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Yii E, Tiong J, Farah S, Al-Talib H, Clarke J, Yii MK. Should Long-Term Survival in Elderly Patients Presenting with Diabetic Foot Complications Impact Treatment Decision Making? INT J LOW EXTR WOUND 2023:15347346231170663. [PMID: 37081800 DOI: 10.1177/15347346231170663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Patients presenting with diabetic foot ulceration (DFU) and associated complications often require revascularisation. Although current evidence advocates for an open bypass first strategy if patients are expected to live more than two years, this may not be appropriate in octogenarians. We sought to investigate the survival of patients aged over 70 years presenting with complicated DFU and chronic limb threatening ischaemia (CLTI) to clarify its prognosis and guide subsequent management. A database of patients admitted into a large tertiary service over the age of 70 years with DFU and CLTI between 2014 and 2017 were included. Survival data was obtained from medical records and public obituaries through to 2020. Patients were divided into three age groups: seventies (70-79 years), eighties (80-89 years) and nineties (≥90 years). Survival was evaluated using a stratified log-rank test and Kaplan-Meier methods. A total of 323 patients were included for analysis. Survival information was available for 225 patients (69%). Mean duration of follow-up was 19 months. There were 113 deaths recorded (35%). Mean survival for patients in their seventies, eighties and nineties was 63 months (95% CI 48.8-65.5), 37 months (95% CI 27.4-44.9) and 6 months (95% CI 2.3-19.2), respectively. In patients over 70 years of age presenting with DFU and CLTI, long-term survival decreases rapidly with increasing age, especially in the octogenarians. With recent technological advances and reduced morbidity, an endovascular approach may sufficiently treat acute presentations in octogenarians while reserving an open first strategy for younger patients with better long-term survival and adequate autologous conduit.
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Affiliation(s)
- Erwin Yii
- Department of Vascular Surgery, Eastern Health, Box Hill, Australia
| | - Jonathan Tiong
- Department of Vascular Surgery, Monash Health, Clayton, Australia
| | - Sam Farah
- Department of Vascular Surgery, Austin Health, Heidelberg, Australia
- Department of Vascular Surgery, Alfred Health, Melbourne, Australia
| | - Husein Al-Talib
- Department of Vascular Surgery, Monash Health, Clayton, Australia
| | - Jonathan Clarke
- Department of Vascular Surgery, Monash Health, Clayton, Australia
| | - Ming Kon Yii
- Department of Vascular Surgery, Monash Health, Clayton, Australia
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Australia
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Bhandari N, Newman JD, Berger JS, Smilowitz NR. Diabetes mellitus and outcomes of lower extremity revascularization for peripheral artery disease. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:298-306. [PMID: 33351089 PMCID: PMC9630873 DOI: 10.1093/ehjqcco/qcaa095] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/09/2020] [Accepted: 12/16/2020] [Indexed: 01/03/2023]
Abstract
AIMS The impact of diabetes mellitus (DM) on outcomes of lower extremity revascularization (LER) for peripheral artery disease (PAD) is uncertain. We characterized associations between DM and post-procedural outcomes in PAD patients undergoing LER. METHODS AND RESULTS Adults undergoing surgical or endovascular LER were identified from the 2014 Nationwide Readmissions Database. DM was defined by ICD-9 diagnosis codes and sub-classified based on the presence or absence of complications (poor glycaemic control or end-organ damage). Major adverse cardiovascular and limb events (MACLEs) were defined as the composite of death, myocardial infarction, ischaemic stroke, or major limb amputation during the index hospitalization for LER. For survivors, all-cause 6-month hospital readmission was determined. Among 39 441 patients with PAD hospitalized for LER, 50.8% had DM. The composite of MACLE after LER was not different in patients with and without DM after covariate adjustment, but patients with DM were more likely to require major limb amputation [5.5% vs. 3.2%, P < 0.001; adjusted odds ratio (aOR) 1.22, 95% confidence interval (CI) 1.03-1.44] and hospital readmission (59.2% vs. 41.3%, P < 0.001; aOR 1.44, 95% CI 1.34-1.55). Of 20 039 patients with DM hospitalized for LER, 55.7% had DM with complications. These patients were more likely to have MACLE after LER (11.1% vs. 5.2%, P < 0.001; aOR 1.56 95% CI 1.28-1.89) and require hospital readmission (61.1% vs. 47.2%, P < 0.001; aOR 1.41 95% CI 1.27-1.57) than patients with uncomplicated DM. CONCLUSIONS DM is present in ≈50% of patients undergoing LER for PAD and is an independent risk factor for major limb amputation and 6-month hospital readmission.
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Affiliation(s)
- Nipun Bhandari
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 423 East 23rd Street, Room 12020-W, New York, NY 10010, USA
| | - Jonathan D Newman
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 423 East 23rd Street, Room 12020-W, New York, NY 10010, USA
| | - Jeffrey S Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 423 East 23rd Street, Room 12020-W, New York, NY 10010, USA
- Department of Surgery, New York University School of Medicine, 550 1st Ave, New York, NY 10016, USA
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 423 East 23rd Street, Room 12020-W, New York, NY 10010, USA
- Division of Cardiology, Department of Medicine, Veterans Affairs New York Harbor Health Care System, 423 E 23rd St, New York, NY 10010, USA
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Luan J, Xu J, Zhong W, Zhou Y, Liu H, Qian K. Adverse Prognosis of Peripheral Artery Disease Treatments Associated With Diabetes: A Comprehensive Meta-Analysis. Angiology 2021; 73:318-330. [PMID: 34544306 DOI: 10.1177/00033197211042494] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many studies have investigated the influence of diabetes mellitus (DM) on outcomes in patients with peripheral artery disease (PAD). We performed a meta-analysis of the outcomes of PAD treatments in DM patients compared with those without DM. Long-term mortality was the primary endpoint. Secondary endpoints were in-hospital/30-day mortality, primary/secondary patency, amputation, and limb salvage. Thirty-one studies reporting 58113 patients were eligible for enrollment. The mean follow-up duration ranged from 1 to 89 months. DM was significantly associated with long-term mortality (relative risk (RR) = 1.67; 95% confidence intervals (CI), 1.43-1.94; P < .001). DM was also associated with significantly lower primary patency (RR = 0.74; 95% CI, 0.58-0.95; P = .001) and secondary patency (RR = 0.80; 95% CI, 0.67-0.96; P = .009). DM is associated with worse outcomes and adverse prognosis of treatment in patients with PAD, and may therefore be a modifiable risk factor for poor prognosis in PAD patients.
