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Introduction: Lower leg pain and symptoms, and poor leg circulation are common in older adults. These can significantly affect their function and quality of life. Neuromuscular electrical stimulation (NMES) applied via the feet as 'foot NMES' activates the leg musculovenous pump. This study investigated the effects of foot NMES administered at home using Revitive ® among community-dwelling older adults with lower leg pain and/or other lower leg symptoms such as cramps, or sensations of tired, aching, and heavy feeling legs., Methods: A randomised placebo-controlled study with three groups (2 NMES, 1 Sham) and three assessments (baseline, week 8, week 12 follow-up) was carried out. Self-reported function using Canadian occupational performance measure (COPM), leg pain, overall leg symptoms score (heaviness, tiredness, aching, or cramps), and ankle blood flow were assessed. Analysis of covariance (ANCOVA) and logistic regression were used to compare the groups. Statistical significance was set at p < 0.05 (two-sided 5%)., Results: Out of 129 participants enrolled, 114 completed the study. The improvement in all outcomes were statistically significant for the NMES interventions compared to Sham at both week 8 (p < 0.01) and week 12 (p < 0.05). The improvement in COPM met the minimal clinically important difference (MCID) for the NMES interventions compared to Sham at both week 8 (p < 0.005) and week 12 (p < 0.05). Improvement in leg pain met MCID at week 8 compared to Sham (p < 0.05). Ankle blood flow increased approximately 3-fold during treatment compared to Sham. Compliance with the interventions was high and no device-related adverse events were reported., Conclusions: The home-based foot NMES is safe, and significantly improved self-reported function, leg pain and overall leg symptoms, and increased ankle blood flow compared to a Sham among older adults., Trial Registration: The trial was prospectively registered in ISRCTN on 17/06/2019 with registration number ISRCTN10576209. It can be accessed at https://www.isrctn.com/ISRCTN10576209 ., (© 2024. The Author(s).)

Background: Arterial vascularization is intimately related to the peroneal tendon ruptures. Our purpose is to describe the vascular anatomy of peroneal tendons and assess differences in the vascularization patterns between peroneus brevis tendon (PBT) and peroneus longus tendon (PLT)., Methods: Anatomical study of 22 cadaveric lower extremities. We exposed tendons' vascularization by injecting latex. To systematize the vascular description, we considered four anatomical regions in the PBT and six in the PLT., Results: Vascularization was supplied by the peroneal, anterior tibial and lateral plantar arteries and from the deep plantar arch through the vincula connecting the tendons. No avascular areas were found in the PLT. 22.7% of specimens had avascular areas in the PBT. Two visual vascularization patterns were found (arcuate and weblike). Increasing age and a web-like vascularization were associated with a lower number of blood vessels at the tendons' post malleolus area., Conclusion: Peroneal tendons are well vascularized throughout their course, running through a common vincula, with vascularization provided by various arteries. Avascular areas were observed in the PBT, but none at the PLT., (Copyright © 2020 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Objective: Clear imaging of below knee and foot arteries is essential to plan distal reconstructions. Contrast enhanced tomographic 3D ultrasound (CEtUS) is novel and entirely safe with no exposure to ionising radiation or nephrotoxic contrast. In the present study, inter- and intra-observer agreement of CEtUS was calculated, and compared with below knee angiography., Methods: In the same week as computed tomography, magnetic resonance or catheter angiography, CEtUS was performed using intravenous 1.2 mL bolus injections of Sonovue with a maximum of 5 mL administered per patient. CEtUS was reported by a vascular scientist blinded to the angiograms reported by a consultant radiologist. Images were compared using a modified Society of Vascular Surgery (SVS) runoff score., Results: Of the 181 patients recruited with peripheral arterial disease, 20 were excluded from analysis as they withdrew consent, could not be cannulated, or their images were non-diagnostic. In the remaining 161 patients, there were 175 comparative patient images split into two groups: 81 had calf imaging and 94 had pedal imaging representing 405 and 198 imaged arteries, respectively. Weighted quadratic kappa/ICC values for intra- and inter-observer agreement were excellent (κ/ICC = 0.83 to 0.95) and had narrow confidence intervals in both groups. When comparing angiography and CEtUS, weighted quadratic κ/ICC agreement was moderate with acceptable confidence intervals in both groups (Calf κ/ICC = 0.54; Pedal κ/ICC = 0.53). Agreement decreased from popliteal to pedal vessels as diameter decreased. Agreement between CEtUS and digital subtraction angiography was best, and computed tomography angiography the weakest., Conclusion: CEtUS is a novel imaging modality with strong observer agreement that achieves clear peripheral and foot images without ionising radiation exposure or nephrotoxic X-ray contrast media. CEtUS enhances visualisation of runoff vessels, which may play a role in planning of limb salvage or targeted assessment., Competing Interests: Conflicts of interest Charles McCollum is a founder of PIUR imaging GmBH., (Copyright © 2020 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Respecting vascular territories is crucial for flap design and viability. There are 6 angiosomes in the foot and ankle originating from the posterior tibial, anterior tibial, and peroneal arteries. Reliable perforators from the 3 major source vessels of the lower extremity are found in 5-cm intervals within intermuscular septa. Computed tomography angiography, Doppler, and infrared cameras can be used preoperatively to help identify the perforators of the lower extremity., Competing Interests: Disclosure The authors declare that they have no relevant or material financial interests that relate to the research described in this article., (Copyright © 2020 Elsevier Inc. All rights reserved.)

We present a method of imaging angiographic structures in human extremities, including hands, arms, legs, and feet, using a newly developed photoacoustic computed tomography (PACT) system. The system features deep penetration (1.8 cm in muscular tissues) with high spatial and temporal resolutions. A volumetric image is acquired within 5 to 15 s while each cross sectional image is acquired within 100  μs. Therefore, we see no blurring from motion in the imaging plane. Longitudinal and latitudinal cross-sectional images of a healthy volunteer clearly show the vascular network of each appendage and highlight the system's ability to image major and minor vasculatures, without the use of an external contrast or ionizing radiation. We also track heartbeat-induced arterial movement at a two-dimensional frame rate of 10 Hz. This work substantiates the idea that PACT could be used as a noninvasive method for imaging human vasculatures.

More blast injuries are encountered in the civilian setting in recent years as terrorist attacks have increased globally. A 17-year-old male patient with severe blast injury of the right lower extremity was admitted to our department on the fifth day after a terrorist bombing attack. Initially he had been admitted to an emergency department with segmental tibia fracture and arterial injury (Gustilo IIIC). An amputation had been foreseen due to ischemia that persisted even after orthopedic fixation and revascularization interventions, followed by fasciotomy incisions. After consultation with our department hyperbaric oxygen (HBO2) therapy was administered twice daily for the first week. Ischemia improved prominently after 10 HBO2 sessions. HBO2 therapy was continued together with antibiotherapy and wound care. The patient underwent a total of 40 HBO2 sessions and two reconstructive operations and healed without amputation. Vascular injuries with concomitant orthopedic trauma cause most of the delayed amputations in bombing attacks since ischemia can persist at the microvascular level even though adequate treatments are applied. HBO2 corrects hypoxia at tissue level and so provides oxygen for the critically ischemic cells in the injured area. HBO2 also enhances host defense and decreases the ischemia reperfusion injury. In this case, HBO2 was effective in survival and functional recovery (salvage) of the extremity together with regular wound care, antibiotherapy and surgical repair., Competing Interests: The authors of this paper declare no conflicts of interest exist with this submission., (Copyright © Undersea and Hyperbaric Medical Society.)

