Dr. Sanjeev Jadhav, Consultant CVTS, Heart & Lung Transplant Surgeon at Apollo Hospitals, Navi Mumbai. He comes with more than 19 years of experience and has performed over 2000 Cardiac Surgeries.
A heart transplant is an operation in which a diseased, failing heart is replaced with a healthier donor heart. Heart transplant is a treatment that's usually reserved for people whose condition hasn't improved enough with medications or other surgeries.
While a heart transplant is a major operation, your chance of survival is good with appropriate follow-up care.
Heart transplants are performed when other treatments for heart problems haven't worked, leading to heart failure. In adults, heart failure can be caused by:
In children, heart failure is most often caused by either a congenital heart defect or cardiomyopathy.
Another organ transplant may be performed at the same time as a heart transplant (multiorgan transplant) in people with certain conditions at select medical centers.
For some people who cannot have a heart transplant, another option may be a ventricular assist device (VAD). A ventricular assist device is a mechanical pump implanted in your chest that helps pump blood from the lower chambers of your heart (ventricles) to the rest of your body.
VADs are commonly used as temporary treatments for people waiting for heart transplants. These devices are increasingly being used as long-term treatments for people who have heart failure but are not eligible for heart transplants. If a VAD doesn't help your heart, doctors may sometimes consider a total artificial heart — a device that replaces the ventricles of your heart — as an alternative short-term treatment while you're waiting for a heart transplant.
Preparations for a heart transplant often begin weeks or months before you receive a donor heart.
Taking the first steps
If your doctor recommends a heart transplant, you'll likely be referred to a heart transplant center for evaluation. Or you can select a transplant center on your own. Check your health insurance to see which transplant centers are covered under your plan.
When evaluating a heart transplant center, consider the number of heart transplants a center performs each year and the survival rates. You can compare transplant center statistics using a database maintained by the Scientific Registry of Transplant Recipients.
You should also check to see if a transplant center offers other services you might need. These include coordinating support groups, assisting with travel arrangements, helping you find local housing for your recovery period or directing you to organizations that can help with these concerns.
Once you decide on a center, you'll need to have an evaluation to see if you're eligible for a transplant. The evaluation will check to see if you:
If the transplant center medical team determines that you're a good candidate for a heart transplant, the center will put you on a waiting list. The wait can be long since there are more people who need hearts than donors. Finding a donor depends on your size, your blood type and how sick you are.
While you're on the waiting list, your medical team will monitor your heart and other organs and adjust your treatment as necessary. The team will help you learn to care for your heart by eating well and being active.
If medical therapy fails to support your vital organs as you wait for a donor heart, your doctors might recommend that you have a device implanted to support your heart while you wait for a donor organ. These devices are known as ventricular assist devices (VADs). The devices are also referred to as bridges to transplantation because they gain you some time to wait until a donor heart is available.
A heart transplant usually needs to occur within four hours of organ removal for the donor organ to remain usable. As a result, hearts are offered first to a transplant center close by and then to centers within certain distances of the donor hospital.
The transplant center will provide you with a pager or cellphone to notify you when a potential heart is available. You must keep your cellphone or pager charged and turned on at all times.
Once you're notified, you and your transplant team have limited time to accept the donation. You'll have to go to the transplant hospital immediately after being notified.
As much as possible, make travel plans ahead of time. Some heart transplant centers provide private air transportation or other travel arrangements. Have a suitcase packed with everything you'll need for your hospital stay, as well as an extra 24-hour supply of your medications.
Once you arrive at the hospital, your doctors and transplant team will conduct a final evaluation to determine if the donor heart is suitable for you and if you're ready for surgery. If your doctors and transplant team decide that either the donor heart or surgery isn't appropriate for you, you might not be able to have the transplant.
A lung transplant is a surgical procedure to replace a diseased or failing lung with a healthy lung, usually from a deceased donor. A lung transplant is reserved for people who have tried other medications or treatments, but their conditions haven't sufficiently improved.
Depending on your medical condition, a lung transplant may involve replacing one of your lungs or both of them. In some situations, the lungs may be transplanted along with a donor heart.
While a lung transplant is a major operation that can involve many complications, it can greatly improve your health and quality of life.
When faced with a decision about having a lung transplant, know what to expect of the lung transplant process, the surgery itself, potential risks and follow-up care.
Unhealthy or damaged lungs can make it difficult for your body to get the oxygen it needs to survive. A variety of diseases and conditions can damage your lungs and hinder their ability to function effectively. Some of the more common causes include:
Lung damage can often be treated with medication or with special breathing devices. But when these measures no longer help or your lung function becomes life-threatening, your doctor might suggest a single-lung transplant or a double-lung transplant.
Some people with coronary artery disease may need a procedure to restore blood flow to a blocked or narrowed artery in the heart, in addition to a lung transplant. In some cases, people with serious heart and lung conditions may need a combined heart-lung transplant.
A lung transplant isn't the right treatment for everyone. Certain factors may mean you're not a good candidate for a lung transplant. While each case is considered individually by a transplant center, a lung transplant may not be appropriate if you:
Complications associated with a lung transplant can be serious and sometimes fatal. Major risks include rejection and infection.
Your immune system defends your body against foreign substances. Even with the best possible match between you and the donor, your immune system will try to attack and reject your new lung or lungs. The risk of rejection is highest soon after the lung transplant and is reduced over time.
Your drug regimen after transplant will include medications to suppress your immune system (immunosuppressant medications) in an effort to prevent organ rejection. You'll likely take these anti-rejection drugs for the rest of your life.
Anti-rejection drugs may cause noticeable side effects, including:
Some anti-rejection medications can also increase your risk of developing new conditions or aggravating existing conditions, such as:
The anti-rejection drugs suppress your immune system, making your body more susceptible to infections, particularly in your lungs.
To help prevent infections, your doctor may recommend that you:
Preparations for a lung transplant often begin long before the surgery to place a transplanted lung. You may begin preparing for a lung transplant weeks, months or years before you receive a donor lung, depending upon the waiting time for a transplant.
If your doctor recommends that you consider a lung transplant, you'll likely be referred to a transplant center for evaluation. You're also free to select a transplant center on your own. When evaluating a lung transplant center:
Once you decide where you would like to have your lung transplant, you'll need to have an evaluation to see if you're eligible for a lung transplant. During an evaluation, your doctors and transplant team may review your medical history, conduct a physical examination, order several tests, and evaluate your mental and emotional health.
Your transplant team will also discuss with you the benefits and risks of a transplant and what to expect before, during and after a transplant.
If the transplant team determines that you're a candidate for a lung transplant, the transplant center will register you and place your name on a waiting list. The number of people needing lung transplants far exceeds the number of donated lungs available. Unfortunately, some people die while waiting for a transplant.
While you're on the waiting list, your medical team will closely monitor your condition and alter your treatment as needed. Your doctor may recommend healthy lifestyle changes, such as eating a healthy diet, getting regular exercise and avoiding tobacco.
Your doctors may recommend that you participate in a pulmonary rehabilitation program while you wait for a donor lung. Pulmonary rehabilitation can help you improve your health and ability to function in daily life before and after your transplant.
When a donor organ becomes available, the donor-recipient matching system administered by the United Network for Organ Sharing (UNOS) finds an appropriate match based on specific criteria, including:
It may take months or even years before a suitable donor becomes available, but you must be prepared to act quickly when one does. Make sure the transplant team knows how to reach you at all times.
Keep your packed hospital bag handy — including an extra 24-hour supply of your medications — and arrange transportation to the transplant center in advance. You may be expected to arrive at the hospital within just a few hours.