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Affiliation(s)
- Jingyang Luan
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, 198153Southern Medical University, Guangzhou, China.,Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jie Xu
- Institute of Neuroscience and Department of Neurology, 220741The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Weiquan Zhong
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, 198153Southern Medical University, Guangzhou, China
| | - Yan Zhou
- Comprehensive Ward, Nanfang Hospital, 198153Southern Medical University, Guangzhou, China
| | - Hao Liu
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, 198153Southern Medical University, Guangzhou, China
| | - Kai Qian
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, 198153Southern Medical University, Guangzhou, China.,Comprehensive Ward, Nanfang Hospital, 198153Southern Medical University, Guangzhou, China
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Martini R, Ghirardini F. Patients with critical limb ischemia (CLI) not suitable for revascularization: the “dark side” of CLI. VASCULAR INVESTIGATION AND THERAPY 2021. [DOI: 10.4103/2589-9686.321924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Darling JD, O'Donnell TFX, Vu GH, Norman AV, St John E, Stangenberg L, Wyers MC, Hamdan AD, Schermerhorn ML. Wound location is independently associated with adverse outcomes following first-time revascularization for tissue loss. J Vasc Surg 2020; 73:1320-1331. [PMID: 32866559 DOI: 10.1016/j.jvs.2020.07.091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/19/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Few studies adequately evaluate the impact of wound location on patient outcomes after lower extremity revascularization. Consequently, we evaluated the relationship between lower extremity wound location and long-term outcomes. METHODS We reviewed all patients at our institution undergoing any first-time open surgical bypass or percutaneous transluminal angioplasty with or without stenting for tissue loss between 2005 and 2014. We categorized wounds into three distinct groups: forefoot (ie, toes and metatarsal heads), midfoot (ie, dorsal, plantar, lateral, medial surfaces excluding toes, metatarsal heads, or heel), and heel. Limbs with multiple wounds were excluded from analyses. We compared rates of perioperative complications, wound healing, reintervention, limb salvage, amputation-free survival, and survival using χ2, Kaplan-Meier, and Cox regression analyses. RESULTS Of 2869 infrainguinal revascularizations from 2005 to 2014, 1126 underwent a first-time revascularization for tissue loss, of which 253 patients had multiple wounds, 197 had wounds proximal to the ankle, 100 had unreliable wound information, and 576 (forefoot, n = 397; midfoot, n = 61; heel, n = 118) fit our criteria and had a single foot wound with reliable information regarding wound specifics. Patients with forefoot, midfoot, and heel wounds had similar rates of coronary artery disease, hypertension, diabetes, and smoking history (all P > .05). Conversely, there were significant differences in patient age (71 vs 69 vs 70 years), prevalence of gangrene (41% vs 5% vs 21%), and dialysis dependence (18% vs 17% vs 30%) (all P < .05). There were no statistically significant differences in perioperative mortality (1.3% vs 4.9% vs 4.2%; P = .06) or postoperative complications among the three groups. Between forefoot, midfoot, and heel wounds, there were significant differences in unadjusted 6-month rates of complete wound healing (69% vs 64% vs 53%), 3-year rates of amputation-free survival (54% vs 57% vs 35%), and survival (61% vs 72% vs 41%) (all P < .05). After adjustment, compared with forefoot wounds, heel wounds were associated with higher rates of incomplete 6-month wound healing (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.1-2.]), major amputation or mortality (HR, 1.7; 95% CI, 1.1-2.7), and all-cause mortality (HR, 1.8; 95% CI, 1.1-3.0), but not major amputation alone (HR, 2.1; 95% CI, 0.9-4.5). In open surgical bypass-first patients, heel wounds were solely associated with an increased risk of all-cause mortality (HR, 1.7; 95% CI, 1.1-2.8), whereas heel wounds in percutaneous transluminal angioplasty-first patients were associated with an increased risk of incomplete wound healing (HR, 2.2; 95% CI, 1.3-3.7), major amputation or mortality (HR, 2.3; 95% CI, 1.1-5.4), and all-cause mortality (HR, 2.8; 95% CI, 1.1-7.2). CONCLUSIONS Heel wounds confer considerably higher short- and long-term morbidity and mortality compared with midfoot or forefoot wounds in patients undergoing any first-time lower extremity revascularization.
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Affiliation(s)
- Jeremy D Darling
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Tufts University School of Medicine, Boston, Mass
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Giap H Vu
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | | | | | - Lars Stangenberg
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Allen D Hamdan
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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Darling JD, O'Donnell TFX, Deery SE, Norman AV, Vu GH, Guzman RJ, Wyers MC, Hamdan AD, Schermerhorn ML. Outcomes after first-time lower extremity revascularization for chronic limb-threatening ischemia in insulin-dependent diabetic patients. J Vasc Surg 2019; 68:1455-1464.e1. [PMID: 30360841 DOI: 10.1016/j.jvs.2018.01.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 01/06/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Historically, open surgical bypass provided a durable repair among diabetic patients with chronic limb-threatening ischemia (CLTI). In the current endovascular era, however, the difference in long-term outcomes between first-time revascularization strategies among patients with insulin-dependent diabetes mellitus (IDDM) is poorly understood. METHODS We reviewed the records of all patients with IDDM undergoing a first-time infrainguinal bypass graft (BPG) or percutaneous transluminal angioplasty with or without stenting (PTA/S) for CLTI at our institution from 2005 to 2014. We defined IDDM as use of chronic insulin administration at baseline to control blood glucose levels and recorded the most recent glycated hemoglobin value available within 3 months before the procedure and fasting blood glucose level on the day of the procedure. We compared rates of wound healing, restenosis, reintervention, major amputation, and mortality between BPG and PTA/S in our population using χ2, Kaplan-Meier, and Cox regression analyses. As a sensitivity analysis, we calculated propensity scores and employed inverse probability weighting to account for nonrandom assignment to BPG vs PTA/S. RESULTS Of 2869 infrainguinal revascularizations from 2005 to 2014, 655 limbs (316 BPG, 339 PTA/S) in 580 patients fit our criteria and underwent a first-time revascularization for CLTI. Patients undergoing BPG, compared with PTA/S, were similar in age (69 vs 68 years; P = .55), had similar rates of tissue loss (87% vs 91%; P = .07) and dialysis dependence (26% vs 28%; P = .55), were less likely to be hypertensive (84% vs 92%; P < .001), and were more likely to be current smokers (21% vs 14%; P = .02). There were no differences between BPG and PTA/S patients in mean glycated hemoglobin levels (8.1% vs 8.0%; P = .51) or mean fasting blood glucose levels (158 vs 150 mg/dL; P = .18). Although total hospital length of stay was significantly longer among BPG patients (11 vs 8 days; P < .001), perioperative complications did not differ, including acute kidney injury (19% vs 23%; P = .24), hematoma (6.0% vs 3.8%; P = .20), acute myocardial infarction (1.3% vs 2.1%; P = .43), and mortality (3.8% vs 3.0%; P = .55). BPG-first patients had significantly lower unadjusted 6-month rates of incomplete wound healing (49% vs 57%) and 5-year rates of restenosis (53% vs 72%) and reintervention (47% vs 58%; all P < .05). After adjustment, multivariable analysis suggested PTA/S-first intervention to be significantly associated with higher risk of restenosis (hazard ratio, 1.9; 95% confidence interval, 1.3-2.7) and reintervention (1.9 [1.2-2.7]). These results remained robust after inverse probability weighting. CONCLUSIONS Among patients with IDDM and CLTI, a bypass-first strategy is associated with similar 30-day outcomes and lower restenosis and reintervention rates. These data suggest that a bypass-first approach may best serve appropriately selected, anatomically suitable patients with IDDM and pedal ischemia that requires revascularization.
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Affiliation(s)
- Jeremy D Darling
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | | | - Giap H Vu
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Raul J Guzman
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Allen D Hamdan
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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Martini R. Trends of the treatment of Critical Limb Ischemia during the last two decades. Clin Hemorheol Microcirc 2018; 69:447-456. [PMID: 29504528 DOI: 10.3233/ch-170352] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In this review 14 studies were identified reporting the treatment strategy in 4891 patients with Critical Limb Ischemia (CLI) with the aim to investigate if the strategy of treatment of the first episode of CLI has changed during the last 15-20 years. A computer research has been performed on PubMed and Scopus databases on November 2016. The used terms for the investigation about studies evaluating the strategy of treatment of CLI at the first-time presentation, have been "critical leg ischemia", "critical limb ischemia", "critical lower limb ischemia" along with the terms "placebo", "medical treatment" and/or "conservative" revascularisation, surgical revascularisation, endovascular revascularisation, hybrid revascularisation and primary amputation. Studies were included if they were either retrospective or prospective and reporting the rate of patients who underwent to any form of revascularization, conservative treatment and primary amputation. The one-year limb and life survival rates have been reported as major outcomes. The pooled rate of revascularization was 72.5% (95% CI 80-64.96) of which 54.5%, surgical, 38.3% endovascular and 7.1% hybrid. The bivariate regression of revascularisation procedures has been with not significant increase, from 68% in 1993 to 88% in 2015. The endovascular procedures have shown a significant increase of the trend, from 2% to more the 50% (p 0.007), while surgical and hybrid procedures have not. The pooled rate of conservative treatment was 18% (95% CI 11.6-24.5%) with a not significant increasing trend and primary amputation pooled rate was 8.7% (95% CI 12.0-5,4) with a significant decreasing trend (p 0.009). The one-year limb survival rate was 75,4% (95% CI 81.5-69.3%) and the life survival was 76%. (95% CI 85.4-66.1%) both with a not significant increasing trend. In conclusion, this review highlights how the treatment strategy of the first CLI manifestation has changed over the last 15-20 years. It has shown an increase of the rate of revascularization procedures, particularly for endovascular and a significant reduction of the rate of primary amputations. The rate of patients treated conservatively appears to be unchanged and maybe influencing the rate of limb and life survival, that have remained unchanged.