Background:  Peroneus brevis muscle flap is a distinguished, distally based safe flap that can be manipulated to cover small defects in the leg and ankle. For large-sized defects, a more distal, larger flap is required either locally or distantly., Methods:  Forty-two distally based peroneus brevis muscle flaps were elevated in 42 patients (30 males and 12 females) with major lower leg, ankle, and proximal foot defects of 6 to 15 cm in length and 6 to 12 cm in width. Anatomical findings were recorded as number, size, and sources of blood supply, entry sites, the lowermost two arterial supplies, internal distribution of blood supply to the muscle, the relationship between external and internal distribution of the blood vessels, the length of the muscle, the entry site of the main artery, and the splitting of the proximal portion of the peroneus brevis muscle to increase its width to sufficiently cover large defects., Results:  The anatomical findings suggested that the muscle can be safely extended to cover a large defect in the leg, ankle, or proximal foot. In addition, the longitudinal splitting of the muscle increases its width by up to three times, making it an excellent long-surviving flap to cover a large defect., Conclusion:  A distally based peroneus brevis muscle flap has a rich blood supply and safely reaches the proximal foot, with a secure splitting to cover large defects in the leg, ankle, and proximal foot., Competing Interests: None. Disclosure The author has no financial or personal relationships with other people or organizations that could inappropriately influence my work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: In critical limb ischaemia (CLI), a pedal vein graft bypass offers good long-term results regarding function and limb salvage. However, some cases require bypasses to branches of pedal arteries based on angiographic findings. Methods: In a retrospective database we analysed all patients who received a vein graft bypass to branches of pedal arteries for treatment of critical limb ischaemia. Results: From January 1998 to June 2014 we performed bypasses to branches of pedal arteries in 72 patients (59 men and 13 women) out of a total of 534 patients who underwent pedal bypass surgery. The proximal bypass anastomosis was above the knee in 30 cases and below the knee in 42 patients. In 6 cases the bypass connection was made to the lateral tarsal artery, in 15 cases it was made to the lateral and in 24 cases to the medial plantar artery. In 27 patients a direct connection was made to the plantar bifurcation. All reconstructions were completely autologous. The limb salvage rate after 5 and 10 years was 82 %. Conclusion: A bypass to branches of pedal arteries is a procedure recommendable for limb salvage in cases of critical ischaemia where arteries with a larger diameter are no longer available., Competing Interests: Interessenkonflikt: Nein, (Georg Thieme Verlag KG Stuttgart · New York.)

One third of patients with critical limb ischemia (CLI) has below the knee lesions and requires a restoration of direct blood flow into the foot. However, many of these patients are ineligible for open surgery. The primary goals thus become pain relief and limb salvage over patency. The angiosome concept helps determine the target artery to treat in priority. The endovascular approach has decreased morbidity and mortality rates compared to distal bypass surgery; while subintimal retrograde, trans-collateral and loop techniques push the limits of open surgery by reopening the plantar arch, thereby improving run-off. Early restenosis phenomena after angioplasty have been improved by the use of - limus drug eluting balloons and balloon expandable stents in case of flow limiting dissection or recoil with increased limb salvage rates. Moreover, drug-eluting stents have been proposed, and allow a reduction in reintervention and in-stent restenosis rates in short lesions; however, results on amputation rates or survival are limited. Vessel preparation is a key to overcoming some current limitations, including atherectomy, which increases technical success rates and reduces restenosis rates, especially in calcified lesions, chronic total occlusions and restenosis. These advanced techniques in distal endovascular revascularization have revolutionized limb salvage and support the interest of an endovascular first approach in CLI treatment., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

The confluence of several chronic conditions--in particular ageing, peripheral artery disease, diabetes, and chronic kidney disease--has created a global wave of lower limbs at risk for major amputation. While frequently asymptomatic or not lifestyle limiting, at least 1% of the population has peripheral artery disease of sufficient severity to be limb threatening. To avoid the critical error of failing to diagnose ischaemia, all patients with diabetic foot ulcers and gangrene should routinely undergo physiologic evaluation of foot perfusion. Ankle brachial index is useful when measurable, but may be falsely elevated or not obtainable in as many as 30% of patients with diabetic foot ulcers primarily because of medial calcinosis. Toe pressures and skin perfusion pressures are applicable to such patients., (Copyright © 2016 John Wiley & Sons, Ltd.)

BACKGROUND In patients with chronic leg ischemia, the beneficial effect of arterial revascularization can be significantly decreased due to postoperative leg swelling. The aim of this study was to assess the effects of intermittent pneumatic compression (IPC) on skin flow normalization in patients undergoing revascularization procedures due to chronic leg ischemia. MATERIAL AND METHODS We evaluated 116 patients with chronic leg ischemia. The patients were divided into groups according to the performed treatment (endovascular or surgical) and implementation of IPC postoperatively. The leg edema assessment and microcirculation flow assessment were performed pre- and postoperatively, using percutaneous O2 pressure (TcpO2), cutaneous blood perfusion (CBP) measurements, and skin flow motion assessment. RESULTS In patients who did not receive IPC, a decrease in CBP value was observed in the 1st postoperative assessment. Among patients receiving IPC, the CBD value increased at the 1st and 2nd postoperative measurements, especially in the surgical group. The lowest TcpO2 values were observed in by-pass surgery group without IPC postoperatively. CONCLUSIONS The benefits of the by-pass procedure in patients with leg ischemia can be significantly reduced by postoperative edema. Among patients with postoperative leg edema, local tissue blood perfusion can be improved by the use of IPC, which can result in decreased local leg swelling, as well as improved skin blood perfusion and TcpO2.