Once you arrive at the hospital, you will undergo tests to make sure the lung is a good match and that you are healthy enough to have the surgery. The donor lung also must be healthy, or it will be declined by the transplant team. The transplant will be canceled if it doesn't appear that the surgery will be a success.
Heart bypass surgery, or coronary artery bypass graft (CABG) surgery, is used to improve blood flow to your heart. A surgeon uses blood vessels taken from another area of your body to bypass the damaged arteries.
This surgery is done when coronary arteries become blocked or damaged. These arteries supply your heart with oxygenated blood. If these arteries are blocked or blood flow is restricted, the heart doesn’t work properly. This can lead to heart failure.
Your doctor will recommend a certain type of bypass surgery depending on how many of your arteries are blocked.
Your risk of having a heart attack, heart failure, or another cardiac issue depends on the number of arteries blocked. Blockage in more arteries also means that the surgery may take longer or become more complex.
When a material in your blood called plaque builds up on your arterial walls, less blood flows to the heart muscle. This type of coronary artery disease (CAD) is known as atherosclerosis.
The heart is more likely to become exhausted and fail if it’s not receiving enough blood. Atherosclerosis can affect any arteries in the body.
Your doctor may recommend heart bypass surgery if your coronary arteries become so narrowed or blocked that you run a high risk of a heart attack.
Your doctor will also recommend bypass surgery when the blockage is too severe to manage with medication or other treatments.
A team of doctors, including a cardiologist, identify whether you can undergo open-heart surgery. Some medical conditions can complicate surgery or eliminate it as a possibility.
Conditions that can cause complications include:
Discuss these issues with your doctor before scheduling your surgery. You’ll also want to talk about your family medical history and any prescription and over-the-counter (OTC) medications you’re taking. Planned surgery outcomes are usually better than emergency surgery.
As with any open-heart surgery, heart bypass surgery carries risks. Recent technological advancements have improved the procedure, increasing the chances of a successful surgery.
There’s still a risk for some complications after surgery. These complications could include:
In the past decade, more alternatives to heart bypass surgery have become available. These include:
Balloon angioplasty is the alternative that’s most likely to be recommended by doctors. During this treatment, a tube is threaded through your blocked artery. Afterward, a small balloon is inflated to widen the artery.
The doctor then removes the tube and the balloon. A small metal scaffold, also known as a stent, will be left in place. A stent keeps the artery from contracting back to its original size.
Balloon angioplasty may not be as effective as heart bypass surgery, but it’s less risky.
Congenital (kon-JEN-i-tal) heart defects are problems with the heart's structure that are present at birth. These defects can involve:
Congenital heart defects change the normal flow of blood through the heart.
There are many types of congenital heart defects. They range from simple defects with no symptoms to complex defects with severe, life-threatening symptoms.
Congenital heart defects are the most common type of birth defect. They affect 8 of every 1,000 newborns.
Many of these defects are simple conditions that are easily fixed or need no treatment. A small number of babies are born with complex congenital heart defects that require special medical care soon after birth.
Over the past few decades, the diagnosis and treatment of these complex defects has greatly improved. As a result, almost all children who have complex heart defects survive to adulthood and can live active, productive lives.
Most people who have complex heart defects continue to need special heart care throughout their lives. They may need to pay special attention to how their condition may affect certain issues, such as health insurance, employment, pregnancy and contraception, and other health issues.
To understand congenital heart defects, it's helpful to know how a normal heart works. Your child's heart is a muscle about the size of his or her fist. It works like a pump and beats 100,000 times a day.
The heart has two sides, separated by an inner wall called the septum. The right side of the heart pumps blood to the lungs to pick up oxygen. Then, oxygen-rich blood returns from the lungs to the left side of the heart, and the left side pumps it to the body.
The heart has four chambers and four valves and is connected to various blood vessels. Veins are the blood vessels that carry blood from the body to the heart. Arteries are the blood vessels that carry blood away from the heart to the body.
The illustration shows a cross-section of a healthy heart and its inside structures. The blue arrow shows the direction in which oxygen-poor blood flows from the body to the lungs. The red arrow shows the direction in which oxygen-rich blood flows from the lungs to the rest of the body.
The heart has four chambers or "rooms."
Four valves control the flow of blood from the atria to the ventricles and from the ventricles into the two large arteries connected to the heart.
Valves are like doors that open and close. They open to allow blood to flow through to the next chamber or to one of the arteries, and then they shut to keep blood from flowing backward.
When the heart's valves open and close, they make a "lub-DUB" sound that a doctor can hear using a stethoscope.
Congenital heart defects change the normal flow of blood through the heart. This is because some part of the heart didn't develop properly before birth.
There are many types of congenital heart defects. Some are simple, such as a hole in the septum that allows blood from the left and right sides of the heart to mix, or a narrowed valve that blocks blood flow to the lungs or other parts of the body.
Other defects are more complex. These include combinations of simple defects, problems with where the blood vessels leading to and from the heart are located, and more serious problems with how the heart develops.
The septum is the wall that separates the chambers on the left side of the heart from those on the right. The wall prevents mixing of blood between the two sides of the heart. Sometimes, a baby is born with a hole in the septum. The hole allows blood to mix between the two sides of the heart.
Atrial septal defect (ASD). An ASD is a hole in the part of the septum that separates the atria-the upper chambers of the heart. This heart defect allows oxygen-rich blood from the left atrium to flow into the right atrium instead of flowing to the left ventricle as it should. Many children who have ASDs have few, if any, symptoms.
Heart valve surgery is a procedure to treat heart valve disease. Heart valve disease involves at least one of the four heart valves not working properly. Heart valves keep blood flowing in the correct direction through your heart.
The four valves are the mitral valve, tricuspid valve, pulmonary valve and aortic valve. Each valve has flaps — called leaflets for the mitral and tricuspid valves and cusps for the aortic and pulmonary valves. These flaps open and close once during each heartbeat. Valves that don't open or close properly disrupt blood flow through your heart to your body.
In heart valve surgery, your surgeon repairs or replaces the affected heart valves. Many surgical approaches can be used to repair or replace heart valves, including open-heart surgery or minimally invasive heart surgery.
Your treatment depends on several factors, including your age, your health, the condition of the affected heart valve and the severity of your condition.
There are two basic types of heart valve defects: a narrowing of a valve (stenosis) and a leak in a valve that allows blood to back up (regurgitation). You might need heart valve surgery if you have one of these defects and it's affecting your heart's ability to pump blood.
Your doctor will evaluate you to determine the most appropriate treatment for your condition. If you don't have signs or symptoms, or your condition is mild, your doctor might suggest monitoring over time. In that case, healthy lifestyle changes and medications might help manage symptoms.
Eventually, your valve might need to be repaired or replaced. In some cases, doctors recommend heart valve repair or replacement even if you're not having symptoms. If you need heart surgery for another condition, doctors might repair or replace the affected heart valve at the same time.
Your doctor will discuss with you whether heart valve repair or replacement is more appropriate for your condition. Doctors often recommend heart valve repair when possible, as it preserves your heart valve and might preserve heart function. But sometimes valve replacement is necessary and the best option.
Doctors might also evaluate if you're a candidate for minimally invasive heart surgery. Your doctor will discuss the benefits and risks of each procedure.
Possible heart valve surgery risks include:
Before being admitted to the hospital for your surgery, talk to your family about your hospital stay and discuss help you'll need when you return home. Your doctor and treatment team will give you instructions to follow when you return home, as well as discuss your surgery with you and answer your questions.
Talk to your doctor about:
Your treatment team might recommend that you bring several items to the hospital, including:
You'll need to have your body hair shaved where the incisions will be made. A special soap might be used to wash your skin to help prevent infection.