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Affiliation(s)
- Romeo Martini
- Unità Operativa di Angiologia, Azienda Ospedaliera Universitaria di Padova, Padova, Italy
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Das SK, Yuan YF, Li MQ. Predictors of delayed wound healing after successful isolated below-the-knee endovascular intervention in patients with ischemic foot ulcers. J Vasc Surg 2018; 67:1181-1190. [PMID: 29100807 DOI: 10.1016/j.jvs.2017.08.077] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 08/08/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of this study was to explore the predictors of delayed wound healing and their use in risk stratification for endovascular treatment (EVT) of patients with critical limb ischemia (CLI) due to isolated below-the-knee lesions. METHODS Wound healing rates were analyzed retrospectively in patients who underwent successful below-the-knee percutaneous transluminal balloon angioplasty for CLI with tissue loss between May 2008 and June 2013. We also analyzed the independent predictors of delayed wound healing and their use in risk stratification. RESULTS The cumulative wound healing rates were 13.9%, 43.8%, 57.7%, and 65.7% at 3, 6, 9, and 12 months, respectively. Multivariate Cox proportional hazards analysis revealed the following as independent predictors of wound nonhealing after initial successful EVT: patients with end-stage renal disease receiving dialysis (hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.0-6.3; P = .04); albumin level <3.0 g/dL (HR, 2.0; 95% CI, 1.1-3.8; P = .02); C-reactive protein level >5.0 mg/dL (HR, 3.9; 95% CI, 1.6-9.6; P = .003); major tissue loss (HR, 2.1; 95% CI, 1.3-3.4; P = .003); wound infection (HR, 1.9; 95% CI, 1.2-2.9; P = .005); gangrene (HR, 1.8; 95% CI, 1.2-2.8; P = .008); wound depth (University of Texas grade 3; HR, 3.4; 95% CI, 1.4-8.6; P = .009); duration of ulcer (≥2 months; HR, 2.9; 95% CI, 1.0-8.4; P = .048); insulin use (HR, 1.7; 95% CI, 1.0-2.8; P = .04); and lack of below-the-ankle runoff (HR, 1.9; 95% CI, 1.0-3.4; P = .04). CONCLUSIONS The general status of the patient and the target limb's condition are important predictors of wound nonhealing. Regarding the limb's condition, information on wound depth and duration in addition to wound extent and infection would further enable the selection of suitable CLI patients for EVT. Such information would also enable optimal wound management, leading to successful wound healing and improved limb salvage and survival rates.
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Affiliation(s)
- Sushant Kumar Das
- Department of Interventional and Vascular Surgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Yi Feng Yuan
- Department of Interventional and Vascular Surgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Mao Quan Li
- Department of Interventional and Vascular Surgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China.
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9
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Darling JD, Bodewes TCF, Deery SE, Guzman RJ, Wyers MC, Hamdan AD, Verhagen HJ, Schermerhorn ML. Outcomes after first-time lower extremity revascularization for chronic limb-threatening ischemia between patients with and without diabetes. J Vasc Surg 2017; 67:1159-1169. [PMID: 28947228 DOI: 10.1016/j.jvs.2017.06.119] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 06/04/2017] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The effect of diabetes type and insulin dependence on short- and long-term outcomes after lower extremity revascularization for chronic limb-threatening ischemia (CLTI) warrants additional study and more targeted focus. We sought to address this paucity of information by evaluating outcomes in insulin-dependent and noninsulin-dependent patients after any first-time revascularization. METHODS We reviewed all limbs undergoing first-time infrainguinal bypass grafting (BPG) or percutaneous transluminal angioplasty with or without stenting (PTA/S) for CLTI at our institution from 2005 to 2014. Based on preoperative medication regimen, patients were categorized as having insulin-dependent diabetes (IDDM), noninsulin-dependent diabetes (NIDDM), or no diabetes (NDM). Outcomes included wound healing; major amputation; RAS events (reintervention, major amputation, or stenosis); major adverse limb events; and mortality. Outcomes were evaluated using χ2, Kaplan-Meier, and Cox regression analyses. RESULTS Of 2869 infrainguinal revascularizations from 2005 to 2014, 1294 limbs (646 BPG, 648 PTA/S) fit our criteria. Overall, our analysis included 703 IDDM, 262 NIDDM, and 329 NDM limbs. IDDM patients, compared with NIDDM and NDM patients, were younger (69 vs 73 vs 77 years; P < .001) and more often presented with tissue loss (89% vs 77% vs 67%; P < .001), coronary artery disease (57% vs 48% vs 43%; P < .001), and end-stage renal disease (26% vs 13% vs 12%; P < .001). Perioperative complications, including mortality (3% vs 2% vs 5%; P = .07), did not differ between groups; however, complete wound healing at 6-month follow-up was significantly worse among IDDM patients (41% vs 49% vs 61%; P < .001). IDDM patients had significantly higher 3-year major amputation rates (23% vs 11% vs 8%; P < .001). Multivariable analyses illustrated that compared with NDM, IDDM was associated with significantly higher risk of both major amputation and RAS events after any first-time intervention (hazard ratio, 2.0 [95% confidence interval, 1.1-4.1] and 1.4 [1.1-1.8], respectively). Similar associations between IDDM and both major amputation and RAS events were found in patients undergoing a PTA/S-first intervention (4.1 [1.3-12.6] and 1.5 [1.1-2.2], respectively), whereas IDDM in BPG-first patients was associated with only incomplete wound healing (2.0 [1.4-4.5]). Last, compared with NDM, NIDDM was associated with lower late mortality (0.7 [0.5-0.9]). CONCLUSIONS Compared with NDM, IDDM is associated with similar perioperative and long-term mortality but a higher risk of incomplete wound healing, major amputation, and future RAS events, especially after a PTA/S-first approach. NIDDM, on the other hand, is associated with lower long-term mortality and few adverse limb events. Overall, these data demonstrate both the importance of distinguishing between diabetes types and the potential long-term benefit of a BPG-first strategy in appropriately selected IDDM patients with CLTI.
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Affiliation(s)
- Jeremy D Darling
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Thomas C F Bodewes
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Raul J Guzman
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Allen D Hamdan
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Hence J Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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Long-term Results of Inframalleolar Bypass for Critical Limb Ischaemia. Eur J Vasc Endovasc Surg 2016; 52:815-822. [DOI: 10.1016/j.ejvs.2016.08.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 08/29/2016] [Indexed: 11/21/2022]
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Thiruvoipati T, Kielhorn CE, Armstrong EJ. Peripheral artery disease in patients with diabetes: Epidemiology, mechanisms, and outcomes. World J Diabetes 2015; 6:961-969. [PMID: 26185603 PMCID: PMC4499529 DOI: 10.4239/wjd.v6.i7.961] [Citation(s) in RCA: 218] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 11/20/2014] [Accepted: 04/02/2015] [Indexed: 02/05/2023] Open
Abstract
Peripheral artery disease (PAD) is the atherosclerosis of lower extremity arteries and is also associated with atherothrombosis of other vascular beds, including the cardiovascular and cerebrovascular systems. The presence of diabetes mellitus greatly increases the risk of PAD, as well as accelerates its course, making these patients more susceptible to ischemic events and impaired functional status compared to patients without diabetes. To minimize these cardiovascular risks it is critical to understand the pathophysiology of atherosclerosis in diabetic patients. This, in turn, can offer insights into the therapeutic avenues available for these patients. This article provides an overview of the epidemiology of PAD in diabetic patients, followed by an analysis of the mechanisms by which altered metabolism in diabetes promotes atherosclerosis and plaque instability. Outcomes of PAD in diabetic patients are also discussed, with a focus on diabetic ulcers and critical limb ischemia.
