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Endovascular and subintimal approaches fails in obtaining a below-the-knee recanalization in 10-40% of cases, even in high-volume and expertise centers. The presence of long calcified occlusions, characterized by a complex anatomy, often necessitate the use of alternative techniques in order to obtain a direct blood flow to the foot arteries. Recanalization using pedal and plantar loop angioplasty could improve outcomes in the presence of a communication between the dorsal and plantar arch of the foot, if conventional techniques are not effective.

Aim: Endovascular therapy (ET) is the treatment of choice for critical limb ischemia (CLI) and tibial arteries disease (TAD) in focal lesions with restorable run-off; ankle and foot bypass (BPG) is indicated in patients unfit for ET with foot or ankle arteries suitable for surgery. The aim of this study was to evaluate limb salvage (LS), primary patency (PP) and survival (S) of patients underwent BPG in the era of ET for TAD and to define the correlated prognostic factors., Methods: Between February 2000 and November 2008, patients with CLI and TAD were collected prospectively in a data-base (demographics, Fontaine's stage, Texas University Wound Classification [TUC]of ulcers, risk-factors, TAD, techniques of foot revascularization and surgical factors). BPG was performed in tibial arteries occlusion longer than 4 cm or focal occlusion without line-flow to pedal arteries. Clinical and Duplex-ultrasound follow-up was performed at discharge, 1, 3, 6 months and every 6 months. LS, PP, and S rates were assessed with Kaplan-Meier method; factors influencing outcomes were sought by multivariate Cox proportional hazards model analysis., Results: A total of 410 revascularizations were performed in patients with CLI and TAD; BPG in 153 patients (mean age: 69.3±10.6, male/female=117/36, diabetes mellitus=75.2% hyperlypidemia=54.9%, hypertension=87.6%, renal disease=32.7%, coronary arteries disease=51.6%, Fontaine stage IV=96.1%, TUC grade-III=65.4%, TUC stage-D=51%). All autologous grafts in 96.7% (non-reversed saphenous vein=74.5%, reversed=7.2%, composite vein graft=12.4%, arm's veins=2.6%). LS and S after 1 month were 88.2% and 97.1%, respectively. Mean follow-up was 23 months. At 12 and 36 months: LS 76.7% and 70.9%, PP 62.3% and 52.9%, S 91.5% and 74.6%. LS was negatively associated with age (HR=1.041 [95%CI=1.005-1.079]), infected ulcers (HR=3.377 [95%CI=1.571-7.258]), run-off arteries diameter <1.8 mm (HR=5.854[95% CI=2.274-15.070]). PP was negatively associated with hyperlipidemia (HR=2.555 [95% CI=1.418-4.603]), female gender (HR=2.125[95% CI=1.182-3.823]), run-off arteries diameter <1.8 mm (HR=6.165 [95% CI=2.774-13.699]), reversed saphenous graft (HR=3.105 [95% CI=1.166-8.272]), composite vein graft (HR=2.930 [95% CI=1.406-6.107]) and homograft (HR=2.762 [95% CI=1.040-7.333]); instead it is positively related with hypertension (HR=4.229 [95% CI=2.089-8.563]). S was negatively correlated with renal disease (HR=3.035 [95% CI=1.363-6.756])., Conclusion: BPG may be a reasonable first treatment for CLI patients with TAD unfit for ET; female gender, hyperlipidemia, use of reversed saphenous, composite vein or alternative grafts, foot infection and renal disease are associated with worse outcome.