During the procedure
You'll receive anesthetics to put you in a sleep-like state during the procedure. You'll be connected to a heart-lung bypass machine, which keeps blood moving through your body during the procedure.
Heart valve surgery can be performed using standard open-heart surgery, which involves cutting your chest through your breastbone. Minimally invasive heart surgery involves smaller incisions than those used in open-heart surgery.
Minimally invasive heart surgery includes surgery performed using long instruments inserted through one or more small incisions in the chest (thoracoscopic surgery), surgery performed through a small incision in the chest, or surgery performed by a surgeon using the assistance of a robot (robot-assisted heart surgery).
Minimally invasive heart surgery might involve a shorter hospital stay, quicker recovery and less pain than you'd have with open-heart surgery. Minimally invasive heart surgery ideally should be performed at medical centers with medical teams experienced in performing these types of procedures.
Your doctor may often recommend heart valve repair when possible, as it preserves your heart valve and may preserve heart function. Heart valve repair surgery may include:
Some heart valve repair procedures are performed using a long, thin tube (catheter) and clips, plugs or other devices, and regular technology advances allow new procedures to be done.
Doctors might treat a valve with a narrowed opening with a catheter procedure called a balloon valvuloplasty. A doctor inserts a catheter with a balloon on the tip into an artery in your arm or groin and guides it to the affected valve.
Minimally invasive heart surgery involves making small incisions in the right side of the chest to reach the heart between the ribs, rather than cutting through the breastbone, as is done in open-heart surgery.
Minimally invasive heart surgery can be done to treat a variety of heart conditions. Compared with open-heart surgery, this type of surgery might mean less pain and a quicker recovery for many people.
Many types of heart procedures may be performed with minimally invasive heart surgery, including:
The potential benefits of minimally invasive heart surgery when compared with open-heart surgery can include:
Minimally invasive heart surgery isn't right for everyone. Your doctor and treatment team will work with you to determine whether it's an option to treat your condition.
To determine whether minimally invasive heart surgery is the best option, your doctor will likely review your medical history and order tests to get more information about your heart health.
Minimally invasive heart surgery is a complex surgical procedure that requires training and experience. You might be referred to a medical center with surgeons and a surgical team who have the needed expertise in performing minimally invasive procedures.
Minimally invasive heart surgery can involve risks similar to open-heart surgery, such as:
Before minimally invasive heart surgery, your doctor and treatment team will explain to you what to expect before, during and after the surgery and potential risks of the surgery.
Your doctor and team will discuss concerns you have about your surgery. Your doctor or another member of your treatment team might discuss with you advance directives or other information to consider prior to your surgery.
You may need to have your hair shaved at the areas of your body where the procedure will take place. Your skin might be washed with special soap to reduce the risk of infection.
Before being admitted to the hospital for your surgery, talk to your family about your hospital stay and discuss help you might need when you return home. Your doctor and treatment team will give you instructions to follow during your recovery when you return home.
Talk to your doctor about:
During the procedure
Minimally invasive heart surgery includes robot-assisted heart surgery, thoracoscopic surgery and surgery through a small incision in the chest (direct less invasive access heart surgery). In all types, surgeons reach your heart through small incisions between the ribs of your chest.
A tool with a small video camera inserted through one of the incisions is used to help the surgeon see inside your body.
Most minimally invasive procedures use a heart-lung bypass machine, as is used in open-heart surgery. The machine keeps blood moving through your body during the procedure.
In robot-assisted heart surgery, the surgeon uses robotic arms, rather than his or her hands, to perform the exact maneuvers used in traditional open-heart surgery.
During this procedure, your surgeon works at a remote console and views your heart in a magnified high-definition 3D view on a video monitor. From the console, your surgeon's hand movements translate precisely to the robotic arms at the operating table, which move similarly to the human wrist.
A second surgeon and surgical team assist at the operating table, changing surgical instruments attached to the robotic arms.
In thoracoscopic surgery (sometimes referred to as a minithoracotomy), your surgeon inserts a long, thin tube (thoracoscope) containing a tiny video camera into a small incision in your chest.
Your surgeon repairs your heart using long instruments inserted through small incisions between your ribs.
You'll generally spend a day or so in the intensive care unit (ICU). You'll be given fluids and medications through intravenous (IV) lines. Other tubes placed during surgery will drain urine from your bladder and fluid and blood from your chest. You might be given oxygen through a face mask or prongs in your nose.
After the ICU, you'll be moved to a regular hospital room for several days. The time you spend in the ICU and hospital will depend on your condition and surgery.
Your treatment team will:
Your doctor will give you instructions to follow during your recovery, such as watching for signs of infection, caring for your incisions, taking medications and managing pain.
Your doctor will tell you when you can return to daily activities, such as working, driving and exercise.
Minimally invasive heart surgery may help reduce aortic stenosis symptoms and improve your quality of life.
You'll usually need regular checkups with a doctor to monitor your heart condition. Tests may be done to check your heart health.
Your doctor may also recommend following a heart-healthy lifestyle, which includes eating a healthy diet, exercising, managing stress and avoiding tobacco use. Sometimes, a personalized program of education and exercise designed to improve health after heart surgery (cardiac rehabilitation) is also recommended.
A pacemaker is a small device that's placed (implanted) in your chest to help control your heartbeat. It's used to prevent your heart from beating too slowly. Implanting a pacemaker in your chest requires a surgical procedure.
A pacemaker is also called a cardiac pacing device.
Depending on your condition, you might have one of the following types of pacemakers.
Cardiac resynchronization therapy
A pacemaker is implanted to help control your heartbeat. Your doctor may recommend a temporary pacemaker when you have a slow heartbeat (bradycardia) after a heart attack, surgery or medication overdose but your heartbeat is otherwise expected to recover. A pacemaker may be implanted permanently to correct a chronic slow or irregular heartbeat or to help treat heart failure
The heart is a muscular, fist-sized pump with four chambers, two on the left side and two on the right. The upper chambers (right and left atria) and the lower chambers (right and left ventricles) work with your heart's electrical system to keep your heart beating at an appropriate rate — usually 60 to 100 beats a minute for adults at rest.
Your heart's electrical system controls your heartbeat, beginning in a group of cells at the top of the heart (sinus node) and spreading to the bottom, causing it to contract and pump blood. Aging, heart muscle damage from a heart attack, some medications and certain genetic conditions can cause an abnormal heart rhythm.
Pacemakers work only when needed. If your heartbeat is too slow (bradycardia), the pacemaker sends electrical signals to your heart to correct the beat.
Some newer pacemakers also have sensors that detect body motion or breathing rate and signal the devices to increase heart rate during exercise, as needed.
A pacemaker has two parts:
Complications related to pacemaker surgery or having a pacemaker are uncommon, but could include:
Before your doctor decides if you need a pacemaker, you'll have several tests done to find the cause of your irregular heartbeat. Tests done before you get a pacemaker could include:
Before the procedure
You'll likely be awake during the surgery to implant the pacemaker, which typically takes a few hours. A specialist will insert an IV into your forearm or hand and give you a medication called a sedative to help you relax. Your chest is cleaned with special soap.
Most pacemaker implantations are done using local anesthesia to numb the area of the incisions. However, the amount of sedation needed for the procedure depends on your specific health conditions. You may be fully awake or lightly sedated, or you may be given general anesthesia (fully asleep).
One or more wires are inserted into a major vein under or near your collarbone and guided to your heart using X-ray images. One end of each wire is secured at the appropriate position in your heart, while the other end is attached to the pulse generator, which is usually implanted under the skin beneath your collarbone.