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Lower-extremity arterial revascularization: Is there any evidence for diabetic foot ulcer-healing? DIABETES & METABOLISM 2015; 42:4-15. [PMID: 26072053 DOI: 10.1016/j.diabet.2015.05.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 05/13/2015] [Accepted: 05/14/2015] [Indexed: 12/21/2022]
Abstract
The presence of peripheral arterial disease (PAD) is an important consideration in the management of diabetic foot ulcers. Indeed, arteriopathy is a major factor in delayed healing and the increased risk of amputation. Revascularization is commonly performed in patients with critical limb ischaemia (CLI) and diabetic foot ulcer (DFU), but also in patients with less severe arteriopathy. The ulcer-healing rate obtained after revascularization ranges from 46% to 91% at 1 year and appears to be improved compared to patients without revascularization. However, in those studies, healing was often a secondary criterion, and there was no description of the initial wound or its management. Furthermore, specific alterations associated with diabetes, such as microcirculation disorders, abnormal angiogenesis and glycation of proteins, can alter healing and the benefits of revascularization. In this review, critical assessment of data from the literature was performed on the relationship between PAD, revascularization and healing of DFUs. Also, the impact of diabetes on the effectiveness of revascularization was analyzed and potential new therapeutic targets described.
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Forsythe RO, Brownrigg J, Hinchliffe RJ. Peripheral arterial disease and revascularization of the diabetic foot. Diabetes Obes Metab 2015; 17:435-44. [PMID: 25469642 DOI: 10.1111/dom.12422] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 11/19/2014] [Accepted: 11/28/2014] [Indexed: 01/03/2023]
Abstract
Diabetes is a complex disease with many serious potential sequelae, including large vessel arterial disease and microvascular dysfunction. Peripheral arterial disease is a common large vessel complication of diabetes, implicated in the development of tissue loss in up to half of patients with diabetic foot ulceration. In addition to peripheral arterial disease, functional changes in the microcirculation also contribute to the development of a diabetic foot ulcer, along with other factors such as infection, oedema and abnormal biomechanical loading. Peripheral arterial disease typically affects the distal vessels, resulting in multi-level occlusions and diffuse disease, which often necessitates challenging distal revascularisation surgery or angioplasty in order to improve blood flow. However, technically successful revascularisation does not always result in wound healing. The confounding effects of microvascular dysfunction must be recognised--treatment of a patient with a diabetic foot ulcer and peripheral arterial disease should address this complex interplay of pathophysiological changes. In the case of non-revascularisable peripheral arterial disease or poor response to conventional treatment, alternative approaches such as cell-based treatment, hyperbaric oxygen therapy and the use of vasodilators may appear attractive, however more robust evidence is required to justify these novel approaches.
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Affiliation(s)
- R O Forsythe
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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Pernès JM, Auguste M, Borie H, Kovarsky S, Bouchareb A, Despujole C, Coppé G. Infrapopliteal arterial recanalization: A true advance for limb salvage in diabetics. Diagn Interv Imaging 2015; 96:423-34. [PMID: 25704905 DOI: 10.1016/j.diii.2014.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 06/04/2014] [Accepted: 09/15/2014] [Indexed: 10/24/2022]
Abstract
The world is facing an epidemic of diabetes; consequently in the next years, critical limb ischemia (CLI) due to diabetic arterial disease, characterized by multiple and long occlusions of below-the-knee (BTK) vessels, will become a major issue for vascular operators. Revascularization is a key therapy in these patients as restoring adequate blood supply to the wound is essential for healing, thus avoiding major amputations. Endoluminal therapy for BTK arteries is now a key part of the vascular specialist armamentarium. Tibial artery endovascular approaches have been shown to achieve high limb salvage rates with low morbidity and mortality and endovascular interventions one should now consider to be the first line treatment in the majority of CLI patients, especially in those with associated medical comorbidities. To do so, the vascular specialist requires detailed knowledge of the BTK endovascular techniques and devices. The first step decision in tibial endovascular therapy is access. In this context, the anterograde ipsilateral approach is generally preferred. The next critical decision is the choice of the vessel(s) to be approached in order to achieve successful limb salvage. Obtaining pulsatile flow to the correct portion of the foot is the paramount for ulcer healing. As such, a good understanding of the current angiosome model should enhance clinical results. The devices used should be carefully selected and optimal choice of guide wire is also extremely important and should be based on the characteristics of the lesion (location, length, and stenosis/occlusion) together with the characteristics of the guide wire itself (tip load, stiffness, hydrophilic/hydrophobic coating, flexibility, torque transmission, trackability, and pushability). Passing through chronic total occlusions can be quite challenging. The vascular interventional radiologist needs therefore to master the techniques that have been recently described: anterograde approaches, including the drilling technique, the penetrating technique, the subintimal technique and the parallel technique; subintimal arterial flossing with anterograde-retrograde procedures (Safari); the pedal-plantar loop technique and revascularization through collateral fibular artery vessels.
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Affiliation(s)
- J-M Pernès
- Wounds and healing centre, Antony private hospital, 1, rue Velpeau, 92160 Antony, France.
| | - M Auguste
- Wounds and healing centre, Antony private hospital, 1, rue Velpeau, 92160 Antony, France
| | - H Borie
- Wounds and healing centre, Antony private hospital, 1, rue Velpeau, 92160 Antony, France
| | - S Kovarsky
- Wounds and healing centre, Antony private hospital, 1, rue Velpeau, 92160 Antony, France
| | - A Bouchareb
- Wounds and healing centre, Antony private hospital, 1, rue Velpeau, 92160 Antony, France
| | - C Despujole
- Wounds and healing centre, Antony private hospital, 1, rue Velpeau, 92160 Antony, France
| | - G Coppé
- Wounds and healing centre, Antony private hospital, 1, rue Velpeau, 92160 Antony, France
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Ghoneim B, Elwan H, Eldaly W, Khairy H, Taha A, Gad A. Management of critical lower limb ischemia in endovascular era: experience from 511 patients. Int J Angiol 2014; 23:197-206. [PMID: 25317033 PMCID: PMC4172447 DOI: 10.1055/s-0034-1382825] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
This study aims at the assessment of the achievability of the endovascular treatment of patients with critical limb ischemia (CLI) and the role of bypass in such patient. This is a prospective study conducted on patients with chronic atherosclerotic critical lower limb ischemia presenting to us over a period of 3 years. Patients presenting with nonsalvageable limbs requiring primary major amputation and nonatherosclerotic causes of CLI were excluded. Endovascular treatment was the first choice modality of treatment in revascularization of all patients. Open surgery was offered selectively for patient whom endovascular failed or complicated and for long TransAtlantic Inter-Society Consensus (TASC) II lesions in fit patients. This study included 511 cases of CLI, and the mean age was 64.5 years. Patients with Rutherford IV, V, and VI were 19.25, 60.5, and 19.25%, respectively. The TASC II aortoiliac lesions were as follows: A, B, C, and D in 33.7, 12,15.7, and 38.6%, respectively, and infrainguinal lesions were A, B, C, and D in 3.7, 19, 35.4, and 68.3%, respectively. A total of 78.3% of patients were treated by endovascular totally, while 16% were treated by surgery from the start, 3.7% of endovascular cases were converted to open surgery after failure of endovascular treatment, and 2% was offered hybrid treatment. Crossing of lesions by subintimal and intraluminal was 12.5 and 87.5%, respectively. Technical success in endovascular was 94%; however, we could successfully revascularize 96.8% of all CLI presented in this study by either surgery or endovascular. On 24 months follow-up, primary patency, secondary patency, and limb salvage by percutaneous transluminal angioplasty are 77.8, 84.7, and 90.7%, respectively. Revascularization by endovascular achieves high technical success and limb salvage in CLI, hence should be considered as preferred choice of treatment. However, both endovascular and surgery should not be counteracting each other and using both can revascularize 96.6% of CLI.
