Critical lower limb ischaemia following excision of the rectum

Critical lower limb ischaemia can occur following rectal surgery by a number of mechanisms. Patients with aorto-iliac stenosis or occlusion may be dependent on collateral circulation to the lower limbs from the visceral arteries supplying the descending colon, sigmoid colon and the rectum. Division of these collaterals can precipitate critical ischaemia of the leg. This is an uncommon scenario but one that should be considered in arteriopaths undergoing rectal surgery. Two cases of this complication are reported and the mechanisms discussed.     

Critical limb ischaemia: initial treatment and predictors of amputation-free survival

ObjectivesTo evaluate initial treatment and risk factors for amputation-free survival in patients with critical limb ischaemia (CLI).DesignProspective clinical cohort study at a single vascular surgical centre in Germany.MethodsData on 104 consecutive patients (115 ischaemic limbs) presenting with their first episode of CLI were collected prospectively over a 3-year period. Initial treatment was classified as conservative therapy, intervention, surgery, or major amputation. Patient co-morbidities were assessed by uni- and multivariate analysis to determine risk factors for limb salvage, survival and amputation-free survival.ResultsIndications for treatment were rest pain in 27 (23.5%) and tissue loss in 88 (76.5%) limbs. Revascularisation was attempted in 65% of all limbs: 45% by intervention and 55% by surgery. In 9% primary amputation was necessary and 22% received conservative therapy. Median follow-up was 28 months (1–42). The 3-year limb salvage, patient survival, and amputation-free survival rates were 73%, 41%, and 31%, respectively. Diabetes, cardiac disease and renal insufficiency were associated with poor survival. Combined cardiac and renal disease adversely affected amputation-free survival (HR, 3.68; 95% CI, 1.51–8.94; P < 0.001).ConclusionsAt least two third of all patients presenting with CLI can be offered some type of direct revascularisation. In patients with major cardiac disease and renal insufficiency, a poor outcome in terms of amputation-free survival is to be anticipated.     

Coma and cerebral ischaemia

The differential diagnosis of coma includes cerebral ischaemia. Four patterns of disorder are recognized: focal cerebral ischaemia; diffuse cerebral hypoxia; global cerebral ischaemia; and cerebral infarction. Of these, the last two types are more commonly associated with coma. This article outlines the initial management and investigation of a patient who is comatose, and gives an overview of the causes of cerebral ischaemia. Specific management of stroke due to thrombosis or embolism are discussed. The role of anti-platelet therapy, anticoagulation, thrombolysis, and surgical decompression are summarized.     

Clinical outcome and its predictors in 1560 patients with critical leg ischaemia. Chronic Critical Leg Ischaemia Group.

OBJECTIVE: to assess the predictivity of clinical variables in patients with chronic critical leg ischaemia (CLI). Design observational prospective cohort study. METHODS: the i.c.a.i. (ischemia critica degli arti inferiori) trial database was used to assess the impact of patients' history, cardiovascular risk, manifestations of the disease and specific invasive and pharmacological interventions on mortality, amputation rate and persistence of CLI. RESULTS: of 1560 patients, 298 died within one year; at six months 187 were amputees and 746 still suffered from CLI. Prior major vascular events doubled the risk of dying within one year. Previous revascularisation was associated with a lower mortality, but also with a higher probability of amputation. Among cardiovascular risk factors, only diabetes affected prognosis, in terms of increased mortality and lower probability of recovery from CLI. Patients with tissue loss had a higher amputation rate and less probability of recovery. Ankle pressure was predictive of mortality and amputation only when unmeasurable. Patients requiring revascularisation had better chances of recovering from CLI, but not of longer-term survival or limb salvage compared to those in whom surgery was deemed unnecessary. Antiplatelet drugs caused resolution of CLI and decreased the amputation rate by about 1/3, while the advantage of the test treatment (alprostadil-alpha-cyclodextrine) was confined to CLI resolution only. CONCLUSIONS: this study documents the high mortality and heterogeneity of patients with CLI. It provides stratification criteria for reliably estimating the achievable benefit in routine practice and for clinical trials.     

