Critical Limb Ischemia

Critical limb ischemia (CLI), defined as chronic ischemic rest pain, ulcers, or gangrene attributable to objectively proven arterial occlusive disease, is the most advanced form of peripheral arterial disease. Traditionally, open surgical bypass was the only effective treatment strategy for limb revascularization in this patient population. However, during the past decade, the introduction and evolution of endovascular procedures have significantly increased treatment options. In a certain subset of patients for whom either surgical or endovascular revascularization may not be appropriate, primary amputation remains a third treatment option. Definitive high-level evidence on which to base treatment decisions, with an emphasis on clinical and cost effectiveness, is still lacking. Treatment decisions in CLI are individualized, based on life expectancy, functional status, anatomy of the arterial occlusive disease, and surgical risk. For patients with aortoiliac disease, endovascular therapy has become first-line therapy for all but the most severe patterns of occlusion, and aortofemoral bypass surgery is a highly effective and durable treatment for the latter group. For infrainguinal disease, the available data suggest that surgical bypass with vein is the preferred therapy for CLI patients likely to survive 2 years or more, and for those with long segment occlusions or severe infrapopliteal disease who have an acceptable surgical risk. Endovascular therapy may be preferred in patients with reduced life expectancy, those who lack usable vein for bypass or who are at elevated risk for operation, and those with less severe arterial occlusions. Patients with unreconstructable disease, extensive necrosis involving weight-bearing areas, nonambulatory status, or other severe comorbidities may be considered for primary amputation or palliative measures

Influence of peripheral arterial disease and supervised walking on heart rate variability

Objective: To examine the influence of peripheral arterial disease (PAD) on heart rate variability (HRV) in patients, and to examine the influence of an intense long-term (12 months) exercise program on HRV in PAD patients.\ud \ud Methods: This study involved ambulatory patients attending a local hospital and university center. Participants were twenty-five patients with diagnosed PAD and intermittent claudication and 24 healthy, age-matched adults. Interventions involved random allocation of PAD patients to 12 months of conservative medical treatment (Conservative) or medical treatment with supervised treadmill walking (Exercise). The main outcome measures were time- and frequency-domain, nonlinear HRV measures during supine rest, and maximal walking capacity prior to and following the intervention.\ud \ud Results: Despite significantly worse walking capacity (285 ± 190 m vs 941 ± 336 m; P < .05), PAD patients exhibited similar resting HRV to healthy adults. At the 12-month follow-up, Exercise patients exhibited a significantly greater improvement in walking capacity (183% ± 185% vs 57% ± 135%; P = .03) with similar small nonsignificant changes in HRV compared with Conservative patients.\ud \ud Conclusions: The current study demonstrated that PAD patients exhibited similar resting HRV to healthy adults with 12 months of intense supervised walking producing similar HRV changes to that of conservative medical treatment. The greater walking capacity of healthy adults and PAD patients following supervised exercise does not appear to be associated with enhanced HRV