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Affiliation(s)
- Baker Ghoneim
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Hussein Elwan
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Waleed Eldaly
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Hussein Khairy
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Ahmad Taha
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Amr Gad
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
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Kobayashi N, Hirano K, Nakano M, Muramatsu T, Tsukahara R, Ito Y, Ishimori H, Yamawaki M, Araki M, Kato T. Predictors of non-healing in patients with critical limb ischemia and tissue loss following successful endovascular therapy. Catheter Cardiovasc Interv 2014; 85:850-8. [DOI: 10.1002/ccd.25625] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Revised: 07/18/2014] [Accepted: 08/01/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Norihiro Kobayashi
- Department of Cardiology; Saiseikai Yokohama City Eastern Hospital; Kanagawa Japan
| | - Keisuke Hirano
- Department of Cardiology; Saiseikai Yokohama City Eastern Hospital; Kanagawa Japan
| | - Masatsugu Nakano
- Department of Cardiology; Saiseikai Yokohama City Eastern Hospital; Kanagawa Japan
| | - Toshiya Muramatsu
- Department of Cardiology; Saiseikai Yokohama City Eastern Hospital; Kanagawa Japan
| | - Reiko Tsukahara
- Department of Cardiology; Saiseikai Yokohama City Eastern Hospital; Kanagawa Japan
| | - Yoshiaki Ito
- Department of Cardiology; Saiseikai Yokohama City Eastern Hospital; Kanagawa Japan
| | - Hiroshi Ishimori
- Department of Cardiology; Saiseikai Yokohama City Eastern Hospital; Kanagawa Japan
| | - Masahiro Yamawaki
- Department of Cardiology; Saiseikai Yokohama City Eastern Hospital; Kanagawa Japan
| | - Motoharu Araki
- Department of Cardiology; Saiseikai Yokohama City Eastern Hospital; Kanagawa Japan
| | - Tamon Kato
- Department of Cardiology; Saiseikai Yokohama City Eastern Hospital; Kanagawa Japan
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Skrepnek GH, Armstrong DG, Mills JL. Open bypass and endovascular procedures among diabetic foot ulcer cases in the United States from 2001 to 2010. J Vasc Surg 2014; 60:1255-1265. [PMID: 25017514 DOI: 10.1016/j.jvs.2014.04.071] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 04/29/2014] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate trends in outcomes of inpatient mortality, surgical complications, charges, and length of stay stratified according to open vs endovascular revascularization and amputation status in patients admitted to the hospital with diabetic foot ulcers (DFUs). METHODS Inpatient discharge records from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project were used in this retrospective cohort study spanning 2001 to 2010. Multivariate regression analyses were used to simultaneously control for patient demographic and socioeconomic attributes, hospital characteristics, and comorbid case-mix disease severity. RESULTS During the study period, 2.5 million inpatient DFU cases were observed, of which 412,051 (16.5%) involved amputation (34.8% major, 61.2% minor). Overall, 211,534 (8.5%) of DFU cases underwent revascularization (43.5% open, 51.1% endovascular treatment [EVT], 5.4% both). From 2001 vs 2010, the volume of open procedures decreased 34.9%, and EVT volume increased 197.1%. The percentage of amputations for DFUs remained relatively unchanged, and a major:minor ratio of 0.534 was observed among all cases. Across specific procedure type and amputation status, multivariate analyses indicated equal or decreased inpatient mortality and lengths of stay since 2001, and inflation-adjusted charges generally increased. The presence of a surgical complication, however, was observed to increase by >50% for open procedures involving minor amputations and >30% for open procedures involving no amputations. Because of many potential factors, surgical complications were noted to exceed approximately 900% among cases of EVT involving major amputations beginning in 2007 relative to 2001. CONCLUSIONS This nationally-representative investigation found that DFU admissions are common, long, and costly (often >$100,000 per case), with a marked shift having occurred from open bypass to EVT. Although hospital mortality and length of stay either remained the same or have decreased significantly, an increase in procedure-specific surgical complications was observed across several intervention categories.
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Affiliation(s)
- Grant H Skrepnek
- Southern Arizona Limb Salvage Alliance (SALSA), Division of Vascular and Endovascular Surgery, Department of Surgery, University of Arizona College of Medicine, Tucson, Ariz; The University of Oklahoma Health Sciences Center, College of Pharmacy, Oklahoma City, Okla.
| | - David G Armstrong
- Southern Arizona Limb Salvage Alliance (SALSA), Division of Vascular and Endovascular Surgery, Department of Surgery, University of Arizona College of Medicine, Tucson, Ariz
| | - Joseph L Mills
- Southern Arizona Limb Salvage Alliance (SALSA), Division of Vascular and Endovascular Surgery, Department of Surgery, University of Arizona College of Medicine, Tucson, Ariz
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Hughes K, Padilla L, Al-zubeidy B, Bolorunduro O, Rose D, Cornwell E, Turner P, Greene W. Diabetes is not associated with an increased peri-operative mortality or non-infectious morbidity following lower extremity arterial reconstruction. Am J Surg 2014; 207:573-7. [DOI: 10.1016/j.amjsurg.2013.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Revised: 03/21/2013] [Accepted: 03/21/2013] [Indexed: 11/25/2022]
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Ballotta E, Toniato A, Piatto G, Mazzalai F, Da Giau G. Lower extremity arterial reconstruction for critical limb ischemia in diabetes. J Vasc Surg 2014; 59:708-19. [DOI: 10.1016/j.jvs.2013.08.103] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 08/19/2013] [Accepted: 08/22/2013] [Indexed: 10/25/2022]
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Rollins KE, Jackson D, Coughlin PA. Meta-analysis of contemporary short- and long-term mortality rates in patients diagnosed with critical leg ischaemia. Br J Surg 2013; 100:1002-8. [PMID: 23649310 DOI: 10.1002/bjs.9127] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND Critical leg ischaemia (CLI) has been associated with high mortality rates. There is a lack of contemporary data on both short- and long-term mortality rates in patients diagnosed with CLI. METHODS This was a systematic literature search for studies prospectively reporting mortality in patients diagnosed with CLI. Meta-analysis and meta-regression models were developed to determine overall mortality rates and specific patient-related factors that were associated with death. RESULTS A total of 50 studies were included in the analysis The estimated probability of all-cause mortality in patients with CLI was 3·7 per cent at 30 days, 17·5 per cent at 1 year, 35·1 per cent at 3 years and 46·2 per cent at 5 years. Men had a statistically significant survival benefit at 30 days and 3 years. The presence of ischaemic heart disease, tissue loss and older age resulted in a higher probability of death at 3 years. CONCLUSION Early mortality rates in patients diagnosed with CLI have improved slightly compared with previous historical data, but long-term mortality rates are still high.