Background: Helping people make well-informed decisions about dysvascular partial foot amputation is becoming increasingly important as improvements in diabetes care and vascular surgery make more distal amputations increasingly possible. The high rates of complications and reamputations associated with partial foot amputation are of concern, particularly given that transtibial amputation seems to result in similar outcomes (e.g., mobility and quality of life) with comparatively few complications and reamputations. The aim of this review is to describe the outcomes of dysvascular partial foot amputation and compare these to transtibial amputation. Results from the review are intended for use in the development of shared decision-making resources., Methods/design: A comprehensive range of databases-MEDLINE, EMBASE, PsycINFO, AMED, Cumulative Index of Nursing and Allied Health Literature (CINAHL), ProQuest Nursing and Allied Health, and Web of Science-will be searched using National Library of Medicine, Medical Subject Headings (MeSH) terms as well as title, abstract, and keywords relating to different amputation levels and outcomes of interest; specifically: incidence, prevalence, and rate of amputation; rate of mortality, wound failure, dehiscence, and time between index and ipsilateral reamputations; and mobility, functional ability, activity and participation, quality of life, pain, and psychosocial outcomes including depression and anxiety. Articles that meet the inclusion criteria will be hand-searched for relevant citations. A forward citation search using Google Scholar will be used to identify articles not yet indexed. Original research published in the English language after 1 January 2000 will be included. The McMaster Critical Review Forms will be used to assess methodological quality and identify sources of bias. Included articles will be independently appraised by two reviewers. Data will be extracted using a spreadsheet based on the Cochrane Consumers and Communication Review Group's data extraction template by a primary reviewer and checked for accuracy and clarity by a second reviewer. Findings from the review will be reported as a narrative without meta-analysis given the anticipated heterogeneity of the literature., Discussion: Results from the review can be used in the design of shared decision-making resources to help inform difficult decisions about partial foot amputation., Systematic Review Registration: PROSPERO CRD42015029186.

Introduction: The measurement of transcutaneous oxygen pressure (TcpO2) is a non-invasive method to quantify skin oxygenation at capillary level and their nutritive ability needed to heal the ischemic defect. TcpO2 pressure values below 30 mm Hg are specific for critical limb ischemia and predict complicated healing. The purpose of this study was to verify the cut-off pressure in patient unable to undergo vascular reconstruction, and to verify the possibility of using this method to evaluate the effectiveness of vascular reconstructive surgery., Methods: The group included 52 patients (35 men and 17 women). The mean age of patients in the group was 66.5 years (max. 85, min. 44)., Results: In our group of patients we confirmed that the TcpO2 values of successfully healed ischemic wounds were equal or greater than 30 mm Hg (mean TcpO2 value at the dorsum of the foot was 37.0 mm Hg ± 9.5 mm Hg), compared to the group of unsuccessfully healed patients whose values were lower (mean TcpO2 value at the dorsum of the foot was 9.0 mm Hg ± 5.3 mm Hg)., Conclusion: TcpO2 is a suitable method in predicting the healing of ischemic defects and any possible need for surgical or endovascular revascularization. Thanks to its non-invasive nature and undemanding measurement, it surely helps to make better decisions in choosing the therapeutic procedure needed to heal the defect.

Purpose: To develop and validate a method for choosing the optimal two-dimensional CAIPIRINHA kernel for subtraction contrast-enhanced MR angiography (CE-MRA) and estimate the degree of image quality improvement versus that of some reference acceleration parameter set at R ≥ 8., Methods: A metric based on patient-specific coil calibration information was defined for evaluating optimality of CAIPIRINHA kernels as applied to subtraction CE-MRA. Evaluation in retrospective studies using archived coil calibration data from abdomen, calf, foot, and hand CE-MRA exams was accomplished with an evaluation metric comparing the geometry factor (g-factor) histograms. Prospective calf, foot, and hand CE-MRA studies were evaluated with vessel signal-to-noise ratio (SNR)., Results: Retrospective studies show g-factor improvement for the selected CAIPIRINHA kernels was significant in the feet, moderate in the abdomen, and modest in the calves and hands. Prospective CE-MRA studies using optimal CAIPIRINHA show reduced noise amplification with identical acquisition time in studies of the feet, with minor improvements in the hands and calves., Conclusion: A method for selection of the optimal CAIPIRINHA kernel for high (R ≥ 8) acceleration CE-MRA exams given a specific patient and receiver array was demonstrated. CAIPIRINHA optimization appears valuable in accelerated CE-MRA of the feet and to a lesser extent in the abdomen., (© 2014 Wiley Periodicals, Inc.)

Background: Claudication is one of the sequelae of peripheral arterial disease (PAD). To date, no effective treatment has been found for this condition., Objectives: To investigate a new device to treat PAD. The device administers pre-programmed protocols of oscillations to the foot., Methods: Fifteen patients aged 40-70 years who suffered from intermittent claudication secondary to PAD were recruited to an open prospective study. Each patient was treated once for 30 minutes. The following parameters were evaluated: pain-free and maximal walking distances, skin blood flux by laser-Doppler, skin temperature, ankle-brachial and toe-brachial indices, transcutaneous oxygen pressure (tcpO2) and transcutaneous carbon dioxide pressure (tcpCO2). Non-parametric signed-rank test was applied for testing differences between baseline assessment and post-treatment assessments for quantitative parameters., Results: Mean pain-free walking distance was 122 +/- 33 m and increased to 277 +/- 67 m, after the treatment session (P = 0.004). Mean maximal walking distance was 213 +/- 37 m and it increased to 603 +/- 77 m (P < 0.001). Foot skin perfusion also improved, as demonstrated by an increase in tcpO2 by 28.6 +/- 4.1 mmHg (P < 0.001), a decrease in tcpCO2 by 2.8 +/- 1.3 (P= 0.032), and up to twofold improvement in blood flux parameters, and an increase in skin temperature by 1.9 +/- 0.5 degrees C (P < 0.001). Ankle-brachial index increased by 0.06 +/- 0.01 (P = 0.003) and toe-brachial index by 0.17 +/- 0.02 (P < 0.001)., Conclusions: Preprogrammed oscillations applied to the foot had a positive effect on microcirculation, tissue oxygenation and CO2 clearance; they had a smaller though significant effect on arterial blood pressure indices, and the change in the arterial-brachial index correlated with the change in the pain-free walking distance.

Charcot neuroarthropathy is a low-incidence complication of diabetic foot and is associated with ankle and hind foot deformity. Patients who have not developed deep ulcers are managed with offloading and supportive bracing or orthopedic arthrodesis. In patients who have developed ulcers and severe ankle instability and deformity, below-the-knee amputation is often indicated, especially when deformity and cutaneous involvement result in osteomyelitis. Ischemic association has not been described but can be present as a part of peripheral arterial disease in the diabetic population. In this extreme and advanced stage of combined neuroischemic diabetic foot disease, revascularization strategies can support surgical and orthopedic therapy, thus preventing osteomyelitis and leading to limb and foot salvage.

Purpose: We evaluated the limitations of the ankle-brachial index (ABI) in the revascularisation of diabetic patients with critical limb ischaemia (CLI) who were undergoing peripheral transluminal angioplasty (PTA) compared with the degree of arterial stenosis and with transcutaneous oxygen tension (TcpO2)., Materials and Methods: This prospective study assessed 250 consecutive diabetic patients in whom we evaluated results of posterior tibial and dorsalis pedis Doppler, ABI, TcpO2, and duplex scans. In total, 104 patients were considered suitable candidates for PTA., Results: In 42% of the patients studied, ABI could either not be used (9.34% due to no signal; 14.02% because the artery could not be compressed) or was incorrect (18.7% before PTA; 15.9% after PTA). In contrast, TcpO2 was determined in all cases. After PTA, vessel stenosis decreased from 58.33±20.07% to 21.87±13.57% (p<0.001), whereas ABI increased from 0.79±0.57 to 0.95±0.47 (p<0.001) and TcpO2 from 27.37±10.40 mmHg to 38.23±10.25 mmHg (p<0.001). A statistical analysis revealed scant correlation between techniques (TcpO2 and ABI) (r=0.14)., Conclusions: ABI shows significant limitations for the diagnosing and treating CLI patients compared with TcpO2.