Aim: The authors aimed to assess clinical results following percutaneous transluminal angioplasty (PTA) of pedal arteries and digital branches in order to avoid minor amputations or support surgical skin incisions, in patients with CLI and distal wounds on the toes., Methods: Baseline, procedural and mid-term outcome data of all consecutive patients with CLI and ulcerative lesion on the toes, in which endovascular treatment of the foot arteries and digital branches was attempted, were prospectively collected between January 2010 and January 2011. The primary end-point was acute success (i.e. technical, angiographic and procedural success). Secondary end-points included limb, foot and toes salvage rates, minor amputations, reocclusion/restenosis and repeat treatment., Results: 1057 consecutive patients with CLI were treated and in 24 cases (2.3%), after tibial and foot arteries PTA, related to the presence of arterial lesion (stenosis/occlusion) in the digital branches, the recanalization of the target vessel was performed. Acute technical success was achieved in 100% of cases, with adequate angiographic results without peri-procedural complications. Clinical improvement was obtained and maintained after an average of 9 months. Amputation was avoided in 9 patients (37.5%), in 8 patients (29.6%) amputation involved only a distal phalange, in 5 patients (20.8%) toe amputations was necessary, in 2 patients (8.4%) trans-metatarsal amputation was performed. No below the ankle (BTA) or major amputations were performed., Conclusion: Endovascular recanalization of digital branches in patients with CLI and distal wounds on the toes is feasible and safe; represent a support to avoid minor amputations or surgical skin lesion healing.

The angiosome model was first pioneered by Jan Taylor in 1987 by his influential anatomical works in the plastic reconstructive surgery field. The concept depicts the human body into three-dimensional blocks of tissue, fed by specific arterial and venous irrigation sources, the "angiosomes". Adjacent angiosomes are linked by a vast compensatory collateral web "the choke vessels". This collateral network provides a remarkable "rescue system" in non-atherosclerotic and non-diabetic patients. However, it could be dramatically damaged in chronic limb ischemia (CLI) subjects witnessing miscellaneous systemic arterial disease. The angiosome concept may provide useful information on the human vascular anatomy and related pathology, with specific applications in surgical and vascular interventional therapies. This knowledge may become particularly beneficial in CLI while treating advanced atherosclerotic disease that adds extended collateral depletion. The concept may allow to deliberately focus arterial flow reconstruction in specific limb ischemic areas that exhibit tissue loss and fluctuating "rescue-vessels" supply. The implementation of angiosome-derived strategies in Rutherford grade III CLI presentations, may afford encouraging wound healing and limb preservation rates for both, bypass or endovascular techniques. The present paper proposes a parallel review of the main contemporary publications that share this theory in dedicated CLI literature, with practical considerations for its daily use. Recent applications of the angiosome concept in current CLI revascularization seem to evince benefic results in tissue cicatrization, although comparative and prospective data are further mandatory to cast any pertinent clinical validation.

Few data are available focusing on controlled blunt microdissection during below-the-knee interventions as sole or synchronous technique coupled to subintimal angioplasty, particularly in the management of diabetic critical-ischemic foot wounds. We present two cases of targeted recanalizations in the tibial and pedal trunks for plantar and forefoot diabetic ischemic tissue defects, following an angiosome-model for perfusion.

Ischemic foot is a condition of decreased arterial perfusion. It has several etiologies, atherosclerotic peripheral arterial disease, including that secondary to diabetes mellitus, being the most common. Other potential causes of ischemic foot are acute embolism from cardiac, arterial or paradoxical sources, and thrombosis secondary to arterial blood clots due to procoagulative states (e.g. vasculitis and hematologic disorders), arterial spasms or injury resulting from drug use or from external or iatrogenic trauma. Prompt diagnosis and revascularization of the affected limb play a crucial role in the treatment of ischemic foot. The angiosome principle, defined by Ian Taylor's landmark anatomic study in 1987, divides the body into three-dimensional anatomic units of tissue fed by a source artery (the angiosome). Detailed knowledge of the vascular anatomy of the leg, and in particular of angiosomes in the foot, helps the clinician make better decisions when dealing with ischemic foot. The physician can better estimate the possibility of wound healing, and decide which type of revascularization has the most chance of success, given the existing blood supply. If surgical or endovascular revascularization is successful, the foot should no longer appear ischemic and painful, and the wounds should granulate. Newly granulating wounds should be carefully protected, and meticulous daily local wound care should be performed to promote healing and prevent infection. The quality of subsequent wound care is also a critical component in promoting healing and avoiding further tissue loss.