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Affiliation(s)
- K E Rollins
- Department of Vascular Surgery, Addenbrooke's Hospital, Cambridge, UK
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Bifurcated coronary stents for infrapopliteal angioplasty in critical limb ischemia. J Vasc Surg 2013; 57:1006-13. [DOI: 10.1016/j.jvs.2012.09.080] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Revised: 09/25/2012] [Accepted: 09/30/2012] [Indexed: 11/21/2022]
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Georgakarakos E, Papanas N, Papadaki E, Georgiadis GS, Maltezos E, Lazarides MK. Endovascular treatment of critical ischemia in the diabetic foot: new thresholds, new anatomies. Angiology 2012; 64:583-91. [PMID: 23129734 DOI: 10.1177/0003319712465172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This review discusses the role of endovascular treatment in diabetic patients with critical limb ischemia (CLI). Angioplasty of the femoropopliteal region achieves similar technical success and limb salvage rates in diabetic and nondiabetic patients. Angioplasty in as many as possible tibial vessels is accompanied by more complete and faster ulcer healing as well as better limb salvage rates compared to isolated tibial angioplasty. Targeted revascularization of a specific vessel responsible for the perfusion of a specific ulcerated area is a promising new approach: it replaces revascularization of the angiographically easiest-to-access tibial vessel, even if this is not directly responsible for the perfusion of the ulcerated area, by revascularization of area-specific vascular territories. In conclusion, the endovascular approach shows very high efficacy in ulcer healing for diabetic patients with CLI. Larger prospective studies are now needed to estimate the long-term results of this approach.
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Wallaert JB, Nolan BW, Adams J, Stanley AC, Eldrup-Jorgensen J, Cronenwett JL, Goodney PP. The impact of diabetes on postoperative outcomes following lower-extremity bypass surgery. J Vasc Surg 2012; 56:1317-23. [PMID: 22819754 DOI: 10.1016/j.jvs.2012.04.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 04/03/2012] [Accepted: 04/04/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The effect of diabetes type (noninsulin dependent vs insulin dependent) on outcomes after lower-extremity bypass (LEB) has not been clearly defined. Therefore, we analyzed associations between diabetes type and outcomes after LEB in patients with critical limb ischemia. METHODS We performed a retrospective analysis of 1977 infrainguinal LEB operations done for critical limb ischemia between 2003 and 2010 within the Vascular Study Group of New England. Patients were categorized as nondiabetic (ND), noninsulin-dependent diabetic (NIDD), or insulin-dependent diabetic (IDD) based on their preoperative medication regimen. Our main outcome measures were in-hospital mortality and major adverse events (MAEs)--a composite outcome, including myocardial infarction, dysrhythmia, congestive heart failure, wound infection, renal insufficiency, and major amputation. We compared crude and adjusted rates of mortality and MAEs using logistic regression across diabetes categories. RESULTS Overall, 41% of patients were ND, 28% were NIDD, and 31% were IDD. Crude rates of in-hospital mortality were similar across these groups (1.7% vs 3.1% vs 2.1%; P = .211). Adjusted analyses accounting for differences in patient characteristics showed that diabetes is not associated with increased risk of in-hospital mortality. However, type of diabetes was associated with a higher risk of MAEs in both crude (15.1% for ND; 21.1% for NIDD; and 25.2% for IDD; P < .001) and adjusted analyses (odds ratio for NIDD, 1.41; 95% confidence interval, 1.2-1.7; odds ratio for IDD, 1.53; 95% confidence interval, 1.3-1.8). CONCLUSIONS Diabetes is a significant contributor to the risk of postoperative complications after LEB surgery, and insulin dependence is associated with higher risk. Quality measures aimed at limiting complications after LEB may have the most impact if these initiatives are focused on patients who are IDD.
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Affiliation(s)
- Jessica B Wallaert
- Department of Surgery, Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03765, USA.
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Pedrajas FG, Cafasso DE, Schneider PA. Endovascular Therapy: Is It Effective in the Diabetic Limb? Semin Vasc Surg 2012; 25:93-101. [DOI: 10.1053/j.semvascsurg.2012.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Faglia E, Clerici G, Losa S, Tavano D, Caminiti M, Miramonti M, Somalvico F, Airoldi F. Limb revascularization feasibility in diabetic patients with critical limb ischemia: results from a cohort of 344 consecutive unselected diabetic patients evaluated in 2009. Diabetes Res Clin Pract 2012; 95:364-71. [PMID: 22104261 DOI: 10.1016/j.diabres.2011.10.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 10/10/2011] [Accepted: 10/24/2011] [Indexed: 12/15/2022]
Abstract
AIMS To evaluate the feasibility of peripheral revascularization by angioplasty (PTA) or bypass grafting (BPG) in diabetic patients with critical limb ischemia (CLI). METHODS All diabetic patients referred to our Diabetic Foot Centre for foot lesion or rest pain were assessed for the presence of CLI as assessed by the TASC criteria. All patients underwent angiography that was evaluated jointly by an interventional radiologist, a vascular surgeon and a diabetologist of the diabetic foot care team. RESULTS During 2009, 344 diabetics were admitted because of CLI in a total of 360 limbs. PTA was performed in 308 (85.6%) limbs, and BPG was performed in 40 (11.1%) limbs in which PTA was not feasible. Revascularization could not be carried out in 12 (3.3%) limbs due to the lack of target vessel (9 limbs) or high surgical risk (3 limbs). According to the judgement of the vascular surgeon, BPG was anatomically feasible in 180 (58.4%) of the 308 limbs that underwent PTA. Therefore, considering also the 40 limbs that underwent BPG, surgical revascularization was judged anatomically possible in a total of 220 (61.1%) limbs. At 30 days, 19 (5.3%) above-the-ankle amputations were performed: 8 (66.7%) amputations were performed in the 12 non-revascularized limbs, 8 (2.6%) amputations were performed in the 308 limbs treated with PTA and 3 (7.5%) amputations were performed in the 40 limbs treated with BPG. CONCLUSIONS Revascularization by PTA is highly feasible in diabetics with CLI. The feasibility of revascularization by BPG is lower but nonetheless consistent. In centres where both revascularization procedures are available, it is possible to revascularize more than 96% of diabetics with CLI.
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Affiliation(s)
- Ezio Faglia
- Diabetology Centre, Diabetic Foot Centre, IRCCS Multimedica, Via Milanese 300, 20099 Sesto San Giovanni, Milano, Italy
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Engelhardt M, Boos J, Bruijnen H, Wohlgemuth W, Willy C, Tannheimer M, Wölfle K. Critical Limb Ischaemia: Initial Treatment and Predictors of Amputation-free Survival. Eur J Vasc Endovasc Surg 2012; 43:55-61. [DOI: 10.1016/j.ejvs.2011.09.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 09/09/2011] [Indexed: 10/16/2022]
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Caiafa JS, Castro AA, Fidelis C, Santos VP, Silva ESD, Sitrângulo Jr. CJ. Atenção integral ao portador de pé diabético. J Vasc Bras 2011. [DOI: 10.1590/s1677-54492011000600001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Söderström MI, Arvela EM, Korhonen M, Halmesmäki KH, Albäck AN, Biancari F, Lepäntalo MJ, Venermo MA. Infrapopliteal Percutaneous Transluminal Angioplasty Versus Bypass Surgery as First-Line Strategies in Critical Leg Ischemia. Ann Surg 2010; 252:765-73. [DOI: 10.1097/sla.0b013e3181fc3c73] [Citation(s) in RCA: 133] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FGR, Gillespie I, Ruckley CV, Raab GM. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: An intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg 2010; 51:5S-17S. [PMID: 20435258 DOI: 10.1016/j.jvs.2010.01.073] [Citation(s) in RCA: 384] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Revised: 05/20/2009] [Accepted: 01/24/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND A 2005 interim analysis of the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial showed that in patients with severe lower limb ischemia (SLI; rest pain, ulceration, gangrene) due to infrainguinal disease, bypass surgery (BSX)-first and balloon angioplasty (BAP)-first revascularization strategies led to similar short-term clinical outcomes, although BSX was about one-third more expensive and morbidity was higher. We have monitored patients for a further 2.5 years and now report a final intention-to-treat (ITT) analysis of amputation-free survival (AFS) and overall survival (OS). METHODS Of 452 enrolled patients in 27 United Kingdom hospitals, 228 were randomized to a BSX-first and 224 to a BAP-first revascularization strategy. All patients were monitored for 3 years and more than half for >5 years. RESULTS At the end of follow-up, 250 patients were dead (56%), 168 (38%) were alive without amputation, and 30 (7%) were alive with amputation. Four were lost to follow-up. AFS and OS did not differ between randomized treatments during the follow-up. For those patients surviving 2 years from randomization, however, BSX-first revascularization was associated with a reduced hazard ratio (HR) for subsequent AFS of 0.85 (95% confidence interval [CI], 0.5-1.07; P = .108) and for subsequent OS of 0.61 (95% CI, 0.50-0.75; P = .009) in an adjusted, time-dependent Cox proportional hazards model. For those patients who survived for 2 years after randomization, initial randomization to a BSX-first revascularization strategy was associated with an increase in subsequent restricted mean overall survival of 7.3 months (95% CI, 1.2-13.4 months, P = .02) and an increase in restricted mean AFS of 5.9 months (95% CI, 0.2-12.0 months, P = .06) during the subsequent mean follow-up of 3.1 years (range, 1-5.7 years). CONCLUSIONS Overall, there was no significant difference in AFS or OS between the two strategies. However, for those patients who survived for at least 2 years after randomization, a BSX-first revascularization strategy was associated with a significant increase in subsequent OS and a trend towards improved AFS.