We examine volumetric CT perfusion in soft tissues of the entire foot with an en bloc technique to provide a meaningful measure of differentiation between mild and major vascular impairment. With Institutional Review Board approval, 22 healthy male subjects between the ages of 21 and 50 (mean 37) were enrolled. Volumetric computed tomography using an en bloc technique was conducted on 14 subjects for validation while unilateral vascular obstruction was simulated in the calves of the remaining 8 subjects. Perfusion estimates were made using in-house software and differences in perfusion estimates between feet were evaluated with Student's t-test at 95% confidence. Subjects with simulated major vascular obstruction (calf blood pressure cuff inflated to 200 mmHg) showed significantly higher ratios of perfusion estimates between the unobstructed and obstructed foot compared to subjects with simulated mild vascular obstruction (cuff inflated to 120 mmHg), mean 4.6, SD 2.6 vs. mean 1.3, SD 0.2; P = 0.05. CT perfusion using an en bloc technique shows promise for the future evaluation of patients with critical limb ischemia and particularly for re-characterization post medical, surgical or endovascular intervention.

The mechanisms by which intermittent pneumatic leg compression (IPC) treatment effectively treats symptoms associated with peripheral artery disease remain speculative. With the aim of gaining mechanistic insight into IPC treatment, the purpose of this study was to investigate the effect of IPC frequency on limb hemodynamics, vascular function, and skeletal muscle gene expression. In this two study investigation, healthy male subjects underwent an hour of either high-frequency (HF; 2-s inflation/3-s deflation) or low-frequency (LF; 4-s inflation/16-s deflation) IPC treatment of the foot and calf. In study 1 (n = 11; 23.5 ± 4.7 yr), subjects underwent both HF and LF treatment on separate days. Doppler/ultrasonography was used to measure popliteal artery diameter and blood velocity at baseline and during IPC treatment. Flow-mediated dilation (FMD) and peak reactive hyperemia blood flow (RHBF) were determined before and after IPC treatment. In study 2 (n = 19; 22.0 ± 4.6 yr), skeletal muscle biopsies were taken from the lateral gastrocnemius of the treated and control limb at baseline and at 30- and 150-min posttreatment. Quantitative PCR was used to assess mRNA concentrations of genes associated with inflammation and vascular remodeling. No treatment effect on vascular function was observed. Cuff deflation resulted in increased blood flow (BF) and shear rate (SR) in both treatments at the onset of treatment compared with baseline (P < 0.01). BF and SR significantly diminished by 45 min of HF treatment only (P < 0.01). Both treatments reduced BF and SR and elevated oscillatory shear index compared with baseline (P < 0.01) during cuff inflation. IPC decreased the mRNA expression of cysteine-rich protein 61 from baseline and controls (P <0 .01) and connective tissue growth factor from baseline (P < 0.05) in a frequency-dependent manner. In conclusion, a single session of IPC acutely impacts limb hemodynamics and skeletal muscle gene expression in a frequency-dependent manner but does not impact vascular function.

Acute systemic thermal therapy can improve arterial stiffness in both animals and humans. We examined and compared the effects of acute local thermal therapy (footbath) on an indicator of human arterial stiffness, cardio-ankle vascular index (CAVI), in 16 healthy young (29.4 ± 0.4 years) and 16 older (59.8 ± 1.7 years) women. Measurements were made at baseline (BL) and at 0 and 30 min after footbath in footbath trial, and at corresponding time points without footbath in control trial. In the footbath trial, subjects immersed their lower legs and feet in water for 30 min, with water temperature ranging from 41 to 43°C. The results showed that footbath elicited significant reductions in CAVI at 0 min compared to the same trial's baseline in both young and older groups (0.55 ± 0.07, P = 0.01 for young; 0.42 ± 0.15, P = 0.03 for older, respectively) with no changes found in the control trials. The percentage of CAVI change at 0 min was significantly greater in young women (91.9 ± 1.1%) compared to older women (96.5 ± 1.8%, P < 0.05). This study indicated that acute warm footbath results in transient improvement of systemic arterial stiffness in both healthy young and older women. Despite similar intervention, the percentage response of arterial stiffness to footbath was attenuated in older women.

The main focus of this paper is the selection of proper vessels for successful free tissue transfer in lower extremities which have suffered extensive trauma. The selection of proper recipient vessels for traumatized lower extremities still presents difficulties for surgeons. This review will provide a general guideline for the selection of proper recipient vessels in traumatic lower extremity reconstruction and describe the possible reasons why some recipient vessels present more problems than others., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The authors present the case of a subadventitial rupture of the popliteal artery and devastating injury to the crural arteries due to a crush injury to the proximal shank. The arterial injury was treated by urgent popliteo-pedal bypass grafting. Besides the surgical procedure, the authors also discuss revascularisation syndrome. The subadventitial rupture of the popliteal artery is a serious condition associated with a risk of high amputation.

Objective: assessing the incidence rate of atypical anatomical variants of the development of the popliteal artery and plantar arteries according to the findings of digital subtraction angiography., Material: Retrospective analysis of angiograms of 2,456 lower limbs in 1,305 patients. The character of the arterial lesion and the quality of the angiograms allowed of evaluating the anatomy of the popliteal artery and plantar arteries on a total of 1,609 extremities (65%)., Results: The incidence of atypical ramification of the popliteal artery amounted to 9%. Altered blood supply of the foot was observed in 7.6% of cases. The total incidence rate of atypical anatomical variants in men and women did not differ significantly. In the presence of a typical anatomical variant on one extremity, the prevalence of atypical blood supply of the other limb amounted to 16.3%. In the presence of an atypical anatomical variant on one limb, the incidence of atypical blood supply of the other amounted to 42%. In case of atypical blood supply of the foot on one limb, the incidence rate of the same-type abnormality on the other equalled 48%., Conclusion: In a typical variant of blood supply of one extremity, the probability of typical blood supply of the other amounted to 83 .7%, in an atypical variant decreasing to 58%. In case of atypical blood supply of one foot, one should suppose an analogous anatomical variant on the other foot in half of the cases.

