Clinical features, management, and prognosis of chronic limb-threatening ischemia

Lower extremity artery disease (LEAD) associates with amputations, mortality, and systemic atherosclerosis. The most extensive and severe form of LEAD, chronic limb-threatening ischemia (CLTI), associates with the highest rates of adverse events. CLTI is poorly understood due to its heterogenous nature and unpredictable progression. It is thus substantially underdiagnosed and undertreated. This thesis aimed to investigate in depth the clinical features, treatment, and prognosis of CLTI in patients. The findings indicate that CLTI is an extensive arterial multi-site disease with severe crural involvement with typical associated risk factor profile. Ascertaining the patients with the highest risk of adverse events is challenging and current models have only modest predictive abilities. The information about distal atherosclerosis, the sex of patient, toe-brachial index (TBI) and toe pressure (TP) measurements could enhance the estimation. Despite the predominant location of atherosclerosis, TBI and TP are predictive of mortality. TBI and TP overcome the common problem of medial sclerosis and incompressible ankle arteries and therefore, they should be assessed together with ankle-brachial index (ABI). A surgical revascularization, if possible, should be chosen as it associates with better outcomes compared to an endovascular intervention. However, not all patients can be surgically revascularized; thus, endovascular revascularization or primary amputation may be the most appropriate treatment option in the long-term for such patients. Senescence and diabetes mellitus are becoming more frequent as the main risk factors of LEAD, therefore a proportionate increase could be expected to occur for the number of CLTI patients and for the need of vascular care. This thesis demonstrates that clinical decision making is challenging in the treatment planning of CLTI. Risk factor modification, diagnostics, prognosis, and revascularizations are tools to combat the growing health burden of CLTI. However, amputation remains as the only realistic treatment for a significant proportion of CLTI patients

Toe pressure and toe brachial index are predictive of cardiovascular mortality regardless of the most diseased arterial segment in symptomatic lower-extremity artery disease—A retrospective cohort study

ObjectiveAlthough lower extremity arterial disease (LEAD) is most often multisegmental, the predominant disease location and risk factors differ between patients. Ankle-brachial index (ABI), toe-brachial index (TBI), and toe pressure (TP) are predictive of outcome in LEAD patients. Previously, we reported a classification method defining the most diseased arterial segment (MDAS); crural (CR), femoropopliteal (FP), or aortoiliac (AOI). Current study aimed to analyze the associations between MDAS, peripheral pressure measurements and cardiovascular mortality.Materials and methodsWe reviewed retrospectively 729 consecutive LEAD patients (Rutherford 2–6) who underwent digital subtraction angiography between January, 2009 to August, 2011 and had standardized peripheral pressure measurements.ResultsIn Cox Regression analyses, cardiovascular mortality was associated with MDAS and non-invasive pressure indices as follows; MDAS AOI, TP ConclusionsSymptomatic LEAD appears to be multisegmental with severe infrapopliteal involvement. Because of this, TP and TBI are strongly predictive of cardiovascular mortality and they should be routinely measured despite the predominant disease location or clinical presentation.</p

Alcohol intoxication and lack of helmet use are common in electric scooter-related traumatic brain injuries : a consecutive patient series from a tertiary university hospital

Purpose Clinicians have increasingly encountered traumatic brain injuries (TBI) related to electric scooter (ES) accidents. In this study, we aim to identify the modifiable risk factors for ES-related TBIs. Methods A retrospective cohort of consecutive patients treated for ES-related traumatic brain injuries in a tertiary university hospital between May 2019 and September 2021 was identified and employed for the study. The characteristics of the accidents along with the clinical and imaging findings of the injuries were collected from the patient charts. Results During the study period, 104 TBIs related to ES accidents were identified. There was a high occurrence of accidents late at night and on Saturdays. In four cases, the patient's helmet use was mentioned (3.8%). Seventy-four patients (71%) were intoxicated. At the scene of the accident, seventy-seven (74%) of the patients had a Glasgow Coma Scale score of 13-15, three patients (3%) had a score of 9-12, and two patients (2%) had a score of 3-8. The majority (83%) of TBIs were diagnosed as concussions. Eighteen patients had evidence of intracranial injuries in the imagining. Two patients required neurosurgical procedures. The estimated population standardized incidence increased from 7.0/100,000 (95% CI 3.5-11/100,000) in 2019 to 27/100,000 (95% CI 20-34/100,000) in 2021. Conclusions Alcohol intoxication and the lack of a helmet were common in TBIs caused by ES accidents. Most of the accidents occurred late at night. Targeting these modifiable factors could decrease the incidence of ES-related TBIs.Peer reviewe

Alcohol intoxication and lack of helmet use are common in electric scooter-related traumatic brain injuries: a consecutive patient series from a tertiary university hospital