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Affiliation(s)
- Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Heart of England NHS Foundation Trust, Solihull Hospital, Lode Lane, Birmingham, UK.
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Egorova NN, Guillerme S, Gelijns A, Morrissey N, Dayal R, McKinsey JF, Nowygrod R. An analysis of the outcomes of a decade of experience with lower extremity revascularization including limb salvage, lengths of stay, and safety. J Vasc Surg 2010; 51:878-85, 885.e1. [DOI: 10.1016/j.jvs.2009.10.102] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 10/06/2009] [Accepted: 10/06/2009] [Indexed: 11/27/2022]
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Insulin use is associated with poor limb salvage and survival in diabetic patients with chronic limb ischemia. J Vasc Surg 2010; 51:1178-89; discussion 1188-9. [PMID: 20304581 DOI: 10.1016/j.jvs.2009.11.077] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Revised: 11/15/2009] [Accepted: 11/16/2009] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The goal was to compare the outcomes in patients with disabling claudication (DC) or critical limb ischemia (CLI) to determine if diabetics (DM) have poorer patency, limb salvage (LS), and survival rates than nondiabetic patients and if the diabetic regimen affects these outcomes. METHODS All patients who presented with DC or CLI between June 2001 and September 2008 were included. Non-DM patients were compared with those with DM who are currently managed by diet only or oral medications (D-OM), oral medications plus insulin (OM+INS), or insulin alone (INS). RESULTS Of the 746 patients (886 limbs), there were 406 patients (464 limbs) in non-DM, 96 patients (135 limbs) in D-OM, 98 patients (118 limbs) in OM+INS, and 146 patients (185 limbs) in INS groups. There were more patients with coronary artery disease, hypertension, and renal insufficiency in the DM group than non-DM, with the INS group having the highest incidence of renal insufficiency/dialysis (46%/20%). Gangrene and foot sepsis were significantly more frequent in patients in OM+INS (45%/3%) and INS (50%/6%) than non-DM (15%/0.2%) and D-OM groups (25%/1%; P < .001). More patients in the INS group (14%) and OM+INS (9%) had primary amputation than non-DM (4%) and D-OM (4%; P < .01). Mean follow-up was 26.3 +/- 20.7 months. Overall survival following revascularization was similar in D-OM and non-DM and OM+INS and INS, the latter being significantly worse (P < .001). The LS rate in D-OM and non-DM was also identical, whereas OM-INS and INS had significantly worse LS, with OM-INS marginally better than INS (P = .094). Primary patency (PP) was worse in endovascular-treated patients on insulin than non-DM and D-OM patients (P < .001), whereas PP was similar between groups in open-treated patients. Multivariate analysis showed that coronary artery disease, renal insufficiency, chronic obstructive pulmonary disease, indication for intervention, insulin use, nonambulatory status, and statin drug non-use were independently associated with decreased survival, whereas insulin use, presence of gangrene, need for infrapopliteal interventions, and nonambulatory status were independently associated with limb loss. TransAtlantic Inter-Society Consensus (TASC) classification of the treated lesions being C or D, infrapopliteal interventions, and indication of intervention (DC vs CLI) were independently associated with primary patency, whereas insulin use was not. CONCLUSIONS Diabetic patients who present with limb ischemia can be subdivided into three distinct subgroups based on their diabetic regimen. The survival and LS rates of those controlled with diet or OM are nearly identical to nondiabetics, both of which are significantly better than OM+INS or INS. The PP rate in endovascular-treated patients is worse in patients who are on insulin. Being on insulin is independently associated with decreased survival and limb loss but not PP.
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Flu HC, Ploeg AJ, Marang-van de Mheen PJ, Veen EJ, Lange CP, Breslau PJ, Roukema JA, Hamming JF, Lardenoye JWH. Patient and procedure-related risk factors for adverse events after infrainguinal bypass. J Vasc Surg 2010; 51:622-7. [DOI: 10.1016/j.jvs.2009.09.055] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2009] [Revised: 09/22/2009] [Accepted: 09/30/2009] [Indexed: 11/15/2022]
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Vamos EP, Bottle A, Majeed A, Millett C. Trends in lower extremity amputations in people with and without diabetes in England, 1996-2005. Diabetes Res Clin Pract 2010; 87:275-82. [PMID: 20022126 DOI: 10.1016/j.diabres.2009.11.016] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Revised: 10/30/2009] [Accepted: 11/24/2009] [Indexed: 11/24/2022]
Abstract
AIMS To examine trends in non-traumatic lower extremity amputations over a 10-year-period in people with and without diabetes (DM) in England. METHODS All individuals admitted to NHS hospitals for non-traumatic amputations between 1996 and 2005 in England were identified using hospital activity data. Postoperative and 1-year mortality were examined between 2000 and 2004. RESULTS There was a reduction in minor and major amputations during the study period. The number of type 1 DM- and non-DM-related minor amputations decreased by 11.4% and 32.4%, respectively, while the number of type 2 DM-related minor amputations almost doubled. The incidence of type 1- and non-DM-related minor amputations decreased from 1.5 to 1.2 and from 8.1 to 5.1/100,000 population, respectively, while type 2 DM-related amputations increased from 2.4 to 4.1/100,000 population. The number of type 1- and non-DM-related major amputations declined by 41% and 22%, respectively, whereas type 2 DM-related amputations increased by 43%. The incidence of type 2 DM-related amputations increased from 2.0 to 2.7/100,000 population. Overall perioperative and 1-year mortality did not significantly change between 2000 and 2004. CONCLUSIONS While several factors may explain the increase in type 2 DM-related LEAs, these findings highlight the importance of diabetes prevention strategies and controlling risk factors for LEAs in people with diabetes.
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Affiliation(s)
- Eszter Panna Vamos
- Department of Primary Care and Public Health, Imperial College London, UK.