Perfusion of a fibular flap is based on the peroneal artery. To avoid ischaemia of the lower leg postoperatively after the artery has been sacrificed, adequate perfusion must be guaranteed preoperatively. Although common anatomical variations and pathological changes are well recognised, the best way to evaluate the vascular system preoperatively is controversial. Our aim was to identify anatomical vascular patterns that may jeopardise either the limb or the flap while the fibula is being harvested, and provide a few simple rules for the assessment of preoperative evaluation techniques. We dissected 128 lower legs preserved in formalin and evaluated them for the incidence of vascular anatomical variants. In addition we measured absolute and relative loss of volume. Volume loss from the peroneal artery was considerable, with a loss of 23%. On two occasions the peroneal artery mimicked the anterior tibial artery in its course to the dorsalis pedis artery at the dorsum of foot; four times the tibial artery arose directly from the peroneal artery; and five times only a rudimentary posterior tibial artery could be found. There are numerous vascular variants in the lower leg, some of which could put the flap or the limb at risk. We therefore think that preoperative evaluation of the vascular system is advisable., (Copyright © 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Vascular imaging can be essential in the diagnosis, monitoring, and planning and assessment of treatment of patients with peripheral vascular disease. The purpose of this work is to describe a recently developed three-dimensional (3D) time-resolved contrast-enhanced MR angiography (CE-MRA) technique, Cartesian Acquisition with Projection Reconstruction-like sampling (CAPR), and its application to imaging of the vasculature of the lower legs and feet. CAPR implements accelerated imaging techniques and uses specialized multielement imaging coil arrays to achieve high temporal and high spatial resolution imaging. Volunteer and patient studies of the vasculature of the lower legs and feet have been performed. Temporal resolution of 4.9-6.5 sec and spatial resolution less than or equal to 1 mm in all directions allow for the depiction of progressive arterial filling and complex flow patterns as well as sharp visualization of vascular structure as small as the fine muscular branches. High-quality diagnostic imaging is made possible with CAPR's advanced acquisition and reconstruction techniques and the use of specialized coil arrays., (Copyright © 2011 Wiley-Liss, Inc.)

Objective: To examine the association between diabetes-related lower-extremity amputation (LEA) and ethnicity, age, source of payment, geographic location, diabetes severity, and health condition in adults with diabetes mellitus type 2 living in border and non-border counties in Texas, United States of America, and to assess intra-border region geographic differences in post-LEA treatment., Methods: This correlational study was based on secondary data from the 2003 Texas Inpatient Hospital Discharge Data. The sample consisted of individuals 45 years of age and older with type 2 diabetes who had undergone a nontraumatic LEA (n = 5,865). Descriptive statistics and logistic regression analyses were applied., Results: The following characteristics were predictors of LEA: being Hispanic or African American, male, ≥ 55 years old, and a Medicare or Medicaid user, and living in a border county. Persons with moderate diabetes and those who suffered from cardiovascular disease or stroke also had higher odds of undergoing an LEA. Post-LEA occupational therapy was significantly less prevalent among border residents (9.5%) than non-border residents (15.3%) (P < 0.001)., Conclusion: Understanding the factors that influence diabetes-related LEA may lead to early detection and effective treatment of this disabling consequence of diabetes along the U.S.-Mexico border.

Spinal cord stimulation (SCS) has been successfully used to treat chronic pain syndromes for decades. For this purpose, an electrode is implanted into the epidural space under local anaesthesia and connected to a neurostimulator which applies a weak direct current to the dorsal roots of the spinal column. Besides pain control, SCS increases the blood supply in the stimulated area. This effect is mediated by a sympathicolytic effect and the liberation of vasodilatators within the stimulated skin area. A Cochrane meta-analysis has revealed a significantly increased limb salvage rate in patients with non-reconstructable critical limb ischaemia (CLI) treated with SCS. The effect of SCS in CLI might be predicted by the measurement of forefoot transcutaneous pO (2) in supine and dependent positions, which renders trial stimulation unnecessary in many cases., (Georg Thieme Verlag Stuttgart ˙ New York.)

Objective: We investigated the role of the angiosome concept in endovascular therapy (EVT) for limb salvage., Background: The angiosome concept is clinically useful in bypass surgery for critical limbs ischemia (CLI). However, comparison with direct and indirect flow to the site of ulceration based on angiosome concept regarding freedom from amputation has not been systematically studied for the patient with CLI undergoing EVT., Methods: We analyzed 203 limbs in 177 consecutive patients (male = 127, age = 70 +/- 11 years) with ischemic ulceration that was Rutherford 5 or 6 (5 in 145 limbs and 6 in 58 limbs; pretreatment ankle-brachial index = 0.74 +/- 0.27), who underwent EVT alone without bypass surgery. We classified these patients into direct and indirect groups depending on whether feeding artery flow to the site of ulceration was successfully acquired or not acquired based on the angiosome concept. Freedom from amputation was compared between the direct and the indirect groups by Kaplan-Meier analysis., Results: The overall limb salvage rate was 82% (167/203). Skin perfusion pressure was significantly higher in the direct group (67 +/- 25 mm Hg) than in the indirect group (41 +/- 20 mm Hg, P = 0.002). The limb salvage rate was also significantly (P = 0.03) higher in the direct group (86%) than in the indirect group (69%) for up to 4 years after the procedure. The number of vessels with run-off flow did not influence the limb salvage rate in either the direct group (P = 0.84) or the indirect group (P = 0.90)., Conclusion: Acquiring direct flow based on the angiosome concept is important for limb salvage by EVT in patients with CLI., (Copyright 2010 Wiley-Liss, Inc.)

Background: The use of pnuemoperitonium to create the working environment for laproscopic cholecystectomy results in an increase in intraabdominal pressure, which exceeds the pressure of the venous-return from the legs. The resulting venous stasis may increase the risk of thrombosis formation and deep vein thrombosis in the lower limbs. However, there is no information as to whether the venous stasis will also exacerbate the coagulabililty of blood flowing out of the lower limbs., Aim: The aim of the study is to find evidence of haemostatic activation in the blood draining the lower limbs, which experience venous stasis as a result of the laparoscopic cholecystectomy (LC) procedure., Materials and Methods: In this study, we prospectively studied 25 patients who underwent LC for uncomplicated cholelithiasis; 20 were female and 5 were male, aged between 17 to 65 years. LC was carried out according to a standard procedure. After general anesthesia, the patients were laid in a 30 degrees anti-Trendelenburg position, and pnuemoperitonium was maintained during the procedure with abdominal pressure of 12 mm Hg. The mean operating time was 55 minutes (range 25 to 118 min).Blood samples were collected simultaneously from the antecubetal fossa (the upper limb) and the dorsum of the foot (the lower limb), on 4 different occasions: i. preoperative; ii. after the induction of anesthesia, and before the inflation of the abdomen; iii. at the end of surgery, before deflation of the abdomen, and iv. 24 hours after surgery. LABORATORY ASSAYS: Prothrombin time, activated partial thromboplastin time, thrombin time, and plasma fibrinogen, Plasma Protein S (total and free), Protein C, Antithrombin, tissue plasminogen activator, and plasminogen activator inhibitor (PAI-I). Platelet function was assessed by the platelet function analyser (PFA100)., Results: No significant differences were noted in all measured haemostatic parameters, including PFA100 closure times, when comparing the measurements that were taken simultaneously in the upper and lower limbs' blood. Plasma fibrinogen increased significantly 24 hours after surgery, and antithrombin levels dropped slightly, immediately after surgery, but recovered preoperative levels 24 hours after surgery. Coagulation inhibitors (total and free protein S and protein C), and fibrinolytic parameters did not show any significant fluctuations throughout the study intervals., Conclusion: The finding of this study is of no significant activation of coagulation in the blood flowing out of the lower limbs at the time of venous stasis, adds to the criteria of safety of the current surgical procedure used in LC, including reverse Trendelenburg position and pneumoperitoneum that unavoidably produce significant stasis in the lower limbs.

