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Patients with chronic limb-threatening ischemia (CLTI) require revascularization to improve limb perfusion and thereby limit the risk of amputation. It is uncertain whether an initial strategy of endovascular therapy or surgical revascularization for CLTI is superior for improving limb outcomes. In this international, randomized trial, we enrolled 1830 patients with CLTI and infrainguinal peripheral artery disease in two parallel-cohort trials. Patients who had a single segment of great saphenous vein that could be used for surgery were assigned to cohort 1. Patients who needed an alternative bypass conduit were assigned to cohort 2. The primary outcome was a composite of a major adverse limb event - which was defined as amputation above the ankle or a major limb reintervention (a new bypass graft or graft revision, thrombectomy, or thrombolysis) - or death from any cause. In cohort 1, after a median follow-up of 2.7 years, a primary-outcome event occurred in 302 of 709 patients (42.6%) in the surgical group and in 408 of 711 patients (57.4%) in the endovascular group (hazard ratio, 0.68; 95% confidence interval [CI], 0.59 to 0.79; P<0.001). In cohort 2, a primary-outcome event occurred in 83 of 194 patients (42.8%) in the surgical group and in 95 of 199 patients (47.7%) in the endovascular group (hazard ratio, 0.79; 95% CI, 0.58 to 1.06; P = 0.12) after a median follow-up of 1.6 years. The incidence of adverse events was similar in the two groups in the two cohorts. Among patients with CLTI who had an adequate great saphenous vein for surgical revascularization (cohort 1), the incidence of a major adverse limb event or death was significantly lower in the surgical group than in the endovascular group. Among the patients who lacked an adequate saphenous vein conduit (cohort 2), the outcomes in the two groups were similar. (Funded by the National Heart, Lung, and Blood Institute; BEST-CLI ClinicalTrials.gov number, NCT02060630.).

AbstractObjectiveTo determine which primary endovascular revascularisation strategy represents the most clinically effective treatment for patients with chronic limb threatening ischaemia who require endovascular femoro-popliteal, with or without infra-popliteal, revascularisation.DesignThree arm, open label, pragmatic, multicentre, randomised, phase 3 superiority trial (BASIL-3).Setting35 UK NHS vascular units.ParticipantsPatients with chronic limb threatening ischaemia who required endovascular femoro-popliteal, with or without infra-popliteal, revascularisation.InterventionsParticipants were randomly assigned (1:1:1) to femoro-popliteal plain balloon angioplasty with or without bare metal stenting (PBA±BMS), drug coated balloon angioplasty with or without bare metal stenting (DCBA±BMS), or drug eluting stenting (DES) as their first revascularisation strategy.Main outcome measuresThe primary outcome was amputation free survival defined as time to first major amputation or death from any cause. Secondary outcomes included the composite components of the primary outcome, major adverse limb events, major adverse cardiac events, and other prespecified clinical and patient reported outcome measures. Serious adverse events were collected up to 30 days after the first revascularisation procedure.ResultsBetween 29 January 2016 and 31 August 2021, 481 participants were randomised (167 (35%) women, mean age 71.8 years (standard deviation 10.8)). Major amputation or death occurred in 106 of 160 (66%) participants in the PBA±BMS group, 97 of 161 (60%) in the DCBA±BMS group, and 93 of 159 (58%) in the DES group (adjusted hazard ratios: PBA±BMS v DCBA±BMS: 0.84, 97.5% confidence interval 0.61 to 1.16, P=0.22; PBA±BMS v DES: 0.83, 0.60 to 1.15, P=0.20). No differences in serious adverse events were reported between the groups.ConclusionsNeither DCBA±BMS nor DES conferred significant clinical benefit over PBA±BMS in the femoro-popliteal segment in patients with chronic limb threatening ischaemia undergoing endovascular femoro-popliteal, with or without infra-popliteal, revascularisation.Trial registrationISRCTN registry ISRCTN14469736

Cell therapy is becoming an attractive alternative for the treatment of patients with no-option critical limb ischemia (CLI). The main benefits of cell therapy are the induction of therapeutic angiogenesis and neovascularization that lead to an increase in blood flow in the ischemic limb and tissue regeneration in non-healing cutaneous trophic lesions. In the present review, the current state of the art of strategies in the cell therapy field are summarized, focusing on intra-operative autologous cell concentrates in diabetic patients with CLI, examining different sources of cell concentrates and their mechanisms of action. The present study underlined the detrimental effects of the diabetic condition on different sources of autologous cells used in cell therapy, and also in delaying wound healing capacity. Moreover, relevant clinical trials and critical issues arising from cell therapy trials are discussed. Finally, the new concept of cell therapy as an adjuvant therapy to increase wound healing in revascularized diabetic patients is introduced.