A leadless pacemaker is smaller and typically requires a less invasive surgery to implant the device. The pulse generator and other pacemaker parts are contained in a single capsule. The doctor inserts a flexible sheath (catheter) in a vein in the groin and then guides the single component pacemaker through the catheter to the proper position in the heart.
You'll likely stay in the hospital for a day after having a pacemaker implanted. Your pacemaker will be programmed to fit your heart rhythm needs. You'll need to arrange to have someone drive you home from the hospital.
Your doctor might recommend that you avoid vigorous exercise or heavy lifting for about a month. Avoid putting pressure on the area where the pacemaker was implanted. If you have pain in that area, ask your doctor about taking medicines available without a prescription, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others).
It's unlikely that your pacemaker would stop working properly because of electrical interference. Still, you'll need to take a few precautions:
Devices that are unlikely to interfere with your pacemaker include microwave ovens, televisions and remote controls, radios, toasters, electric blankets, electric shavers, and electric drills.
Having a pacemaker should improve symptoms caused by a slow heartbeat such as fatigue, lightheadedness and fainting. Because most of today's pacemakers automatically adjust the heart rate to match the level of physical activity, they may can allow you to resume a more active lifestyle.
Your doctor should check your pacemaker every 3 to 6 months. Tell your doctor if you gain weight, if your legs or ankles get puffy, or if you faint or get dizzy.
Most pacemakers can be checked by your doctor remotely, which means you don't have to go into the doctor's office. Your pacemaker sends information to your doctor, including your heart rate and rhythm, how your pacemaker is working, and how much battery life is left.
Your pacemaker's battery should last 5 to 15 years. When the battery stops working, you'll need surgery to replace it. The procedure to change your pacemaker's battery is often quicker and requires less recovery time than the procedure to implant your pacemaker.
The lungs are a pair of breathing organs located within the chest which remove carbon dioxide from and bring oxygen to the blood. There is a right and left lung. Lung surgery is used to repair or remove lung tissue. Thoracic surgery refers to procedures on the chest wall or soft tissues of the chest (mediastinum).
Two common ways to do surgery on your lungs are thoracotomy and video-assisted thoracoscopic surgery (VATS).
Lung surgery using a thoracotomy is called open surgery. In this surgery:
Most people stay in the hospital for 5 to 7 days for open thoracotomy and 1 to 3 days after Video-Assisted Thoracoscopic Surgery (VATS). You may spend time in the intensive care unit (ICU) after either surgery.
During your hospital stay, you will:
Tuberculosis (TB) is considered a leading cause of morbidity and mortality worldwide and, therefore, is a public health priority, especially in low-and middle-income countries, where TB incidence is estimated to be the highest. Over 9.6 million new TB cases and 1.5 million deaths are estimated to have occurred in 2014, mostly in Africa and South-East Asia (1).
People living with HIV (PLHIV) are disproportionately affected by TB; however, other medical conditions have been associated with an increased risk of TB (2-5).
A significant decline in TB incidence has been observed in high income countries since the second half of the 20th century, following the improvement of socio-economic conditions and the introduction of the first anti-TB drugs (6). When rifampicin began to be routinely used in the 1960s, the therapeutic approach to TB was revolutionized, making chemotherapy the first therapeutic option and surgical treatment a less convenient approach (7). Current drug regimens achieve a cure rate >85%, with poorer outcomes in geographical areas where multidrug-resistant (MDR) strains are prevalent. MDR-TB, whose estimated incidence was approximately 480,000 cases in 2014, is a TB form caused by Mycobacterium tuberculosis strains resistant to at least rifampicin and isoniazid (1). However, only one third of the estimated cases are actually diagnosed and a quarter receives a second-line treatment (8). MDR-TB is a man-made phenomenon, resulting from clinical mismanagement of TB cases (e.g., inappropriate regimens and/or drug dosages, insufficient duration of treatment and poor adherence) (9). The World Health Organization (WHO) guidelines on MDR-TB management suggest a combination of five to seven second-line drugs, whose effectiveness and safety profiles are currently sub-optimal (10). Although clinical observational and experimental research on repurposed (carbapenems, linezolid, mefloquine, etc.) and new (bedaquiline and delamanid) drugs has showed interesting findings, a lot of work is still needed to assess the best options to treat MDR-TB (11-15). In this critical global scenario with few effective drug options, TB surgery could be crucial to clinically and bacteriologically address severe forms of pleuro-pulmonary MDR-TB in combination with appropriate chemotherapy (16,17). The need for surgery is estimated to have increased from 5% to 15% over the last twenty years due to the growing emergence of MDR-TB (18). Old and new surgical techniques are still in use, often in absence of a clear evidence on their effectiveness
We carried out a non-systematic literature review based on a PubMed search using specific key-words, including various combinations of TB, surgery, MDR-TB. References of the most important papers were retrieved to improve the search sensitivity.
Manuscripts written in English and Russian were selected.
The main indications for surgery to support diagnosis and treatment of TB patients include both old and modern approaches; they are presently summarized as follows:
This explorative surgical approach can be recommended in patients with suspected lung cancer, in those with a pulmonary dissemination and those with mediastinal lymphadenopathy of unknown origin.
Distinguishing between TB and lung cancer can be rather challenging. The coexistence of TB and lung cancer, either within the same lesion or in different ones, has also been reported. Diagnostic delay and inappropriate treatment can be avoided through prompt identification of TB and/or lung cancer. Pulmonary cavitations should be carefully assessed before administering anti-TB drugs since a considerable proportion of elderly patients may also have an underlying malignancy
The increasing incidence of pulmonary TB in older patients in high-income countries, together with a more indolent course of lung cancer, make surgical exploration a reasonable option. It is estimated that TB is confirmed in up to 40% of surgical specimens from patients suspected of having lung cancer (Figure 2) (20). The discrepancy between presumptive and confirmed malignancy may be very high, up to 34% versus 6.25% according to some case series, and TB-associated lung cancer can be found in more than 25% of patients (21). Also, radiographic criteria for malignancy can be identified in up to 66% of patients with a confirmed tuberculoma
When TB and lung cancer coexist, the neoplastic portion of the lesion is usually characterized by irregular margins and convergence of peripheral vessels on High Resolution Computed Tomography (HRCT) scans showing gradual enhancement on time-attenuation curve, while smooth margins and a cavity with peripheral contrast-enhancement are typical features of the benign portion (23). Also, homogeneous contrast-enhancement is commonly observed in carcinomas, while capsular or no enhancement are suggestive of tuberculomas or hamartomas (24,25). Some radiographic signs should be evaluated in case of undefined solitary lesions: (I) nodular conglomeration in the area of previous tuberculous involvement; (II) recently developed satellite lesions surrounding tuberculous sequelae; or (III) parenchymal cavitations in areas where only nodular lesions were previously noted.
Carcinoma-related subpleural scars are usually adenocarcinomas. According to some reports, nearly 90% of patients with scar cancer show stage I disease, as a consequence of a regular radiologic TB monitoring
If disseminated pulmonary lesions (often associated with hilar and/or mediastinal lymphadenopathies) are detected, TB must always be suspected especially in immunocompromised individuals, although other conditions should also be considered such as cardiovascular disorders, systemic syndromes, and several occupational diseases (27-29). In such cases, surgery, based on minimally invasive techniques, can help to diagnose TB disease (30). Radiological findings are not reliable to definitely diagnose a TB case (31). For instance, hilar and mediastinal lymphadenopathy may be identified in primary and secondary TB patients. Such nodes, frequently associated with post-inflammatory adhesions in the interlobar fissures, must be carefully considered before performing Video-Assisted Thoracoscopic Surgery (VATS) or thoracotomy for lymph node biopsy in the absence of parenchymal lesions (32). Cervical mediastinoscopy plays a marginal role in the diagnosis of mediastinal TB since the proportion of patients benefitting from this procedure is considerably limited (33,34). Sayar et al. reported a series of 19 patients with no parenchymal abnormalities who underwent mediastinoscopy and TB was confirmed in 16 of them. However, a minimum of 3–5 nodal station biopsies is thought to be needed to increase the diagnostic probabilities
The diagnostic value of transbronchial lung biopsy in patients with a miliary TB pattern ranges between 30% and 58% or 64% and 90% depending on inclusion criteria (36,37). Percutaneous biopsy of parenchymal lung lesions shows a poorer performance, with 20–55% of diagnostic yield (38). Surgical lung biopsy may, therefore, be required for diagnosis in a proportion of patients suspected of having TB, although operative and infectious risks should be cautiously evaluated.
