ORIGINAL ARTICLES   

Minerva Cardioangiologica 2006 August;54(4):481-98

Copyright © 2006 EDIZIONI MINERVA MEDICA

language: English

Is transcutaneous oxygen and carbon dioxide monitorino indispensable in short- and long-term therapeutic management of non-reconstructable lower critical limb ischemia?

Melillo E., Nuti M., Pedrinelli R., Buttitta F., Balbarini A.

Angiology Unit, Cardio-Thoracic Department Azienda Ospedaliero-Universitaria Pisana Pisa, Italy

Aim. The aim of this study was to evaluate the capacity of transcutaneous partial pressure of O2 (TCpO2) and CO2 (TCpCO2) to predict clinical response to pharmacological treatment in short- and long-term follow-up of unreconstructable critical limb ischemia (CLI) treated with prostanoids; to suggest a diagnostic and therapeutic algorhythm able to define the possibility of prostanoid therapy in unreconstructable CLI at high risk of limb loss.
Methods. Twenty-six consecutive patients with CLI (21 with distal trophic lesions, 31 symptomatic limbs) considered unreconstructable after peripheral angiography and with a history of type 2 diabetes mellitus underwent daily parenteral Iloprost treatment for 2-3 weeks.
Results. Transcutaneous gas-analytic monitoring (TGM) in non-reconstructable CLI treated with Iloprost divided patients into 2 groups: early responders (ER) with increased TcpO2 and normalization of TcpCO2, and non responders (NR) with unchanged TcpO2 and TcpCO2 parameters. In the NR who underwent a second cycle of Iloprost within a few months of the first, TGM further divided the patients into another subgroup of late responders (LR) with TcpO2 and TcpCO2 similar to the ER group and a subgroup of NR, who, after pharmacological treatment failure, should undergo eventual surgical re-timing and/or spinal cord stimulation in a final attempt to save the limb.
Conclusions. In the short-term follow-up of CLI, a marked reduction in supine/dependent TcpO2 and a marked increase in supine TcpCO2 at the symptomatic forefoot proved to be significant predictors of major amputation risk. In the long-term follow-up period, TGM showed that, in ER and in LR, the favourable effect of pharmacological therapy observed in the first 6 months will disappear over the next 6 months, suggesting an algorhythm of 2- to 3-week cycles of prostanoid therapy repeated every year. In NR treated with surgical and/or alternative therapies who did not undergo major amputations, prolonged instrumental TGM will provide a constant evaluation of metabolic parameters, thus providing the possibility to save the limb with additional pharmacological therapy.