos casos, embora a taxa de reestenose persistisse elevada. os stents eluidores de medicamentos proporcionaram à cardiologia intervencionista a possibilidade de oferecer, em todos os subgrupos de pacientes com lesões obstrutivas coronarias, substancial melhora do seguimento clínico, por redução de necessidade de nova revascularização da lesão tratada. Essa evolução propiciou o desenvolvimento de novas técnicas para tratamento das lesões que envolvem bifurcação, assim como abriu perspectiva de utilização de próteses estritamente dedicadas a esse segmento, que, em última análise, podem significar a resposta final a esse problema.

The impact of preprocedural aminophylline administration on the development of bradyarrhythmias and hemodynamic changes during rotational atherectomy / 대한내과학회지

BACKGROUND: Rotational atherectomy or rotablation in right coronary artery (RCA) or dominant left circumflex artery (LCX) can cause bradyarrhythmias and requires the placement of prophylactic pacemaker. Adenosine is released endogenously by ischemic or hypoxic cells and mediates the bradyarrhythmias associated with impaired coronary flow. Aminophylline, an adenosine receptor antagonist, is known to prevent hypoxic bradyarrhythmias. The purpose of this study was to assess the impact of preprocedural aminophylline administration on the development of bradyarrhythmias and hemodynamic changes during rotablation. METHODS: High-speed rotablation was performed using a stepped burr approach in 38 patients following intravenous infusion of aminophylline (381.3+/-38.5 mg). The development of transient bradyarrhythmias and change of blood pressure and heart rate during the rotablation were assessed. RESULTS: Mean age was 56.9+/-8.8 years and 76% of the patients was male. Sixty-six percent of the patients has multivessel coronary artery disease and mean ejection fraction was 58%. Mean lesion length was 19.2+/-9.8 mm and RCA or dominant LCX lesions were 32 (84%). Mean burr/artery ratio was 0.61+/-0.05, maximum burr used was 1.69+/-0.16 mm, including 2.0 mm in 5 (13%) lesions, and mean ablation number was 6.4+/-2.8. Rotablation was successful without no reflow phenomenon in all patients. Low-pressure balloon angioplasty in all lesions and additional stenting in 24 (63%) lesions were followed. Neither severe discomfort nor serious arrhythmia occurred during the procedures. Systolic blood pressure and heart rate were not changed significantly before and after the aminophylline infusion, and during the rotablation (121.5+/-18.0 vs. 108.7+/-17.3 vs. 109.3+/-16.9 mmHg, p=0.062; 72.6+/-12.1 vs. 78.4+/-16.5 vs. 75.9+/-15.5 bpm, p=0.084, respectively). No bradyarrhythmias occurred during the rotablation with prior aminophylline infusion. Plasma aminophylline level measured after the procedure in 19 patients was 9.8+/-1.9 micro gram/mL. CONCLUSION: Preprocedural aminophylline administration may prevent the development of bradyarrhythmias during rotablation without significant hemodynamic changes. It seems a useful measure to obviate unfavorable pacing or even routine prophylactic placement of a pacemaker during the rotablation employing small burrs.

New Methods of Vascular Brachytherapy for Coronary Stent Restenosis

Over the last decade, stenting has emerged as the dominant form of percutaneous coronary intervention (PCI) and is currently performed in 80% of all PCIs. As a result, treatment of in-stent restenosis (ISR) has become an increasingly frequent challenge for the interventional cardiologist. Any anti-restenosis therapy under consideration must contend with the two basic mechanisms of vessel re-narrowing following coronary intervention: vascular contraction, which can be mechanically blocked with a typical balloon expandable stent; and neointimal proliferation, which is a complex cellular reaction to the injury caused by the actions of mechanical devices such as balloons, stents, and atherectomy catheters. Recently, several randomized clinical trials have demonstrated that intracoronary brachytherapy can substantially reduce the rates of both angiographic and clinical restenosis in patients undergoing PCI for ISR. Vascular radiotherapy is the first proven, clinically effective anti-restenosis therapy. Despite its established efficacy, there remains much room for improvement in the aspects of safety and cost effectiveness. We have developed novel methods of brachytherapy using local delivery of 99mTc-HMPAO and 166Ho-coated balloon, which are safe and effective in the prevention of coronary stent restenosis.

Metabolismo e fluxo coronário no diabetes melito / Coronary blood flow and myocardial glucose in diabetes mellitus

A mortalidade relativa às síndromes isquêmicas agudas é duas vezes maior em pacientes diabéticos. As alterações do fluxo de reserva coronária decorrentes do acometimento da microcirculação coronária, dos distúrbios funcionais da vasodilatação coronária metabólica e endotélio-dependente e da presença de neuropatia autonômica contribuem para o agravamento do processo isquêmico res- ponsável pela evolução desfavorável desses pacientes. Concomitantemente, as modificações do metabolismo miocárdico da glicose, representadas pelo desacoplamento entre a glicólise e a oxidação da glicose decorrentes de falta de insulina, resistência à insulina e aumento de ácidos graxos livres circujantes, aumentam a disfunção miocárdica...