TB patients with a persistently positive sputum smear may benefit from surgical resection of bacillary pulmonary lesions. This therapeutic approach is mainly reserved to MDR-TB cases and aims to cure patients and prevent further M. tuberculosis transmission, increasing the probability of treatment success.
MDR-TB radiographic patterns are usually associated with the underlying drug-resistant form: patients with primary resistance are more likely to have non-cavitary solid lesions, pleural effusions and primary TB classical features, while those who develop secondary drug resistance often present with cavitary consolidations and a post-primary TB pattern.
Patients with one or more of the following clinical features can be considered as potential candidates to surgery: (I) persistently positive sputum smear and/or culture despite appropriate chemotherapy; (II) relapse; (III) high risk of relapse based on drug resistance profile (e.g., XDR-TB cases)
Surgical resection is recommended for infectious TB patients after at least 6–8 months of appropriate anti-TB therapy (10,46-48).
A recent meta-analysis reported a treatment success of 84% for pulmonary resection in M/XDR-TB patients, with a 6% failure rate, 3% relapse, and 5% mortality (49). Excessive surgical delay may favour disease progression and development of further drug resistances (50). Although some authors suggested that surgery can be performed after only three months of medical therapy, a period of six to eight months is now recommended to make treatment success more likely (51). Other important prognostic factors include unilateral pulmonary involvement, absence of TB bronchitis, radiologic improvement of parenchymal sequelae, complicated pulmonary TB (e.g., haemoptysis, superimposed infections, etc.).
A maximally parenchymal-sparing surgery is recommended whenever possible since disease relapse may occur despite adequate surgical intervention and appropriate chemotherapy (Figure 4). According to the scientific literature, lobectomy is performed more frequently compared to pneumonectomy (63.7% vs. 21.8%) .
The term “destroyed lung” refers to the radiographic appearance of fibrotic cavities combined with caseous lesions, frequently accompanied by sub-lobar atelectasis or bronchiectasis. Other typical signs are the upward displacement of the lung hilus, the mediastinal shift towards the affected side and a narrow intercostal space (Figure 5). Most patients with this medical condition have a history of exposure to multiple TB therapies, with delayed recovery and/or drug resistance (17,61). The surgical rationale is to interrupt further M. tuberculosis transmission and to prevent life-threatening complications.
In high TB burden areas, TB is the leading cause of haemoptysis and recurrent episodes may reflect tubercular cavitations or destroyed lungs (62-65). Although haemoptysis represents an indication for surgery, an assessment of lesions not responsible for bleeding can be very difficult and mortality rate may be up to 40% for procedures performed in emergency situations (66). The risk of complications after embolization of bronchial arteries is usually low, with 75–94% of patients immediately clinically recovering; however, the recurrence rate ranges between 18% and 42% (67,68). If massive haemoptysis occurs and embolization cannot be performed, emergency thoracotomy is recommended (62,69).
In a single-centre cohort study published in 2007, four risk factors were associated with recurrence after successful embolization for life-threatening haemoptysis: (I) lack of complete cessation of haemoptysis within seven days after the procedure; (II) need for blood transfusion; (III) presence of aspergillomas; (V) absence of TB (70).
In patients with haemoptysis and destroyed lung, surgical delay may be life-threatening. In a series of 38 patients with destroyed lungs combined with aspergillomas and haemoptysis, undergoing pneumonectomy or pleuro-pneumonectomy, one out of seven with post-surgical empyema died .
Bronchial stenosis, often combined with a destroyed lung, should be distinguished from TB of the bronchus; however, it does not constitute an obstacle for pneumonectomy (72). An extrapleural approach is usually required since other interventions are not feasible.
Lung cancer surgery is an option for some patients depending on the type, location and stage of their lung cancer and other medical conditions. Attempts to cure lung cancer with the surgery involve removing the tumor along with some surrounding lung tissue and often lymph nodes in the region of the tumor. Removing the tumor with lung cancer surgery is considered the best option when the cancer is localized and unlikely to have spread. This includes early stage non-small cell lung cancers and carcinoid tumors.
There are two commonly used approaches to removing portions of the lung. The choice depends on the location, size and stage of the lung tumor and the expertise of the surgeon.
Each type of lung cancer treatment option has possible side effects.It is important to know the potential side effects and ways to cope with them before beginning lung cancer treatment. You might experience:
Video-assisted thoracoscopic surgery (VATS) is a minimally invasive surgical technique used to diagnose and treat problems in your chest.
During a VATS procedure, a tiny camera (thoracoscope) and surgical instruments are inserted into your chest through one or more small incisions in your chest wall. The thoracoscope transmits images of the inside of your chest onto a video monitor, guiding the surgeon in performing the procedure.
Surgeons use the video-assisted thoracoscopic surgery technique to perform a variety of procedures, such as:
Possible complications of video-assisted thoracoscopic surgery include:
VATS can be a good option for people who are not good candidates for open surgery due to health concerns. However, VATS may not be appropriate for people who have had chest surgery previously. Talk with your doctor about these and other risks of VATS.
You may need to have some tests to determine whether video-assisted thoracoscopic surgery is a good option for you. These may include imaging tests, laboratory tests, pulmonary function tests and cardiac evaluation.
Usually people undergoing video-assisted thoracoscopic surgery are given a general anesthetic, which means they're asleep during surgery. You'll have a breathing tube put down your throat into your trachea to provide oxygen to your lungs. Then a surgeon makes small incisions in your chest and inserts specially designed surgical instruments to perform the procedure.
During VATS, you may be in surgery two to three hours and may stay in the hospital for a few days, though that can vary, depending on the extent of the procedure and your situation.
When compared with a traditional open operation (thoracotomy), video-assisted thoracoscopic surgery typically results in less pain, fewer complications and shortened recovery time.
If the purpose of VATS is to biopsy tissue, you may need additional surgery, depending on the results of the biopsy.
Angioplasty is a procedure to improve blood flow in coronary arteries that have become narrow or blocked. Your coronary arteries supply oxygen-rich blood to the heart. If you have coronary artery disease, a sticky material called plaque builds up in the coronary arteries. Plaque is made of cholesterol, calcium, and other substances in your blood. Over time, it can narrow your arteries or fully block them. When this happens, some parts of your heart don't get enough blood.
Angioplasty widens the blocked part of the artery so more blood can get through. It is also called percutaneous coronary intervention (PCI).
Doctors use angioplasty to:
Angioplasty does not cure coronary artery disease. To help prevent more plaque blockages, you'll need to take any prescribed medicines, eat healthy foods, and get regular exercise.
Most people have angioplasties in a hospital in a special room called a cardiac catheterization, or cath, lab. You will be awake and lying down. You'll get medicine to help you relax through an intravenous (IV) line. This is a small tube that goes into a vein in your hand or arm.