Aim: Recent registries and randomized trials support the role of percutaneous revascularization in patients with critical limb ischemia (CLI) due to below-the-knee (BTK) atherosclerotic disease, as percutaneous transluminal angioplasty (PTA) for BTK disease has shown to be feasible and safe in this setting. Nonetheless, succes rates remain suboptimal with current techniques. The authors aimed to appraise clinical results following PTA of foot vessels exploiting a novel technique, based on the recanalization of both pedal and plantar arteries and their anatomical anastomosis in order to restore direct arterial in-flow from both anterior and posterior tibial vessels, defined as the pedal-plantar loop technique., Methods: Baseline, procedural and mid-term outcome data of all consecutive patients with CLI due to BTK disease in which PTA was attempted using the pedal-plantar loop technique were prospectively collected between January 2007 and September 2008. The primary end-point was acute success (i.e. the composite of technical, angiographic and procedural success). Secondary end-points included limb salvage rate, major (above the ankle) and minor (below the ankle) amputation, change in Rutherford class and transcutaneous oxygen tension, reocclusion/restenosis, rehospitalization, and repeat revascularization after 12 months., Results: A total of 1331 consecutive patients with CLI were treated using BTK PTA and 135 (10.1%) were approached with the pedal-plantar loop technique in order to recanalize the foot arteries. Target lesions were mostly occlusive and diffusely diseased, involving in most cases the tibial arteries as well as the in-flow and out-flow vessels. Acute success was achieved for tibial PTA in 100% of the cases, with ability to position and inflate the balloon and achieve adequate angiographic results without peri-procedural complications in all, whereas acute success for the pedal-plantar loop technique was 85%. Clinical improvement in functional status was obtained and maintained after an average of 12 months, with a significant improvement of transcutaneous oxygen tension after 15 days, 59+/-16 mmHg in the group of patients in which the foot arteries revascularization was successfully feasible, versus 42+/-12 mmHg in patients achieving patency of two BTK vessels at the ankle level with partial out-flow in the foot (P<0.001)., Conclusions: Percutaneous revascularization of foot arteries in patients with CLI is feasible and safe, and appears to provide positive clinical results at both acute and mid-term follow-up.

Aim: This study analyzed the effect of additional means of recovery (passive foot movements [PFM] and electrical stimulation [ES]), on peripheral and systemic circulation., Methods: The subjects were 16 endurance athletes. A period of passive rest (PR), ES and PFM were applied in 3 trials during which arterial blood flow in calf muscles, stroke volume (SV), heart rate (HR) and cardiac output (CO) were recorded. Repetitive exercise loading at 75% of maximum voluntary contraction to exhaustion was performed., Results: A 15-min period of PR did not appreciably decrease residual fatigue of the exercised muscles, and working capacity during the second physical loading decreased by 84.9+/-28.3 Nm (P<0.05). After ES and PFM, muscle working capacity decreased insignificantly versus the values after the first loadings. After PR, SV (78+/-4.5 mL, P<0.05) and CO (5+/-0.3 L/min, P<0.05) decreased versus baseline values (95+/-6.6 mL and 5.8+/-0.3 L/min, respectively). After additional ES and PFM, SV and CO decreased insignificantly versus baseline values., Conclusion: ES and PFM improve blood return to the heart. After dynamic exercise, ES and PFM, applied as additional means of recovery, can enhance recovery and restore muscle working capacity.

Aim: In this study the long-term outcomes in patients undergoing pedal bypass grafting were evaluated and the risk of graft occlusion was related to whether, preoperatively, the pedal arteries were visualized by angiography or not and were only detected by duplex ultrasonography., Methods: In 2000-2005, 81 pedal bypass grafts were performed in patients with chronic critical lower-limb ischemia, of which 54 (66.7%) had diabetes. Tissue loss (SVS/ISCVS-category 5) was recorded in 68 (84%) limbs and rest pain (SVS/ISCVS-category 4) in 13 (16%) limbs. In 24 limbs (29.6%) bypass grafts were implanted on the pedal arteries that had not been visualized by preoperative angiography, but had been detected only by duplex ultrasound., Results: During the follow-up (median, 17 months; range, 3-69 months), 18 grafts (22.2%) failed. Seven limbs had to be treated by early thrombectomy, which resulted in long-term graft patency and limb salvage. The early postoperative mortality rate was 2.5%. Cumulative primary and secondary graft patency rates, and limb-salvage rates were 70.2%, 80.2% and 82.4%, respectively. No significant difference in graft occlusion was found between the patients with visible and those with not visible pedal arteries on preoperative arteriograms (Fisher's exact test)., Conclusions: Duplex ultrasonography is a reliable modality for detection of target pedal arteries not visualized by preoperative arteriography and it helps reduce the number of patients with non-operable arterial occlusion disease by about 25%.