Cardiologia intervencionista coronária na era da medicina baseada em evidências / Evidence-based coronary interventional cardiology: a new era

A Cardiologia baseada em evidências tem, entre seus objetivos, nortear as tomadas de decisões por meio de dados científicos mais relevantes. Especial atenção deve ser dada à elaboração do protocolo da pesquisa, a sua condução e à criteriosa análise dos dados. Algumas questões merecem ser discutidas à luz da Cardiologia baseada em evidências: a) o tipo de doença a ser avaliado; b) a intervenção a ser realizada; c) o desfecho clínico obtido; e d) a inclusão do grupo controle adequaao.O fundamento da tomada de decisão na Cardiologia sempre dependeu do conhecimento da fisiopatologia bem como do discernimento clínico. A medicina baseada em evidências não poderá substituir esses importantes atributos, mas deve incorporá-los de forma mais explícita e rigorosa. Assim, a Cardiologia deverá ser avaliada de forma sistemática, com o intuito de trazer à classe médica as evidências que apóiem seu papel na prática diária...

Uso do ultra-som intracoronário como método de avaliação objetiva dos resultados das intervenções percutâneas / The role of intravascular ultrasound in the objective evaluation of the results of percutaneous catheter interventions

O ultra-som intracoronário é uma técnica tomográfica invasiva, que permite o estudo "in vivo" da parede vascular normal, dos componentes da placa aterosclerótica e das características quantitativas e qualitativas que envolvem o ateroma. No campo da pesquisa, o ultra-som intracoronário trouxe contribuições incontestes para o melhor conhecimento da doença aterosclerótica e do fenômeno da reestenose. Esta revisão propõe-se a discutir as indicações do ultra-som intracoronário no diagnóstico e durante o tratamento percutâneo da doença coronária. No campo diagnóstico, o ultra-som tem se mostrado bastante útil na avaliação dos diferentes tipos morfológicos de placa aterosclerótica. Sua maior contribuição, no campo terapêutico, tem sido no auxílio ao implante dos stents coronários. A utilização do ultra-som nesse mister permite a perfeita aposição das hastes do stent contra a parede do vaso, assim como sua perfeita expansão, o que potencialmente pode promover a diminuição dos índices de trombose subaguda da endoprótese e de reestenose coronária...

Management of a Patient with Atheromatous Aortic Arch Diagnosed by as Intraoperative Transesophageal Echocardiography during Coronary Artery Bypass Grafting / 대한마취과학회지

Protruding atheromas of the aorta have been identified as one of the sources of a systemic emboli and a major cause of stroke following cardiac surgery. We report a case of surgical modification in a 58-year-old man with an atheromatous aortic arch detected by an intraoperative transesophageal echocardiography (TEE) during coronary artery bypass grafting (CABG). After induction of anesthesia, protruding atheromatous plaques with a mobile element in the aortic arch were identified by a TEE that was not noticed by a preoperative angiography and transthoracic echocardiograpy. Based on the TEE finding, the surgical technique was modified to CABG combined with an aortic atherectomy under deep hypothermic circulatory arrest. The atheromatous areas correlated well with the TEE finding and the patient recovered from anesthesia and surgery without neurologic deficit. Therefore, an intraoperative TEE examination is considered as a safe and reliable technique to identify atherosclerotic disease of the thoracic aorta in patients undergoing CABG and to minimize unexpected neurologic complications after CABG.

Detection of Chlamydia pneumoniae in the Atherosclerotic Tissue by Immunohistochemistry / 대한임상병리학회지

BACKGROUND: Chlamydia pneumoniae is an important pathogen to cause approximately 5-10% of community-acquired respiratory infections and has been recently reported as a tentative causative agent of atherosclerosis in western countries. Considering that the most common cause of death is cerebral artery disease and coronary heart disease in Korea, we attempted to elucidate C. pneumoniae in atheromatous plaques. METHODS: Twenty-eight cases of atherectomy from 1996 to 1998, which included 20 patients with cerebral artery stenosis, two patients with carotid artery stenosis and six patients with coronary artery stenosis were prepared for immunohistochemistry to demonstrate C. pneumoniae. The Coronary arteries from 35 cadavers obtained were also stained with chlamydia genus-specific and C. pneumoniae-specific monoclonal antibodies. RESULTS: Eighteen of 20(90%) of cerebral artery stenosis, one of two of carotid artery stenosis and all six cases of coronary artery stenosis were positive for C. pneumoniae. Thirteen over 35(37.1%) cadavers presented arterial stenosis, while eight cases(61.5%) were positive for C. pneumoniae. CONCLUSIONS: This is the first report demonstrating C. pneumoniae in atheroma in Korea. In regard of the high positive rate of C. pneumoniae(89.3%) in cases of atherosclerosis, C. pneumoniae might be closely associated with atherosclerosis in Korea.

One case of left anterior descending artery fistula-right ventricle complicating rotablator atherectomy with spontaneous occlusion in a following coronary angiogram

No abstract available.