Angioplasty is done through a blood vessel in your arm, wrist, or groin. Your doctor will:
If you had an angioplasty for chest pain, you'll go to a recovery room for a few hours. You may stay in the hospital overnight. Your doctor will probably prescribe medicines to prevent blood clots. Most people can return to their usual activities after a week.
If you had an emergency angioplasty for a heart attack, you'll need to stay in the hospital for about a few more days.
Angioplasty is very safe. You may get a bruise, feel sore, or have some bleeding where the tubes were inserted. More serious problems don't happen very often, but they are possible. They can include serious bleeding, blood clots, and narrowing of the artery again.
PAD, peripheral vascular occlusive disease (PVOD), peripheral arterial occlusive disease (PAOD), “hardening” of the arteries, peripheral atherosclerosis.
PAD is a chronic disease in which plaque builds up in the arteries to the legs. This buildup typically occurs gradually. If allowed to progress, blood flow in that artery can become limited or blocked all together.
PAD is relatively common, affecting more than 10 million people in the U.S. It is more common in people who are 65 or older, but can occur at nearly any age. Smoking; high blood pressure; high cholesterol or triglycerides; diabetes; kidney failure; and obesity increase your risk for PAD.
MAY HIDE
Many patients experience no symptoms.
FATIGUE OR CRAMPING OF MUSCLES WHILE WALKING
Fatigue or cramping of your muscles (claudication) in the calf, thigh, hip, or buttock may signal you have PADS. Typically the discomfort is felt after walking a certain distance and goes away with rest.
PAIN IN TOES OR FEET WHILE RESTING
If you have pain in your toes or feet while resting, you may have an advancing case of PAD.
OPEN WOUND ON TOES OR FEET
An open wound or ulcer on your toes or feet, often at a pressure point on the foot, can signal a serious case of PAD. An ulcer can progress to gangrene. These symptoms require immediate medical attention.
The causes of PAD include smoking, high cholesterol or high triglycerides, high blood pressure, diabetes, kidney failure, and obesity. Genetic factors also play a role, but are not well understood.
SEE A VASCULAR SURGEON
You will be asked questions about symptoms and medical history, including questions about family members. The vascular surgeon will also perform a physical exam.
TESTS MAY BE RECOMMENDED
PAD is usually treated by aggressively managing the risk factors with lifestyle changes and medication. This includes quitting smoking, controlling blood pressure and cholesterol, controlling diabetes, and losing weight. In addition, an exercise program, if followed faithfully, can significantly improve the symptoms of PAD in many cases.
If PAD is causing serious symptoms, further treatments such as balloon angioplasty, stent placement, or surgical bypass can be very effective in improving the blood flow to the affected leg.
To diagnose varicose veins, your doctor will do a physical exam, including looking at your legs while you're standing to check for swelling. Your doctor may also ask you to describe any pain and aching in your legs.
You also may need an ultrasound test to see if the valves in your veins are functioning normally or if there's any evidence of a blood clot. In this noninvasive test, a technician runs a small hand-held device (transducer), about the size of a bar of soap, against your skin over the area of your body being examined. The transducer transmits images of the veins in your legs to a monitor, so a technician and your doctor can see them.
Fortunately, treatment usually doesn't mean a hospital stay or a long, uncomfortable recovery. Thanks to less invasive procedures, varicose veins can generally be treated on an outpatient basis.
Ask your doctor if insurance will cover any of the cost of your treatment. If done for purely cosmetic reasons, you'll likely have to pay for the treatment of varicose veins yourself.
Self-care — such as exercising, losing weight, not wearing tight clothes, elevating your legs, and avoiding long periods of standing or sitting — can ease pain and prevent varicose veins from getting worse.
Wearing compression stockings all day is often the first approach to try before moving on to other treatments. They steadily squeeze your legs, helping veins and leg muscles move blood more efficiently. The amount of compression varies by type and brand.
You can buy compression stockings at most pharmacies and medical supply stores. Prescription-strength stockings also are available, and are likely covered by insurance if your varicose veins are causing symptoms.
If you don't respond to self-care or compression stockings, or if your condition is more severe, your doctor may suggest one of these varicose vein treatments:
Varicose veins that develop during pregnancy generally improve without medical treatment within three to 12 months after delivery.
There are some self-care measures you can take to decrease the discomfort that varicose veins can cause. These same measures can help prevent or slow the development of varicose veins, as well. They include:
Though they haven't been well-studied, a number of alternative therapies claim to be helpful treatments for chronic venous insufficiency, a condition associated with varicose veins in which leg veins have problems returning blood to the heart. These therapies include:
Peripheral artery disease (also called peripheral arterial disease) is a common circulatory problem in which narrowed arteries reduce blood flow to your limbs.
When you develop peripheral artery disease (PAD), your legs or arms — usually your legs — don't receive enough blood flow to keep up with demand. This may cause symptoms, such as leg pain when walking (claudication).
Peripheral artery disease is also likely to be a sign of a buildup of fatty deposits in your arteries (atherosclerosis). This condition may narrow your arteries and reduce blood flow to your legs and, occasionally, your arms.
You often can successfully treat peripheral artery disease by exercising, eating a healthy diet and quitting tobacco in any form.
While many people with peripheral artery disease have mild or no symptoms, some people have leg pain when walking (claudication).
Claudication symptoms include muscle pain or cramping in your legs or arms that's triggered by activity, such as walking, but disappears after a few minutes of rest. The location of the pain depends on the location of the clogged or narrowed artery. Calf pain is the most common location.
The severity of claudication varies widely, from mild discomfort to debilitating pain. Severe claudication can make it hard for you to walk or do other types of physical activity.
Peripheral artery disease is often caused by atherosclerosis. In atherosclerosis, fatty deposits build up on your artery walls and reduce blood flow.
Although discussions of atherosclerosis usually focus on the heart, the disease can and usually does affect arteries throughout your body. When it occurs in the arteries supplying blood to your limbs, it causes peripheral artery disease.
Less commonly, the cause of peripheral artery disease may be blood vessel inflammation, injury to your limbs, unusual anatomy of your ligaments or muscles, or radiation exposure.
Factors that increase your risk of developing peripheral artery disease include:
If your peripheral artery disease is caused by a buildup of plaque in your blood vessels, you're also at risk of developing:
The best way to prevent claudication is to maintain a healthy lifestyle. That means:
Peripheral artery bypass is surgery to reroute the blood supply around a blocked artery in one of your legs. Fatty deposits can build up inside the arteries and block them.
A graft is used to replace or bypass the blocked part of the artery. The graft may be a plastic tube, or it may be a blood vessel (vein) taken from your body (most often the opposite leg) during the same surgery.
Peripheral artery bypass surgery can be done in one or more of the following blood vessels:
During bypass surgery of any artery:
If you are having bypass surgery to treat your aorta and iliac artery or your aorta and both femoral arteries (aortobifemoral):
If you are having bypass surgery to treat your lower leg (femoral popliteal):
Lower-extremity arterial disease (LEAD) is a major endemic disease with an alarming increased prevalence worldwide. It is a common and severe condition with excess risk of major cardiovascular events and death. It also leads to a high rate of lower-limb adverse events and non-traumatic amputation. The American Diabetes Association recommends a widespread medical history and clinical examination to screen for LEAD. The ankle brachial index (ABI) is the first non-invasive tool recommended to diagnose LEAD although its variable performance in patients with diabetes. The performance of ABI is particularly affected by the presence of peripheral neuropathy, medial arterial calcification, and incompressible arteries. There is no strong evidence today to support an alternative test for LEAD diagnosis in these conditions. The management of LEAD requires a strict control of cardiovascular risk factors including diabetes, hypertension, and dyslipidaemia. The benefit of intensive versus standard glucose control on the risk of LEAD has not been clearly established. Antihypertensive, lipid-lowering, and antiplatelet agents are obviously worthfull to reduce major cardiovascular adverse events, but few randomised controlled trials (RCTs) have evaluated the benefits of these treatments in terms of LEAD and its related adverse events. Smoking cessation, physical activity, supervised walking rehabilitation and healthy diet are also crucial in LEAD management. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in LEAD management. The revascularization strategy should take into account several factors including anatomical localizations of lesions, medical history of each patients and operator experience. Further studies, especially RCTs, are needed to evaluate the interest of different therapeutic strategies on the occurrence and progression of LEAD and its related adverse events in patients with diabetes.