Bypass to the dorsalis pedis, tarsal, or plantar artery is often required in efforts to salvage the ischemic lower extremity in diabetic patients. The objective of this review was to summarize the current indications, techniques, and outcomes associated with such distal revascularization procedures. A review of the literature and our own institutional experience with dorsalis pedis (n=1 032), tarsal (n=21), and plantar (n=77) bypass was performed. Bypass to the dorsalis pedis, tarsal, or plantar artery is essential in efforts for limb salvage in the ischemic limb in the absence of a more proximal bypass target option. Inframalleolar bypass can be performed with an acceptable perioperative mortality rate (<1%). Limb salvage and patency rates achieved warrant the consideration of these distal bypass procedures as an alternative to limb amputation. Careful patient selection, detailed preoperative work-up and meticulous operative technique play a crucial role in the success of these arterial reconstructions.

The treatment of multisegment superficial femoral artery and tibial vessels atherosclerotic disease is traditionally a femoro-distal bypass using in situ or reversed autogenous vein. The improved result of balloon angioplasty and stenting of the superficial femoral artery (SFA) has extended its application to treat long segment SFA stenosis. A combined endovascular-open surgery approach of SFA endovascular stenting with a popliteal-distal bypass is an alternative less invasive procedure to achieve optimum distal revascularization for limb salvage.

The author reports a case of isolated thrombosis of plantar veins, a rare finding in the international medical literature, in a patient who had a previous knee arthrocentesis and a strict localized bandage. The clinical aspect of perimalleolar-podalic (mainly plantar) oedema, with localized pain, was followed by colour flow duplex investigation, which is considered the fundamental and most useful means to achieve the diagnosis and to perform an adequate follow-up. Pharmacological therapy of such kinds thrombosis may be of an antithrombotic or anticoagulant nature, always associating elastic compression. Aethiopathogenesis of this localized thrombosis is still uncertain, but probably in situ mechanical compressions may play an important role.

Background: Diabetic foot revascularization by popliteal-to-distal bypass is a procedure for limb salvage spread in the last decade., Methods: The authors report their experience with a consecutive series of 15 ischemic feet (mean transcutaneous oxygen 5.3 +/- 4.1 mmHg) with gangrenous lesions due to extensive tibial arteries occlusive disease beginning at the popliteal artery trifurcation (9 cases) or involving the distal popliteal artery (6 cases). Limb salvage was achieved by popliteal-to-distal bypass with autogenous inverted saphenous vein., Results: No operative death was observed. At a mean follow-up of 35 +/- 23 months (range 3-84 months) 4 bypasses were occluded and two were surgically revised after 4 and 50 months from surgery and subsequently remained patent. One patient was submitted to a major amputation. By life table analysis the cumulative primary and secondary patency and limb salvage rates for this group of diabetic patients were at 2 years 79.3%, 86.2% and 93.1% respectively (SE < 10%)., Conclusions: This small experience and a review of the literature confirm the validity of the popliteal-to-distal bypass and the need for a more aggressive vascular surgical attitude to treat the ischemic diabetic foot.

Complications associated with coronary stent placement have decreased in recent years. One of the complications involved with this procedure is the possibility that the stent is stripped from the delivery catheter prior to deployment and is lost systemically. This paper reports a rare complication which resulted in vascular insufficiency necessitating surgical intervention.