Abstract Chronic limb threatening ischemia (CLTI) is the most severe form of peripheral vascular disease which can lead to amputation with a high associated mortality rate. Endothelial colony forming cells (ECFCs) show potential as a cell therapy to revascularize the limbs of individuals with CLTI. However, autologous ECFCs from patient peripheral blood (PB) have been reported to have a dysfunctional phenotype. We investigated this disease phenotype in individuals with CLTI, with and without diabetes mellitus (DM), to determine ECFC suitability as an autologous cell therapy. PB-ECFCs were isolated from age-matched controls, individuals with DM, and individuals with CLTI, with and without DM. The frequency of isolating ECFCs from this donor cohort was calculated. Furthermore, in vitro characterization assays were performed (growth kinetics, angiogenic properties, and reactive oxygen species [ROS] levels) and compared between donor groups. We report a significantly increased frequency of ECFCs from individuals with CLTI, with and without DM. Furthermore, our results demonstrate no significant disease related effect on the in vitro functional properties of ECFCs between cohorts. However, there is a significantly higher in vitro angiogenic capacity in individuals with DM vs age-matched controls. Our results demonstrate that ECFCs can be isolated in individuals with CLTI, with and without DM, and that ECFC functionality is similar between cohorts. Therefore, if the ∼70% isolation efficiency from both CLTI cohorts is overcome, then autologous PB-ECFCs may be a suitable therapeutic for CLTI. Further analysis is needed to determine the critical quality attributes of ECFCs from this patient population. Graphical abstract Graphical Abstract

Chronic limb-threatening ischemia (CLTI) is a major public health problem. Low-intensity pulsed ultrasound (LIPUS) has been shown to improve ischemic limb conditions in patients with CLTI. However, the possible mechanisms of these benefits require further understanding. A total of 37 atherosclerotic peripheral artery disease patients with CLTI (Fontaine class III or IV) who were not suitable for standard revascularization therapies were enrolled. Patients were treated with LIPUS daily for 20 min. Clinical parameters were evaluated at baseline and after 4 weeks and 12 weeks of treatment with LIPUS. Rest pain intensity on a visual analog scale (P = 0.018), walking impairment questionnaire score (P < 0.001), skin perfusion pressure (P < 0.001), flow-mediated vasodilation (P < 0.001), nitroglycerine-induced vasodilation (P = 0.002), white blood cell count (P = 0.013), ALT (P = 0.001), AST (P = 0.017), and high-sensitivity C-reactive protein (P = 0.011) were significantly improved after LIPUS treatment. None of the patients withdrew from the study due to adverse effects associated with LIPUS. During a mean follow-up period of 91.4 ± 49.0 months, the rate of survival was 88.9% at 1 year and the rate of limb survival was 88.6% at 1 year. LIPUS exposure may have favorable effects on clinical symptoms, inflammation, perfusion parameters, and vascular function in patients with CLTI and it can be used safely. Clinical Trial Registration Information: URL for Clinical Trial: https://www.umin.ac.jp/ctr/index.htm ; Registration Number for Clinical Trial: UMIN000004901, UMIN000014757; https://jrct.niph.go.jp/search ; Registration Number for Clinical Trial: jRCTs062200008.

Autologous cell therapy (ACT) is primarily used in diabetic patients with chronic limb-threatening ischemia (CLTI) who are not candidates for standard revascularization. According to current research, this therapy has been shown in some studies to be effective in improving ischemia parameters, decreasing the major amputation rate, and in foot ulcer healing. This review critically evaluates the efficacy of ACT in patients with no-option CLTI, discusses the use of mononuclear and mesenchymal stem cells, and compares the route of delivery of ACT. In addition to ACT, we also describe the use of new revascularization strategies, e.g., nanodiscs, microbeads, and epigenetics, that could enhance the therapeutic effect. The main aim is to summarize new findings on subcellular and molecular levels with the clinical aspects of ACT.