Mesenteric ischaemia

Mesenteric ischaemia is an uncommon but potentially life-threatening condition encompassing a range of pathology and symptoms. This article considers the spectrum of acute mesenteric ischaemia, venous infarction, acute colonic ischaemia, chronic mesenteric ischaemia and ischaemic colitis.     

Myocardial ischaemia

Myocardial ischaemia occurs frequently during the peri-operative period and is associated with major cardiac events in patients with silent or overt coronary artery disease. Often caused by an imbalance between excessive oxygen demand and limited oxygen supply, ischaemia may also occur as a result of endothelial dysfunction in diseased coronary arteries. Myocardial ischaemia impairs systolic and diastolic ventricular function and facilitates the development of arrhythmias. The effects of myocardial ischaemia may persist after reperfusion (myocardial stunning). When ischaemia is chronic, down-regulation of ventricular function (myocardial hibernation) allows the heart to recover after reperfusion. Peri-operatively myocardial ischaemia is most frequently silent and is caused by haemodynamic aberrations, coagulation disorders and/or hypoxaemia. Prevention of peri-operative silent ischaemia is necessary in order to reduce the risk of adverse cardiac events.     

Mesenteric ischaemia

Acute mesenteric ischaemic (AMI) is a life-threatening vascular condition from which outcomes are poor. It results from acute thrombosis or embolization of one or more mesenteric arteries. Chronic mesenteric ischaemia (CMI) is a clinical syndrome of abdominal pain after eating related to stenosis or occlusion of one or more mesenteric vessels associated with other cardiovascular disease. Mesenteric ischaemia can also result from hypoperfusion, non-occlusive mesenteric ischaemia (NOMI), or mesenteric vein thrombosis (MVT).This article looks at the epidemiology, diagnosis, and management of mesenteric ischaemia. It recognizes the need for resuscitation and time-critical resection of non-viable bowel and revascularization in the acute setting. Improving outcomes necessitates a multidisciplinary approach involving emergency medicine, diagnostic radiology, general surgery, vascular surgery, interventional radiology, anaesthetic, and critical care specialists.     

Mesenteric ischaemia

Mesenteric ischaemia is an uncommon but potentially life-threatening condition encompassing a range of pathology and symptoms. This article considers the spectrum of acute mesenteric ischaemia, venous infarction, acute colonic ischaemia, chronic mesenteric ischaemia and ischaemic colitis.     

Mesenteric ischaemia

Mesenteric ischaemic is a life-threatening condition that occurs as a result of interrupted or reduced blood flow to the bowel. It is categorized as acute or chronic and encompasses a range of pathology and symptoms. This article looks at the presentation, diagnosis and management of acute and chronic mesenteric ischaemia, ischaemic colitis and venous infarction.     

Acute and chronic limb ischaemia

Acute (ALI) and chronic limb ischaemic (CLI) make up a major part of the workload of vascular surgeons and carry considerable morbidity and mortality. Peripheral artery disease (PAD) is the major cause of these conditions. Diagnosis of these conditions involves proper use of imaging including duplex ultrasound, computed tomography angiography (CTA), magnetic resonance angiography (MRA), as well as invasive techniques like digital subtraction angiography (DSA). Management ranges from conservative techniques, the mainstay of management in intermittent claudication (IC), with medical optimization, through to endovascular and open revascularization techniques in CLI and ALI. Finally where no revascularization options exist, primary amputation or palliation must be considered.     

Acute and chronic limb ischaemia

Chronic limb ischaemia presents over time. The most common cause of chronic ischaemia is peripheral arterial disease (PAD). Risk factors for the development of PAD may be modifiable or non-modifiable (age, gender, ethnicity and family history). Intermittent claudication, the most common presenting symptom, may have a relatively benign prognosis in many cases, whereas critical limb ischaemia (CLI) refers to disease progression with threatened limb loss, and requires intervention. In contrast, acute limb ischaemia occurs suddenly, commonly due to thrombosis, embolization or trauma (including iatrogenic causes), and may also be limb threatening, requiring urgent investigation and intervention in order to reduce risks of limb loss.