Background: In this study the circadian skin flux pattern was evaluated in 10 normal reference subjects and in 35 patients (mean age 68 +/- 11) subdivided in groups (10 with intermittent claudication (200-400 m of walking distance), 10 diabetics with claudication, 7 patients with rest pain and 8 with localised gangrene)., Methods: A laser Doppler flowmeter was used to monitor skin flux for 24 hours. In patients with intermittent claudication the circadian pattern was comparable to normal subjects. In diabetics the daily curve showed several irregular peaks mostly dissociated from activity or rest., Results: In patients with critical ischaemia severe alterations of the circadian pattern were observed (the daily curve was flattened and dissociated from activity or rest) particularly in gangrene. PGE1 alpha-ciclodestrina treatment (60 micrograms/day) partially restored the circadian pattern and increased the average values of the 24-hour curve. In rest pain and gangrene the infusion of PGE1 alpha-ciclodestrina in the late evening increased the average night flux (which tended to fall to very low levels causing pain) and prevented or abolished night rest pain.

A total of 89 diabetic patients with foot lesions were treated using amputation during the past 5 years at Niguarda-Ca' Grande Hospital. All patients suffered from gangrene which in 76% of cases was classified as Wagner's stage IV. The lesion was infected in 67 patients. Emergency surgical cleansing was performed in order to drain abscesses and remove necrotic tissue, taking care not to damage healthy tissue. An accurate multidisciplinary study was performed in all cases which included neurological, oculistic and vascular assessment. 83% of patients presented retinopathy and 62.5% were nephropathic. Angiographic tests revealed the presence of distal vascular lesions in 90% of cases. A femoro-distal by-pass was used in 17 cases and the limb was salvaged in 13 patients; ileal-femoral PTA was performed in 10 cases and the limb was salvaged in 7 patients. Amputations were limited wherever possible to distal segments: toes (55 cases), transmetatarsal (12 case), leg (12 cases), thigh (5 cases), atypical resections or ample cleansing of the foot (5 cases). This approach allowed us to record: 1) a low operative mortality (1 case); 2) higher quality of life; 3) the possibility of reoperating on more proximal portions of the limb in the event of immediate or long-term failure. This was necessary in 19 cases which can be classified as follows: reamputation of toe (11 cases), transmetatarsal (4 cases), amputation of leg (4 cases).

Objective: To compare the long-term value of different forms of treatment for primary varicose veins with saphenous vein insufficiency., Experimental Design: A prospective, partially randomized study with 5-year follow-up., Setting: Ambulatory day-case care., Patients and Interventions: The study includes 211 patients (214 lower limbs), who received compression sclerotherapy (CST; n = 78), radical operation (OP; n = 74) or CST combined with high tie under local anesthesia (HT + CST; n = 63)., Measures: The patient's subjective opinion, objective finding by the surgeon and functional (foot-volumetric) assessment were obtained just after treatment and 6 months, 1, 3 and 5 years later., Results: Subjectively the result started to deteriorate in both the CST and HT + CST groups after one year. The patient satisfaction was greatest in the OP group throughout the study period. Objectively the CST group cure rate fell markedly after 6 months and at 5 year follow-up the failure rate reached 51%, while the OP group still had a high rate of cured (60%) and improved (35%) patients. The HT + CST treatment seemed to hold well for three years followed by increasing failure rate with only 16% objectively cured after 5 years. The foot-volumetric parameters expelled volume (= calf pump function) and refilling flow ratio (= venous reflux) increased 51-79% respectively decreased 8-29% post-treatment in all groups. After 5 years these parameters had returned to pre-treatment levels in the CST and HT + CST groups, while the OP group was still significantly improved., Conclusions: Radical surgery is superior to compression sclerotherapy alone or in combination with high tie in the treatment of varicose veins with saphenous vein incompetence. The foot-volumetric assessment correlated well with and supported objective findings as a whole but could not replace the clinical examination of each individual patient.

Multisensory peripheral nerve divisions were performed in 17 elderly patients with severe ischemia, forefoot pain and non-healing lesions or localised gangrene. They were unsuitable for a vascular reconstructive operation, or for localised foot amputation. The mean age of the patients was 73 years; 13 were males and 10 had diabetes mellitus. All were faced with a major amputation. Considerable pain relief was achieved in all patients but only five patients retained a functional lower extremity for more than 6 months. Of these five one was a diabetic and four were non diabetic. Peripheral nerve section is a useful procedure, but should be applied very selectively and only rarely in diabetic patients.

