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THE JOURNAL OF CARDIOVASCULAR SURGERY

Rivista di Chirurgia Cardiaca, Vascolare e Toracica


Indexed/Abstracted in: BIOSIS Previews, Current Contents/Clinical Medicine, EMBASE, PubMed/MEDLINE, Science Citation Index Expanded (SciSearch), Scopus
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REVIEW  RECENT DEVELOPMENTS IN INTERVENTIONAL REVASCULARIZATION IN CRITICAL LIMB ISCHEMIA


The Journal of Cardiovascular Surgery 2017 June;58(3):383-401

DOI: 10.23736/S0021-9509.17.09878-0

Copyright © 2017 EDIZIONI MINERVA MEDICA

lingua: Inglese

Infrapopliteal calcification patterns in critical limb ischemia: diagnostic, pathologic and therapeutic implications in the search for the endovascular holy grail

Jihad A., MUSTAPHA, Larry J. DIAZ-SANDOVAL, Fadi SAAB

Department of Cardiovascular Medicine, Metro Health Hospital, Wyoming, MI, USA


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Critical limb ischemia (CLI) represents the terminal stage of peripheral arterial disease (PAD) and is characterized by multilevel and multivessel disease. Amongst patients with infrainguinal disease, approximately one third have predominantly isolated infrapopliteal disease and the remaining two thirds, a combination of femoropopliteal and infrapopliteal disease. Isolated infrapopliteal disease is mainly seen in the elderly, diabetic, or dialysis-dependent patients. These patients have higher risk of amputation and shorter amputation-free survival. Infrapopliteal disease presents with either complex high-grade calcified tandem lesions in multiple vessels or with long chronic total occlusion (CTO) segments with plaques characterized by higher calcium and lower fibro-fatty content than the inflow vessels, as arterial calcium deposition increases as we progress distally in the arterial tree. Vascular calcification occurs in both intima and media. Intimal calcification leads to development of calcified atheroma and occlusive lesions. Medial calcification leads to stiffening and decrease in arterial wall elasticity and compliance leading to atherosclerosis, reduced perfusion, and PAD, increasing cardiovascular mortality among patients with end-stage renal disease. This article attempts to review the implications of the diverse pathologic patterns of calcium distribution in infrapopliteal vessels of CLI patients, on the diagnostic modalities, technological developments, and the evolution of therapeutic approaches to improve outcomes among these patients. A critical analysis of the currently available data is provided, pointing to the surprising omission on the role of calcium on outcomes, and future directions are discussed. Is infrapopliteal calcium a roadblock or the avenue towards new paths? Necessity remains the mother of invention.


KEY WORDS: Amputation - Atherectomy - Calcium - Endovascular procedures - Excipients - Limb salvage

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Publication History

Issue published online: March 28, 2017
Article first published online: February 27, 2017

Per citare questo articolo

Mustapha JA, Diaz-Sandoval LJ, Saab F. Infrapopliteal calcification patterns in critical limb ischemia: diagnostic, pathologic and therapeutic implications in the search for the endovascular holy grail. J Cardiovasc Surg 2017;58:383-401. DOI: 10.23736/S0021-9509.17.09878-0

Corresponding author e-mail

jihad.mustapha@metrogr.org