Objectives: Major tissue loss caused by the critical limb ischemia requires improvement of distal perfusion and cover of large tissue defects. We propose a new method, the y-shaped subscapular artery flow-through (Y-SCAFT) muscle flap using the subscapular artery that yields an arterial graft and a free muscle flap sustained by a collateral branch of this artery. This prospective study evaluated the feasibility of this technique and analyzed wound healing, graft patency, and limb salvage., Methods: Between 2002 and 2007, 20 patients, mean age 64 years (range, 55-79 years), were treated with this technique. All presented with critical ischemia and major tissue loss, with exposure of the tendons, bones, or joint, and were candidates for major amputation. Revascularization and cover of tissue loss with the same Y-SCAFT anatomic unit was used for all patients. The distal anastomosis was performed between the distal branch of the Y-SCAFT and the pedal artery in 9, posterior tibial artery in 4, peroneal artery in 1, lateral tarsal artery in 3, and the plantar artery in 3. In four patients, the distal part of the arterial graft, including the anastomosis, was covered with the muscle flap because the tissue loss was nearby. The proximal anastomosis was performed between a leg artery and the arterial graft in 10 patients. A venous graft was necessary in 10 patients to extend the bypass proximally., Results: One patient died during the postoperative period. Duplex control evidenced patency all the Y-SCAFT muscle flaps. Healing was achieved in all patients. Mean follow-up was 31 months (range, 6-58 months). No patients died during follow-up. One patient presented occlusion of the Y-SCAFT muscle flap and underwent amputated. One patient had major amputation despite a patent graft. At 2 years, leg salvage was 85%, patency was 94%, and survival was 94%. At the end of the follow-up, 17 patients (1 death, 2 amputations) had a patent graft, a viable muscle flap, wound healing, and a functional leg., Conclusion: We showed the clinical feasibility of the technique of Y-SCAFT muscle flap, which allows for revascularization and cover of major tissue loss with one anatomic unit. This method is particularly useful in selected cases with poor run-off and large ischemic lesions.

Arterial spin labeling (ASL) is a noninvasive magnetic resonance imaging (MRI) technique for microvascular blood flow measurement. We used a continuous ASL scheme (CASL) to investigate the hyperemic flow difference between major muscle groups in human extremities. Twenty-four healthy subjects with no evidence of vascular disease were recruited. MRI was conducted on a 3.0 Tesla Siemens Trio whole body system with a transmit/receive knee coil. A nonmagnetic orthopedic tourniquet system was used to create a 5-min period of ischemia followed by a period of hyperemic flow (occlusion pressure = 250 mmHg). CASL imaging, lasting from 2 min before cuff inflation to 3 min after cuff deflation, was performed on the midcalf, midfoot, and midforearm in separate sessions from which blood flow was quantified with an effective temporal resolution of 16 s. When muscles in the same anatomic location were compared, hyperemic flow was found to be significantly higher in the compartments containing muscles known to have relatively higher slow-twitch type I fiber compositions, such as the soleus muscle in the calf and the extensors in the forearm. In the foot, the plantar flexors exhibited a slightly delayed hyperemic response relative to that of the dorsal compartment, but no between-group flow difference was observed. These results demonstrate that CASL is sensitive to flow heterogeneity between diverse muscle groups and that nonuniform hyperemic flow patterns following an ischemic paradigm correlate with relative fiber-type predominance.

Introduction: The aim of this study was to evaluate the role of intra-operative Prostavasin application during crural bypass surgery. 68 Patients, who underwent infrainguinal autologous vein bypass surgery, were prospectively analyzed., Results: Intra-operative flow measurements and Prostavasin administration were performed in all patients. The mean flow was 105 ml / min (minimal flow 18 ml / min, maximal flow 321 ml / min). The means of maximal and minimal flow were 329 und 30 ml / min, respectively. The mean of the calculated Pulsatility index was 3.1. The mean flow volume increased after administration of Prostavasin in all patients with a mean increase of 103 %. The Pulsatility index decreased by 39 %. Primary and secondary patency rates after 1 year were 70.3 % und 73.1 %, respectively. The differentiated analyses of the region of the distal anastomoses (popliteal / crural) showed a statistically significant bigger increase of Q after Prostavasin application for infrainguinal popliteal bypasses compared to patients with crural reconstructions (p = 0.05). In addition, the decrease of the Pulsatility index was significantly higher in popliteal grafts (p = 0.03). Patients with early bypass graft failure showed a significantly smaller decrease of PI after Prostavasin application compared to the other patients., Conclusion: The profit of intra-operative arterial Prostavasin application is first of all an immediate one. The injection of Prostavasin leads to an instant vessel dilatation. This allows the surgeon to get an impression of the flow capacity of the bypass. The Pulsatility index as an indicator for resistance is an important factor for bypass patency.

Objectives: To report normal values of skin perfusion in healthy subjects in three age groups using a laser Doppler imager; to determine differences attributable to gender, age, site, and use of red or near-infrared lasers; and to correlate transcutaneous oxygen with laser flux values., Design: Flux and transcutaneous oxygen were measured at ten sites in the lower extremity in 60 subjects from three age groups. Heated and unheated sites were scanned with red and near-infrared lasers., Results: Heat hyperemia was prominent at all sites. Small, statistically significant mean +/- SD differences were found between heated and nonheated sites for the red and near-infrared lasers (P = 0.02). All flux ratios were independent of gender but were higher in the oldest group. Plantar sites demonstrated higher flux in unheated areas and lower flux ratios compared with leg sites. Transcutaneous oxygen did not correlate significantly with flux for either laser type., Conclusions: Scanning laser-Doppler imaging flux values provide a reference for identifying patients at risk for tissue ischemia and poor healing potential caused by impaired circulatory reserve in the legs and distal feet. The lack of correlation between flux and transcutaneous oxygen in healthy individuals suggests that they measure different physiologic processes.

On sonographic images, the peripheral nerves have a fibrillary structure, ribboned on longitudinal images and ovoid on cross-section images. The nerves travel between the muscle groups, often with blood vessels, or in canals. Recently improved ultrasound devices are able to investigate the peripheral nerves along their entire length, as far as the sonographer has thorough anatomical knowledge, rigorous technique, and, when searching for pathology, good clinical notions. As in Part I on sonography of the peripheral nerves of the upper limbs, published in this journal, the objective of this general review is to present normal and pathological echoanatomy of the peripheral nerves of the lower limbs in an educational way.