Five patients are reported who failed to heal ischemic foot wounds despite patient, functioning in situ saphenous vein grafts to infrapopliteal arteries. All were diabetic and two died before amputation could be performed. Contributing to this paradoxical failure of attempted limb salvage were: (a) extensive preexistent gangrene, (b) infection and failure of wound management, and (c) occlusive disease in runoff beds despite the distal site of anastomosis. Distal occlusive disease included one or more of the following: (a) stenosis in a named artery of the foot, (b) stenosis of collaterals from the peroneal artery, and (c) incomplete pedal arches. Distal in situ saphenous vein bypass should continue to be broadly applied for limb salvage, but careful judgement in patient selection and attention to the management of the ischemic wound itself remain critical to success.

With the object of saving a very ischemic extremity, when the classic procedures have been unsuccessful or impossible, the authors are using a modification of San Martin's operation. At present, we are making an A-V fistula with a graft interposed between the femoral or popliteal artery and the peripheral long saphenous vein at the foot or near to it. The distal valves are ruptured. In order to prevent the noxious venous overloading resulting from the distal end-to-end anastomosis, it is important to replace it by an end-to-side anastomosis. Eight patients with intense continuous rest pain and necrotic lesions of the toes and heel have been operated on: 3 failures in spite of well functioning A-V fistula; 2 temporary improvements lasted 7 and 16 months when distal thrombosis of the A-V fistula occurred; 3 good results, maintained during 5 months, 4 3/4 years and 9 1/2 years respectively. Postoperative angiography and scintillography reveal a satisfactory retrograde distribution of blood in the fore foot except in the necrotic tissues.

Thirty-four distal arterial reconstructions to the ankle and the foot for limb salvage were performed in 33 patients, 11 of whom underwent additional operative procedures. The follow-up period is up to 4 years. The operative mortality rate was 9.09%. The 6 month, 1 year and 2 year accumulated patency rates calculated by life table analysis were 85%, 86.7% and 77.3%, respectively. Limb salvage was achieved not only in patients with patent grafts but also in a considerable number of patients whose grafts were occluded between 3 and 24 months postoperatively.

It is considered good surgical practice to cleanse the aorta and the vascular prosthesis of debris in aorto-iliac reconstruction by a "downward flush" through the unanastomosed end of the prosthesis, thus prevent the development "trash foot" caused by distal embolization. A method is presented which by applying a filtering device allows the flushed blood to enter the distal arterial tree instead of being discarded, thus allowing the prolongation of the maneuver and the increase of its effectiveness.

A foot arterial resistance index (FARI), determined plethysmographically, was used pre- and postoperatively to compare foot vasomotor tone following arterial reconstructions of the lower limb with and without the addition of lumbar sympathectomy. The index was measured before and during reactive hyperaemia in 40 patients without vascular disease; in 32 patients who underwent aortic reconstructions, 14 of whom were randomly subjected to a concomitant bilateral lumbar sympathectomy; and in 8 patients who had a femoropopliteal bypass for limb salvage. This study indicates that the addition of lumbar sympathectomy to aortic reconstructive operations enhances blood flow to the foot by significantly reducing foot vasomotor tone. Sympathectomy performed to reduce foot arterial resistance in patients undergoing successful femoropopliteal reconstructions may be of no benefit since a persistent marked postoperative hyperaemia of the foot is present.

In a series of 30 femoro-tibial grafts for limb salvage, blood flow through the graft was compared to patency of the primary pedal arch. Where the primary pedal arch was occluded mean flow was 83 +/- 44 ml/min compared to 152 +/- 51 mls/min when the pedal arch was complete (p less than 0.01). In order to increase blood flow through the graft in patients with an occluded pedal arch, an arteriovenous shunt was constructed at the distal tibial anastomosis. Following this procedure mean flow increased to 236 +/- 92 mls/min (p less than 0.001). The cumulative patency rate in patients who required an arteriovenous shunt was 65% at 6 months, compared to 68% in patients with a complete pedal arch in whom an arteriovenous shunt was not thought necessary. The results show that an arteriovenous shunt may be of value when blood flow through a femoro-tibial graft is limited by occlusive disease in the primary pedal arch.