Prevalence and incidence
LEAD affects over 200 millions people worldwide, including 40 millions living in Europe [5]. It is 2–4 times more frequent in people with type 2 diabetes than in the general population [3, 4]. The prevalence of LEAD varies across studies depending to differences in characteristics of the populations including LEAD definition, age, and ethnicity. Usually discovered during the 5th decade of life, the prevalence of LEAD increased exponentially after 65 years of age. In the Action in Diabetes and Vascular Disease: PreterAx and DiamicroN Modified-Release Controlled Evaluation (ADVANCE) trial, the baseline prevalence of LEAD (defined as lower-limb amputation of at least one digit, chronic foot ulceration due to arterial insufficiency, or peripheral revascularization procedure) was estimated at 4.6% [10]. The LEAD prevalence was much higher and may exceed 20% when its definition was based on abnormal ankle–brachial index (ABI) [2, 4, 11]. The prevalence increases also with rising duration of diabetes as shown in the UK Prospective Diabetes Study (UKPDS): 1.2% at diagnosis of diabetes and 12.5% after 18 years of its evolution [12]. In the same manner, different LEAD incidences were reported: 1.2 per 100 patient-years in ADVANCE trial and 3.7 per 100 patient-years in an Australian cohort [2, 13].
LEAD is one of the major causes of diabetic foot. It was present in 49% of patients with diabetic
foot in the EURODIALE study, and one-third of participants had both LEAD and infection [14]. Diabetic
patients with LEAD, compared with those without LEAD, have also a higher risk of CVD, and cardiovascular
and all-cause mortality [2, 10, 11, 15]. The key risk factors are similar to those related to CVD,
including age, sex, tobacco smoking, systolic blood pressure, and plasma concentrations of lipids
[12, 13, 16]. A recent study has suggested that the leg fat distribution may be used as a potential
marker for predicting CVD [17].
Microvascular disease, mainly macroalbuminuria and diabetic retinopathy, have been shown to be
independent risk factors for LEAD [13, 16]. Furthermore, a recent large epidemiological study has
shown that low glomerular filtration rate and pathological albuminuria were independently associated
with excess risk of LEAD [18]. The risk of LEAD may also vary according to differences in region of
origin. In ADVANCE study, the incidence of major LEAD was lesser in Asians compared with participants
from Eastern Europe or Established Market economies [13]. Despite a higher rate of CVD, people from
South Asia, compared with white Europeans, have a lower prevalence of LEAD [19]. The explanation of
this paradox has not yet been clearly elucidated, and genetic predisposition to LEAD may be suspected.
Intermittent claudication results from a diminished inflow of oxygen due to a reduced blood flow
in the lower limbs during physical activity, which is a consequence of stenosis or obstruction of an
artery irrigating the skeletal muscle [20]. Many mechanisms contribute to the development of LEAD,
in particular arterial stiffness, thrombotic abnormalities, low-grade inflammation, advanced
glycation end-products, and oxidative stress (Fig. 1) [21,22,23]. Several studies have suggested
the development of an acute inflammatory reaction in response to ischemia induced by exercise,
with increased release of different biomarkers (thromboxane, interleukin 8, intercellular
adhesion molecules, or von Willebrand factor) and vasoconstrictors including endothelin-1 [24].
We have recently reported an independent association between plasma concentrations of tumor
necrosis factor-α receptor 1 (TNRF1) and ischemia-modified albumin, inflammatory and redox
status biomarkers, and an excess-risk of major LEAD in patients with type 2 diabetes [25].
Interestingly, TNFR1 improves the prediction of LEAD over the traditional risk factors.
Endothelial cells play an important role in vascular biology based on their strategic
location between blood and tissues. They secrete many paracrine factors in the vascular wall
and its lumen. In pathological setting, endothelial dysfunction induces structural, hemodynamic,
and functional vascular abnormalities, altering blood vessels reactivity and relaxation, and
generating atherosclerosis [26]. Endothelial dysfunction and increased arterial wall stiffness
play an important role in the pathogenesis of LEAD in individuals with diabetes [27, 28].
The critical limb ischemia (CLI) is defined as the presence of ischaemic chronic rest pain (2 weeks) typically in the forefoot with or without ischaemic lesions or gangrene due to arterial occlusive disease. It is considered as the last stage of LEAD spectrum, with excessively high risk for CVD and death [55]. The CLI is frequent in patients with diabetes, and it may be suspected even in the absence of pain in patients with peripheral diabetic neuropathy. The diagnosis of CLI is confirmed based on one of the following: ABI 0.4, ankle pressure 50 mmHg, toe pressure 30 mmHg or TcPO2 30 mmHg. Acute limb ischemia, an emergency condition, needs an urgent diagnosis to evaluate the odds of the limb salvage and to determine the requirement of medical and surgical treatments. The wound ischemia and foot infection (WIFI) classification has been recently recommended by the society of vascular surgery (SVS); it provides a risk stratification based on the severity of the wound, ischemia, and foot infection [56].
Intensive versus standard glucose control
Epidemiological studies and RCTs showed the efficiency of intensive blood glucose control in the reduction of the development and progression of long-term microvascular complications (diabetic nephropathy, retinopathy, and neuropathy) in patients with diabetes [59,60,61]. However, the benefit of intensive glucose control in the prevention of CVD and death has not been clearly established, and its effect on the risk of LEAD has been rarely addressed in the literature. In the UKPDS trial, each 1% reduction in HbA1c was associated with a 43% decreased risk of major LEAD (amputation or death following a peripheral vascular event) [62]. However, this benefit did not persist during the post-trial observational period of the UKPDS study [63]. In the ADVANCE trial, the incidence of major LEAD (lower-limb ulceration, amputation, revascularization requirement, or death induced by peripheral arterial disease) was comparable among randomized study arms (intensive versus standard glucose control) [13, 61]. A recent systematic review and meta-analyses (with a low level of evidence) displayed 35% reduction of LLA risk in patients with type 2 diabetes assigned to intensive glycaemic control compared with those assigned to less intensive strategy, but no effect was observed on ischemic disease [64].
Insulin-sensitizing versus insulin-providing therapy
The PROspective pioglitAzone Clinical Trial In macroVascular Events (PROactive) trial showed a non-significant association between use of pioglitazone, an agonist of peroxisome proliferator-activated receptor γ (PPAR γ), and a higher risk of leg revascularization, compared with placebo [65]. However, the post hoc analyses of the Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes (BARI-2D) trial displayed lower incidence of LEAD (new low ABI ≤ 0.9, lower-extremity revascularization or LLA) among patients assigned to insulin-sensitizing therapy (metformin or thiazolidinedione) compared with those assigned to insulin-providing therapy (sulfonylureas, repaglinide, nateglinide or insulin) [66]. Furthermore, another observational study has shown that the use of metformin was associated with a lower prevalence of below-the-knee arterial calcification [67].