Aim: The aim of this study was to determine the role of combined mechanical and pharmacological prophylaxis in the prevention of deep venous thrombosis (DVT) after total knee replacement (TKR)., Design: prospective case series study., Methods: Between October 2002 and June 2003, 38 total knee procedures were carried out on 34 patients (4 patients had bilateral TKR). To exclude the presence of a concomitant DVT echo-color-flow of the legs was performed between 2 and 1 week prior to surgery, in the postoperative period (before discharging) and 30 days after surgery. Patients received one daily subcutaneous injection of nadroparin calcium (dosage adapted to body-weight). An intermittent foot sole pump (IFSP) was applied in the recovery room postoperatively, in both feet for about 5 h a day and all night long, and continued at home until the 15(th) day., Results: No major perioperative or rehabilitation phase-related complications were observed (2 patients required manual drainage of blood clots from the wound). The incidence of DVT was 7.9% (3 cases). In one of these cases we observed a previous DVT so it was classified as rethrombosis. All were successfully treated with therapeutic introduced low molecular weight heparin (LMWH) therapy. No pulmonary embolism or deaths associated with the use of LMWH or IFSP were observed., Conclusions: In our experience the combined prophylaxis with nadroparin calcium and IFSP significantly reduced the incidence of DVT.

Objective: The objective of our study was to describe hybrid peripheral (HyPer) 3D contrast-enhanced MR angiography (CE-MRA) using sagittal acquisition with parallel imaging of the calf and foot station. The benefit of a dedicated sagittal 3D CE-MRA acquisition of the calf and foot was evaluated by assessing the degree of venous contamination and its diagnostic quality compared with standard bolus chase 3D CE-MRA alone., Materials and Methods: Fifty-three patients (99 legs) were scanned with a 1.5-T MR system equipped with a dedicated bilateral lower extremity phased-array coil. First, high-resolution 3D CE-MRA images of the calves and feet were obtained using two separate sagittal slabs with parallel imaging, with a resulting voxel size of 1.4 x 1.0 x 1.0 mm3. Second, standard bolus chase 3D CE-MRA was performed from the abdomen and pelvis station to the calf-foot station. Images were interpreted by two radiologists. The calf-foot arterial trees were divided into 12 segments. Each segment was characterized as diagnostic or nondiagnostic. The degree of venous contamination was assessed as interfering with the diagnosis or not. Paired Student's t test and Wilcoxon's signed rank test were used to test for statistically significant differences between the techniques., Results: For the left leg (n = 48), the mean number (+/- SD) of diagnosed arterial segments for HyPer 3D CE-MRA was 9.2 +/- 2.3 and for bolus chase 3D CE-MRA, 7.1 +/- 4.2 (p < or = 0.0004). For the right leg (n = 51), the corresponding values were 9.4 +/- 2.2 and 7.6 +/- 3.5 (p < or = 0.0005), respectively. For bolus chase 3D CE-MRA, venous contamination interfered with the diagnosis in 24 of 99 legs, whereas with HyPer 3D CE-MRA, there was no interference. Selective analysis of the dorsalis pedis arteries showed that the number of diagnostic vessels was 62 (62.6%) of 99 for HyPer 3D CE-MRA and 13 (13.1%) of 99 for bolus chase 3D CE-MRA., Conclusion: HyPer 3D CE-MRA is an alternative method for time-resolved high-resolution peripheral CE-MRA in evaluating the trifurcation and feet vessels with no venous contamination.

Introduction: The aim of this study was to assess the blood flow in the feet before and after lower limb revascularization using laser Doppler imaging (LDI)., Methods: Ten patients with critical lower limb ischemia were prospectively enrolled from June to October 2004. All patients underwent successful unilateral surgical interventions including above-knee bypass, distal bypass and endarterectomy. Skin blood flow (SBF) over the plantar surface of both forefeet and heels was measured by LDI 24h before and 10 days after revascularization, expressed in perfusion units (PU), and reported as mean+/-SD., Results: Measurements in the forefoot and heel were similar. Before revascularization mean SBF was significantly lower in the ischemic foot (130+/-71 PU) compared to the contralateral foot (212+/-68 PU), p<0.05. After revascularization a significant increase of the SBF in the forefoot (from 135+/-67 to 202+/-86 PU, p=0.001) and hindfoot (from 148+/-58 to 203+/-83, p=0.001) was observed on the treatment side. However, a large decrease of the SBF was seen in forefoot and hindfoot on the untreated side (from 250+/-123 PU to 176+/-83 and from 208+/-116 to 133+/-40, p=0.001, respectively)., Conclusion: This study confirms the benefits of revascularization in patients with nonhealing foot lesions due to critical limb ischemia. A significant increase of the SBF was observed on the treatment side. However, an unexpected decrease was observed on the untreated side.

This study examined the time course of changes in blood flow to the lower leg in response to venous distension--the veni-arteriolar vasoconstrictor response--in 31 healthy males. During a 5-min period of venous distension (thigh cuff pressure 50 mm Hg), calf blood flow (venous occlusion plethysmography) decreased more rapidly (within 30 s) compared to skin perfusion (after 2 min, Laser Doppler flowmetry), consistent with disparate filling times of superficial and deeper veins and a greater increase in deep vein volume. On completion of venous filling, vascular resistance in the skin was unchanged from baseline, implying that the reduction in perfusion was solely the result of reduced perfusion pressure. For the whole calf, vascular resistance was unchanged after 1 min but decreased thereafter by 35-45% from baseline, indicating adjustment of pre- or post-capillary resistances to maintain flow. Repeated plethysmographic flow measurements assisted the decrease in resistance, most likely by intermittent compression of the thigh cuff acting to displace blood volume centrally and alleviate congestion. These findings do not support an active veni-arteriolar vasoconstrictor mechanism in response to venous distension alone in the lower leg, and provide evidence of dynamic flow adjustments that should be acknowledged during procedures that involve prolonged periods of venous congestion.

Pedal bypass (arterial reconstruction with distal anastomosis on the dorsal pedal artery (DPA) or in the submalleolar portion of the posterior tibial artery) is now considered as a standard method of revascularisation in critically ischaemic limb with obliteration of the crural arterial system. While a number of studies in large cohorts have proved the success of this method in saving limbs with chronic critical ischaemia, only few papers report the pedal bypass as an urgent intervention. In this study, the authors describe 3 cases where urgent pedal bypass saved the limb threatened by an acute ischaemia (Fig. 3, Ref. 12).