Purpose: Clinicians have increasingly encountered traumatic brain injuries (TBI) related to electric scooter (ES) accidents. In this study, we aim to identify the modifiable risk factors for ES-related TBIs.Methods: A retrospective cohort of consecutive patients treated for ES-related traumatic brain injuries in a tertiary university hospital between May 2019 and September 2021 was identified and employed for the study. The characteristics of the accidents along with the clinical and imaging findings of the injuries were collected from the patient charts.Results: During the study period, 104 TBIs related to ES accidents were identified. There was a high occurrence of accidents late at night and on Saturdays. In four cases, the patient’s helmet use was mentioned (3.8%). Seventy-four patients (71%) were intoxicated. At the scene of the accident, seventy-seven (74%) of the patients had a Glasgow Coma Scale score of 13–15, three patients (3%) had a score of 9–12, and two patients (2%) had a score of 3–8. The majority (83%) of TBIs were diagnosed as concussions. Eighteen patients had evidence of intracranial injuries in the imagining. Two patients required neurosurgical procedures. The estimated population standardized incidence increased from 7.0/100,000 (95% CI 3.5–11/100,000) in 2019 to 27/100,000 (95% CI 20–34/100,000) in 2021.Conclusions: Alcohol intoxication and the lack of a helmet were common in TBIs caused by ES accidents. Most of the accidents occurred late at night. Targeting these modifiable factors could decrease the incidence of ES-related TBIs.</p

Alcohol intoxication and lack of helmet use are common in electric scooter-related traumatic brain injuries: a consecutive patient series from a tertiary university hospital

Purpose: Clinicians have increasingly encountered traumatic brain injuries (TBI) related to electric scooter (ES) accidents. In this study, we aim to identify the modifiable risk factors for ES-related TBIs.Methods: A retrospective cohort of consecutive patients treated for ES-related traumatic brain injuries in a tertiary university hospital between May 2019 and September 2021 was identified and employed for the study. The characteristics of the accidents along with the clinical and imaging findings of the injuries were collected from the patient charts.Results: During the study period, 104 TBIs related to ES accidents were identified. There was a high occurrence of accidents late at night and on Saturdays. In four cases, the patient’s helmet use was mentioned (3.8%). Seventy-four patients (71%) were intoxicated. At the scene of the accident, seventy-seven (74%) of the patients had a Glasgow Coma Scale score of 13–15, three patients (3%) had a score of 9–12, and two patients (2%) had a score of 3–8. The majority (83%) of TBIs were diagnosed as concussions. Eighteen patients had evidence of intracranial injuries in the imagining. Two patients required neurosurgical procedures. The estimated population standardized incidence increased from 7.0/100,000 (95% CI 3.5–11/100,000) in 2019 to 27/100,000 (95% CI 20–34/100,000) in 2021.Conclusions: Alcohol intoxication and the lack of a helmet were common in TBIs caused by ES accidents. Most of the accidents occurred late at night. Targeting these modifiable factors could decrease the incidence of ES-related TBIs.</p

Amputation free survival and overall survival after either endovascular or surgical infrapopliteal revascularization in diabetic and non-diabetic CLTI patients

Peripheral artery disease is a clinical endpoint of atherosclerotic disease. One of its major risk factors, diabetes mellitus, has a strong association to especially infrapopliteal disease. Revascularization in the infrapopliteal region is most commonly performed for patients with critical limb threatening ischemia, the most advanced form of the peripheral artery disease. A revascularization treatment can be performed either as a surgical or an endovascular intervention. Due to the innovation of technology of the past decades and improved skills of the operating surgeons, endovascular therapy has become the procedure-of-choice for patients with infrapopliteal disease. However, the present literature on superiority between the approaches remain scarce. The aim of the present study was to evaluate the possible differences after infrapopliteal endovascular or open surgery revascularization. Further emphasis was drawn to evaluate whether the outcome of either intervention was affected by diabetes mellitus. The present study was a retrospective analysis of 1024 consecutive peripheral artery disease patients from Department of Vascular Surgery of Turku University Hospital. All patients had infrapopliteal revascularizations, amputations or a combination of both between years 2007-2015. This study indicates that endovascular treatment was more likely to precede amputation compared to bypass surgery in both diabetics and non-diabetics. In overall survival, no difference was found. Additionally, the presence of diabetes mellitus did not worsen the outcome of revascularization. This study shows that a well-performed infrapopliteal surgical bypass with autologous vein offers better limb salvage in the long-term compared to endovascular approach

Major Lower Limb Amputations and Amputees in an Aging Population in Southwest Finland 2007-2017

Purpose: The aim of the present study was to describe and analyze changes in the incidences of lower extremity amputations (LEAs), patient characteristics, vascular history of amputees and survival in Southwest Finland. Patients and Methods: This is a retrospective patient study in the Hospital District of Southwest Finland. All consecutive patients with atherosclerosis and diabetes-caused LEA, between 1st January 2007 and 31st December 2017, were included. The annual incidences of major LEA patients were statistically standardized. Patients' diagnoses, functional status, previous revascularizations and minor amputations were recorded, and survival was analyzed. Results: During the 11-year-period major LEAs were performed on 891 patients, 118 (13.2%) were urgent operations. The overall incidence of major LEA was 17.2/100 000 and was age-dependent (3.1 for = 85 years). A decrease in incidence was detected in the Conclusion: Our results suggest that in an aging population, despite good availability of vascular services, a significant number of patients are not fit for active revascularization, and LEA is the only feasible treatment for critical limb ischemia.</p