Objective The clinical management of patients with chronic limb‐threatening ischemia (CLTI) faces great challenges. Enhancing wound healing and limb preservation rates in this cohort is a critical objective. This study investigates the effectiveness of combining tibial cortex transverse transport (TTT) and endovascular therapy (EVT) for the treatment of patients with severe CLTI. We aim to evaluate the therapeutic results of this combined approach on the specified patient group. Methods We conducted a retrospective study to compare EVT with the combination of TTT and EVT in patients (Rutherford category 5 and above) with CLTI at Guangxi Medical University's First Affiliated Hospital from June 2017 to June 2023. This cohort was subjected to a follow‐up period ranging from a minimum of 6 months to a maximum of 12 months. The primary outcome measures included amputation‐free survival (AFS) (avoidance of above‐ankle amputation or death from any cause), overall mortality, limb salvage rates, wound healing efficiency, and the technical efficacy of the applied treatments. A variety of statistical analyses including chi‐square tests, Fisher's exact tests, and Pearson's and Spearman's correlation analyses. Results In this study, 131 patients with CLTI were included: 76 in the control group receiving only EVT treatment and 55 in the TTT + EVT group. The two groups were matched on demographic and clinical characteristics. In the TTT + EVT group, after more than 6 months of follow‐up, 85.5% of patients achieved AFS, and wound healing was observed in 54.5% (30 of 55 patients). After more than 12 months of follow‐up, 81.9% achieved AFS, with wound healing in 32 patients. Furthermore, after more than 24 months, 74.2% of patients remained amputation‐free, with wound healing in all surviving patients. In the control group, after more than 6 months of follow‐up, 72.4% of patients achieved AFS, and wound healing was observed in 51.3% (39 of 96 patients). After more than 12 months, 48.9% achieved AFS, with wound healing in 21 patients. Conclusion We found that combining therapy of TTT and EVT is safe and can be successfully administered in patients with CLTI and it enhances wound healing and AFS. Combining Tibial Cortex Transverse Transport (TTT) and Endovascular Therapy (EVT) for Limb Salvage in Chronic Limb‐Threatening Ischemia

This study aimed to compare the 3‐year recurrence rates of diabetic foot ulcers (DFU) and the rate of endovascular reintervention for chronic limb‐threatening ischaemia (CLTI) to recurrence rates of advanced‐stage cancers. We systematically collected original data reporting 3‐year DFU recurrence from studies published through 2024 and calculated a pooled mean. These findings were compared to recurrence rates for advanced breast, prostate, colorectal, and lung cancers using contemporary sources from the National Cancer Institute and American Cancer Society. CLTI reintervention data were drawn from the BEST‐CLI trial. The pooled 3‐year DFU recurrence rate was 58%, while the CLTI reintervention rate was 50%—comparable to cancer recurrence rates: breast (25%–40%), prostate (30%–40%), colorectal (30%–50%), and lung (60%–80%). Despite these comparable risks, DFU and CLTI remain underrecognized in terms of their recurrent burden on individuals, families, and health systems. The data presented here underscore the need to reframe healed DFU and post‐intervention CLTI not as an endpoint but as a remission—a state requiring structured surveillance and proactive management, much like in oncology. Developing interdisciplinary survivorship care plans for individuals with DFU and CLTI, modelled on those used in cancer care, may improve communication, enhance secondary prevention, and foster more ulcer‐free, hospital‐free, and activity‐rich days.

Peripheral artery disease (PAD) can develop into critical limb ischemia (CLI), which is characterized by resting pain at rest, ulcerations, or gangrene, with a high risk of amputation. The optimum course of treatment at this point is arterial revascularization, although this has a significant financial cost and is not always feasible or successful in reducing pain, healing ulcers, or preventing amputations. In situations where traditional alternatives for treating PAD have been exhausted, recent developments in cell therapy may offer a viable substitute. The purpose of this study is to assess the safety and effectiveness of using expanded autologous adipose-derived stem cells (ASCs) in cellular therapy for the treatment of PAD patients who developed chronic artery ulcers. An open randomized clinical trial will be carried out with two groups of twenty patients with CLI: In group 1, 2g of abdominal adipose tissue will be taken to produce ASCs. These cells will then be expanded in a lab (cell processing center) for 14-21 days before being applied to the lesion using bio-dressings and perilesional subcutaneous injections. Group 2 will receive conventional treatment with hydrogel-based dressing. There will be regular clinical assessments, supplementary tests, and photo documentation. The main efficacy outcome will be partial or complete healing of the wound. Safety outcomes will be monitored for infections, gangrene, amputations, and death. Participants will be monitored for 90 days. Cases of major amputation of the studied limb will not be included. The results will be evaluated by an independent external evaluator who is blind to the groups. Considering the high prevalence and socioeconomic consequences related to CLI and limb amputation, this study is expected to provide a positive social and financial impact on the Brazilian Unified Health System. ClinicalTrials.gov: NCT06326203.