Objective: In critically ill neonates, peripheral perfusion and oxygenation assessment may provide indirect information on the circulatory failure of vital organs during circulatory shock. The development of pulse oximetry has recently made it possible to calculate the perfusion index (PI), obtained from the ratio between the pulsatile and nonpulsatile signals of absorbed light. The main goals of this study were: (1) to study foot PI; and (2) to evaluate the relationship between foot PI, obtained continuously by pulse oximetry, and a number of variables, i.e. blood flow (BF), oxygen delivery (DO(2)), oxygen consumption (VO(2)), and fractional oxygen extraction (FOE), measured indirectly by near-infrared spectroscopy (NIRS) on the calf in 43 healthy term neonates (weight 3474.6 +/- 466.9 g; gestational age 39.1 +/- 1.4 weeks)., Study Design: Calf BF, DO(2) and VO(2) were assessed by NIRS on short-lived venous and arterial occlusion maneuvers. PI was measured on the contralateral foot., Results: Foot PI was 1.26 +/- 0.39. There was a positive correlation between foot PI and both calf BF (r = 0.32, p = 0.03) and DO(2) (r = 0.32, p = 0.03), but no correlation was found between foot PI and calf FOE and between foot PI and VO(2)., Conclusions: In the neonatal intensive care unit, continuously measuring foot PI by pulse oximetry seems clinically more feasible for peripheral perfusion monitoring than spot measurements of the calf BF and/or VO(2) by indirect NIRS.

Percutaneous cardiopulmonary support (PCPS) is a powerful resuscitation tool for patients in cardiogenic shock. The femoral artery is generally used for arterial access; however, vascular complications, particularly in atherosclerotic arteries, can occur. Although such complications occur infrequently, they can be fatal. We describe the case of a 75-year-old woman who required extended PCPS for cardiogenic shock secondary to coronary spasm after on-pump beating coronary artery bypass grafting. Limb ischemia occurred because of an occlusive cannula, and distal perfusion with a 20G elastic intravenous catheter inserted into the dorsalis pedis artery resolved the ischemia. The catheter was connected to the side port of an oxygenator and provided distal limb perfusion during PCPS. This technique appears to be useful in treating limb ischemia and may have application in patients with arterial occlusive disease who are dependent on mechanical support.

Patients with threatening ischemia of the lower extremities constitute a steadily increasing patient population owing to the increasing age of the general population and the growing incidence of diabetes. The goals of treatment for patients with critical limb ischemia (CLI) are pain control, wound healing, limb salvage, improvement of quality of life and reduction of overall cardiovascular risk. A high proportion of patients with CLI have coexisting diseases, mainly cardiovascular and renal disorders. The purpose of this article is to summarize non-invasive treatment options in patients with CLI and to critically review the results of landmark investigations dealing with conservative therapy for chronic critical limb ischemia.

The term critical limb ischemia refers to a condition characterized by chronic ischemic at-rest pain, ulcers, or gangrene in one or both legs attributable to objectively proven arterial occlusive disease. Critical limb ischemia implies chronicity and is to be distinguished from acute limb ischemia. Its incidence is approximately 500 to 1000 per million year, with the highest rates among older subjects, smokers and diabetics. The rate of primary amputation ranges from 10% to 40%, and was performed only when no graftable distal vessels were present, or in neurologically impaired or hopelessly nonambulatory patients. Contrarily, in some highly specialized and aggressive centres about 90% of patients with CLI had an attempted revascularization. Furthermore, patients with critical limb ischemia have an elevated risk of future myocardial infarction, stroke and vascular death, 3-fold higher than patients with intermittent claudication. Therefore, due to its negative impact on the quality of life and the poor prognosis both in terms of limb salvage and survival, critical limb ischemia is a critical public health issue.

Purpose: To review percutaneous intentional extraluminal recanalization (PIER) for treatment of patients who are poor candidates for infrainguinal arterial bypass surgery (IABS) and have arterial occlusions and chronic critical limb ischemia (CCLI)., Materials and Methods: Patients with CCLI who were poor candidates for IABS were candidates for PIER. PIER was performed to create continuous arterial flow to the foot for limb salvage. PIER was attempted in 40 patients (22 men, 18 women; median age, 69 years; age range, 44-87 years). Of these patients, 24 (60%) had diabetes, 17 (42%) had renal disease, and 26 (66%) had coronary artery disease. Wound healing was evaluated at follow-up. Kaplan-Meier curves were constructed to evaluate limb salvage, survival, and amputation-free survival., Results: Fifty procedures were attempted in 44 limbs. Tissue loss was present in 40 (91%) limbs, and rest pain was present in four (9%); technical success occurred in 38 (86%). Thirty-seven (84%) of 44 limbs treated with PIER involved tibial vessels (tibial vessels only, n = 15; tibial and superior femoral artery [SFA] and/or popliteal vessels, n = 22). Sixty-six infrainguinal arterial vessel segments (SFA, n = 29; tibial, n = 37) in 38 limbs (1.7 segments per limb) were successfully treated with PIER. Thirty-five (95%) of 37 tibial occlusions and 24 (83%) of 29 SFA and/or popliteal occlusions were longer than 10 cm. Median run-off scores were 5.3 (range, 3-8) and 6.6 (range, 3-9) for patients with tibial occlusions and SFA and/or popliteal occlusions, respectively, as scored with modified Rutherford weighting of run-off arteries. Median follow-up was 7.8 months (range, 1-24 months). Twelve months after PIER, Kaplan-Meier analysis showed limb salvage rate was 66%, survival rate was 71%, and amputation-free survival rate was 48% in these patients. The 30-day mortality rate was 2.5%. Major complications occurred in four (10%) patients, and minor complications occurred in an additional four (10%)., Conclusion: PIER is a useful percutaneous technique for limb salvage in patients with CCLI., (Copyright RSNA, 2004)

Background: Long-duration spaceflight results in deconditioning of the cardiovascular system, loss of fluid volume, bone demineralization, and atrophy of skeletal muscles, particularly affecting the lower limbs. We hypothesized that it is possible to improve blood circulation to the lower extremities in simulated microgravity by forcing the blood to deliver heat to the feet through heating parts of the upper body and thighs., Methods: In Study 1, seven men and four women were assessed in an environmental chamber with head-down tilt (HDT) at 14 degrees, wearing a newly developed shortened multi-compartment liquid cooling/warming garment (SLCWG) with local tubing networks covering parts of the head, torso, thigh, arms, and hands, with fingers, lower leg, and feet exposed. Study 2 was the same as Study 1 with a new cohort of four men and two women, and the assessment of toe blood perfusion on all subjects. Heat was applied as follows: Stage 1--SLCWG inlet water temperature 33 degrees C to stabilize comfort; Stage 2--inlet water temperature 8-10 degrees C (in combination with HDT) to reach a criterion of 25 degrees C finger temperature (Tfing); and Stage 3--inlet water temperature 45 degrees C to restore Tfing to 33 degrees C., Results: Improvement of foot circulation by delivering more heat to the upper body and thighs was noted; increases in toe temperature (Ttoe) suggest enhanced perfusion. From Stage 2 to 3, there were significant increases in Ttoe (p < 0.05), a significant decrease in diastolic BP (DBP) (p < 0.05), and a significant change across stages in subjective perception of foot comfort (p < 0.001) and foot heat (p < 0.06). Further, toe blood perfusion increased significantly from Stage 2 to 3 (p < 0.05)., Conclusions: Moderate partial heating of the upper body/thighs improved blood circulation in the feet in simulated microgravity by delivering heat to the lower extremities through restriction of heat exchange with the environment in the heated body parts. This technique could serve as a supplemental countermeasure for increasing blood circulation to the lower extremities.