New anti-diabetic agents
After concerns about the cardiovascular safety of some anti-diabetic drugs, the US Food and Drug Administration (FDA) implemented a guidance statement in 2008 recommending cardiovascular safety trial of each new anti-diabetic agent. Thus, several RCTs were conducted worldwide and demonstrated the non-inferiority of some new inhibitors of dipeptidyl peptidase 4 (DPP-4) or glucagon-like peptide-1 (GLP-1) receptor agonists, compared with placebo in patients with type 2 diabetes [68,69,70,71]. Interestingly, other trials have shown cardiovascular benefit of some GLP-1 receptor agonists (liraglutide, semaglutide, and albiglutide) or sodium glucose co-transporter 2 (SGLT2) inhibitors (empagliflozin and canagliflozin) [72,73,74,75,76]. In contrast to cardiovascular and cerebrovascular endpoints, LEAD was not fully investigated in these studies. Although, Marso et al. reported in the SUSTAIN-6 trial, that participants treated by semaglutide, a prolonged action GLP-1 receptor agonist, had a significant 35% lower risk of coronary and peripheral revascularization, but with no specific data dedicated to lower-limb procedures [73]. A recent post hoc analysis of the liraglutide effect and action in diabetes: evaluation of cardiovascular outcome results (LEADER) trial displayed a fewer LLA rate among patients with diabetic foot assigned to liraglutide, compared with those assigned to placebo [77]. This difference seemed to be driven mainly by major amputation rather than minor amputation, but there was no difference between study arms in diabetic foot requiring peripheral revascularization.
The American Heart Association (AHA) and the American College of Cardiology (ACC) recommend antihypertensive treatment in patients with LEAD to decrease cardiovascular events and stroke (Table 1) [84], but the benefit-risk of each antihypertensive class in term of LEAD-related events has not yet been fully investigated even in the general population [85]. The relationship between blood pressure and LEAD is not simple, and may be U-shaped in the general population [86]. In the type 2 diabetes setting, the risk of LEAD increased with rising systolic blood pressure and decreasing diastolic blood pressure, and is particularly associated with growing pulse pressure [13], which is known as a surrogate of arterial stiffness [87].
Statin therapy
The European Society of Cardiology (ESC) and the European Society for Vascular Surgery (ESVS) recommended targeting serum low-density lipoprotein cholesterol (LDL-C) less than 1.8 mmol/L (mg/dL) or decreased by ≥ 50% if the initial value is between 1.8 and 3.5 mmol/L (70 and 135 mg/dL) for all patients with LEAD (Table 1) [90]. Although the lack of specific evaluations of the effects of lipid-lowering drugs on the occurrence of LEAD-related endpoints, observational studies and few RCTs provide evidence for reductions of cardiovascular events and all-cause mortality in patients using statins [91,92,93]. In the Reduction of Atherothrombosis for Continued Health (REACH) registry, statin use was associated with a 17% decrease in adverse cardiovascular events rates among individuals with LEAD, without heterogeneity regarding diabetes status [94]. Other studies have also suggested that statin may reduce the LLA incidence and improve walking distance in patients suffering for IC [95,96,97,98].
Fibrate therapy
The use of Fenofibrate failed to reduce macrovascular events in participants with type 2 diabetes in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) and the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) trials [99, 100]. However, secondary analyses of the FIELD trial displayed a 36% reduction in the risk of LLA (a pre-specified tertiary endpoint) in participants assigned to fenofibrate, compared with those assigned to placebo [101]. This protection has been especially driven by decreased risk of minor amputation without known large-vessel disease rather than amputation with large-vessel lesions.
PCSK9 inhibitors
Despite the availability of effective drug therapies that reduce LDL-cholesterol, CVD remains an important cause of mortality and morbidity. Therefore, additional LDL-cholesterol reduction may be warranted, especially for patients who are unresponsive to, or unable to take, existing LDL-cholesterol reducing therapies. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a serin protease with effect on the LDL receptor cycle leading to its degradation and therefore inhibition of continuing LDL-cholesterol clearance from the blood. This path is the target of newly developed lipid-lowering drugs, PCSK9 inhibitors, monoclonal antibodies leading to further LDL-cholesterol decrease, with reducing CVD risk, but not cardiovascular or all-cause mortality [102]. The Further Cardiovascular Outcomes Research with PCSK9
Pigmentation on the legs can be age spots or dark spots caused by sun exposure over a period of time. In more serious cases, these brown spots can be an early symptom of an underlying condition such as chronic venous insufficiency. It's important to consult a vein specialist for sudden spots on the legs to get an accurate diagnosis of your leg health for timely treatment.
1. Age Spots
Age spots are the most common cause of this discoloration on the legs. These spots develop from constant sun exposure, hormonal changes, pregnancy, or some types of medications.
Age spots are typically not a medical concern and can be removed with laser treatments.
2. Actinic Keratosis
These are raised, scaly red lesions that appear in the areas that are frequently exposed to the sun. Actinic Keratosis is an early symptom of cancer and is recommended to be removed at an early stage.
3. Diabetes
People with diabetes tend to develop brown spots on the lower legs, especially around the shins. These brown spots rarely cause medical concerns on their own.
4. Venous Insufficiency
Brown spots on the legs can be an early sign of vein disorder, known as chronic venous insufficiency. Our veins contain one-way valves that stop the blood from flowing backward to the legs. As these valves get weakened or damaged, they cause blood to pool in the vessel of the lower leg. Venous insufficiency can lead to blood leakage and cause skin discoloration. Over time, the discoloration can result in skin and tissue damage, which may become permanent.
Other symptoms along with brown spots that might indicate the development of vein disease are:
When brown spots are associated with venous insufficiency, it's best to treat the condition before it develops into venous ulcers. The best way to treat vein disease is to treat the underlying vein disorder. At Physicians Vein Clinics, we offer minimally invasive vein procedures that can help remove the damaged vein and restore the health of the legs.
Reddish-brown staining on the lower legs is often caused by problems with the veins on the lower legs. Blood is pumped from the heart to the rest of our body through arteries. It returns to the hearts through veins. Blood is propelled back to the heart as it pumps, and by being pushed out from the leg and foot muscles as we walk or move our ankles.
Brown spots can be an indication of a serious medical condition that requires timely attention and treatment. How do you know if your brown spots are a concern?
If you have any of the following conditions, there is a chance that your brown spots may indicate vein disease:
Consult a vein doctor for leg health monitoring or brown spots diagnosis if you meet one of the above conditions.
Remember, effective treatment starts with an accurate and timely diagnosis. Vein conditions can worsen over time and cause serious complications (blood clots or deep vein thrombosis) if left untreated.
Deep vein thrombosis (DVT) occurs when a blood clot (thrombus) forms in one or more of the deep veins in your body, usually in your legs. Deep vein thrombosis can cause leg pain or swelling but also can occur with no symptoms.
You can get DVT if you have certain medical conditions that affect how your blood clots. A blood clot in your legs can also happen if you don't move for a long time, such as after you have surgery or an accident, when you're traveling a long distance, or when you're on bed rest.
Deep vein thrombosis can be very serious because blood clots in your veins can break loose, travel through your bloodstream and get stuck in your lungs, blocking blood flow (pulmonary embolism). However, pulmonary embolism can occur with no evidence of DVT.
DVT signs and symptoms can include:
If you develop signs or symptoms of DVT, contact your doctor.
If you develop signs or symptoms of a pulmonary embolism (PE) — a life-threatening complication of deep vein thrombosis — seek emergency medical help.
Anything that prevents your blood from flowing or clotting normally can cause a blood clot.
The main causes of DVT are damage to a vein from surgery or trauma and inflammation due to infection or injury.
Many things can increase your risk of developing DVT. The more risk factors you have, the greater your risk of DVT. Risk factors for DVT include:
Complications of DVT can include:
Measures to prevent deep vein thrombosis include the following:
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