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Flu H, Lardenoye J, Veen E, Van Berge Henegouwen D, Hamming J. Functional status as a prognostic factor for primary revascularization for critical limb ischemia. J Vasc Surg 2010; 51:360-71.e1. [DOI: 10.1016/j.jvs.2009.08.051] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Revised: 08/11/2009] [Accepted: 08/14/2009] [Indexed: 10/19/2022]
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Krolikowska M, Kataja M, Pöyhiä R, Drzewoski J, Hynynen M. Mortality in diabetic patients undergoing non-cardiac surgery: a 7-year follow-up study. Acta Anaesthesiol Scand 2009; 53:749-58. [PMID: 19388895 DOI: 10.1111/j.1399-6576.2009.01963.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The prognosis of diabetic patients after non-cardiac surgery remains controversial. This study was designed to compare the long-term mortality between diabetic and non-diabetic control patients undergoing non-cardiac surgery and to evaluate the possible risk factors. METHODS We investigated 274 consecutive diabetic patients and 282 non-diabetic control patients who underwent non-cardiac surgery within 1 year in a tertiary care hospital in Finland. The control group was matched for the same type of operations. Patients were followed for up to 7 years on average. The main outcome measure was mortality within 7 years. RESULTS Mortality both in the short-term postoperatively (< or =21 days) and in the long-term (up to 87 (1/2) months) was significantly higher in the diabetic patients compared with the non-diabetic group: 3.5 vs. 0% (P<0.05) and 37.2 vs. 15% (P<0.00001), respectively. The major causes of death among diabetic subjects were diseases of the cardiovascular system (56.8%) compared with non-diabetic patients (18.6%), P<0.0001. We found that diabetes mellitus per se is not a risk factor for post-operative mortality but a combination of variables had a significant effect on both short- and long-term mortality. CONCLUSION Diabetic patients undergoing non-cardiac surgery had a significantly higher incidence of short-term post-operative and long-term mortality compared with non-diabetic subjects. We propose a model of predictors of death among diabetic individuals undergoing non-cardiac surgery within a 7-year follow-up. The majority of deaths were associated with cardiovascular diseases.
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Affiliation(s)
- M Krolikowska
- Department of Anesthesia and Intensive Care Medicine, Helsinki University Central Hospital/Jorvi Hospital, Espoo, Finland.
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Value of MDCT angiography in developing treatment strategies for critical limb ischemia. AJR Am J Roentgenol 2009; 192:1416-24. [PMID: 19380571 DOI: 10.2214/ajr.08.1078] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the value of MDCT angiography in the development of strategies for the treatment of patients with critical limb ischemia. MATERIALS AND METHODS During a 12-month period, 150 patients were referred to our department for CT angiography of the peripheral arteries. All patients (n = 28) with clinical stage IV peripheral arterial occlusive disease were included in this retrospective study. The treatment reports, discharge summaries, and follow-up examinations were reviewed to ascertain the number of patients correctly treated on the basis of the CT angiographic findings. RESULTS After CT angiography, endovascular treatment was indicated for eight patients, surgical revascularization for four patients, and a combined endovascular and surgical approach for two patients. That the correct treatment decision had been made in all 14 cases was confirmed on the basis of successful endovascular or surgical revascularization. In eight patients, medical treatment was indicated, and one patient underwent amputation at the level of the thigh. Five patients were referred for complementary digital subtraction angiography, but no additional findings were made. During follow-up, three of the original 28 patients were in grave general condition and died within 7 weeks after CT angiography. Thirteen patients needed no additional treatment during the follow-up period through January 2008. After a median treatment-free interval of 381 days, 12 patients underwent additional revascularization because of clinical progression of disease. CONCLUSION MDCT angiographic findings lead to accurate recommendations for the management of critical limb ischemia. Thus CT angiography seems to be an important technique for the management of stage IV peripheral arterial occlusive disease in patients without absolute contraindications to CT angiography.
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Lazarides MK. The Impact of Interventional Management on Healing of Ischemic Foot Lesions. INT J LOW EXTR WOUND 2009; 8:64-6. [DOI: 10.1177/1534734609334884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Hellingman AA, Smeets HJ. Efficacy and efficiency of a streamlined multidisciplinary foot ulcer service. J Wound Care 2009; 17:541-4. [PMID: 19052519 DOI: 10.12968/jowc.2008.17.12.31764] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The structure of a multidisciplinary foot care service was modified to ensure that patient consultations were only attended by the relevant team members. This audit showed the streamlined service still achieved excellent patient outcomes.
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Affiliation(s)
- A A Hellingman
- Department of Surgery, Bronovo Hospital, The Hague, The Netherlands.
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Nair DG, Samson R. Which diabetics are at risk for lower-extremity problems and what preventive measures can be taken? Semin Vasc Surg 2009; 21:154-9. [PMID: 18774451 DOI: 10.1053/j.semvascsurg.2008.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Diabetes mellitus is a well-known risk factor for development and progression of peripheral arterial disease. Prospective cardiovascular clinical trials have also clearly demonstrated that diabetics fare worse than their nondiabetic counterparts. Diabetics also differ from nondiabetics in that multiple revascularization procedures may be required in order for the clinical outcome to be equivalent to that of a nondiabetic patient. However, by advocating an aggressive approach to peripheral arterial disease, good results in survival and limb salvage can be achieved in diabetic patients despite the presence of increased medical comorbidities. Key to the management of such patients will be identifying which diabetic patients will be at most risk so that preventive measures can be undertaken.
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Affiliation(s)
- Deepak G Nair
- Sarasota Vascular Specialists, 600 N. Cattlemen Road, Suite 220, Sarasota, FL 34232, USA.
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Weis-Müller B, Lippelt I, Römmler V, Porath M, Godehardt E, Sandmann W. Ergebnisse der operativen Revaskularisation beim Diabetespatienten mit arterieller Verschlusskrankheit. DIABETOLOGE 2008. [DOI: 10.1007/s11428-008-0340-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Engelhardt M, Wohlgemuth WA, Willy C, Tannheimer M, Wölfle KD. [Patient assessments of quality of life following bypass for chronic critical limb ischaemia]. Chirurg 2008; 80:324-30. [PMID: 19048220 DOI: 10.1007/s00104-008-1643-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The value of infrainguinal bypass surgery for critical limb ischaemia (CLI) in elderly patients is being scrutinised more as medical resources decline. Despite technically successful revascularisation, patient quality of life seems impaired by delayed wound healing and repeated hospitalisation for interventions and operations. Therefore it is questionable whether these frail patients benefit from bypass surgery with respect to their health-related quality of life. This review examines current evidence of patients with CLI and summarises the effect of bypass surgery on their own quality of life assessments. All in all, patients benefit from the revascularisation because ambulation status improves and independence is preserved. From a patient's perspective these improvements in quality of life justify an aggressive approach towards revascularisation for CLI.
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Affiliation(s)
- M Engelhardt
- Klinik für Gefässchirurgie, Bundeswehrkrankenhaus, Oberer Eselsberg 40, Ulm, Germany.
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Alexandrescu VA, Hubermont G, Philips Y, Guillaumie B, Ngongang C, Vandenbossche P, Azdad K, Ledent G, Horion J. Selective Primary Angioplasty Following an Angiosome Model of Reperfusion in the Treatment of Wagner 1–4 Diabetic Foot Lesions:Practice in a Multidisciplinary Diabetic Limb Service. J Endovasc Ther 2008; 15:580-93. [DOI: 10.1583/08-2460.1] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Engelhardt M, Bruijnen H, Scharmer C, Wohlgemuth W, Willy C, Wölfle K. Prospective 2-Years Follow-up Quality of Life Study after Infrageniculate Bypass Surgery for Limb Salvage: Lasting Improvements Only in Non-diabetic Patients. Eur J Vasc Endovasc Surg 2008; 36:63-70. [DOI: 10.1016/j.ejvs.2008.01.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2007] [Accepted: 01/31/2008] [Indexed: 02/02/2023]
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Primary Infrainguinal Subintimal Angioplasty in Diabetic Patients. Cardiovasc Intervent Radiol 2008; 31:713-22. [DOI: 10.1007/s00270-008-9366-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 05/07/2008] [Accepted: 05/08/2008] [Indexed: 10/22/2022]
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Paraskevas KI, Baker DM, Pompella A, Mikhailidis DP. Does Diabetes Mellitus Play a Role in Restenosis and Patency Rates Following Lower Extremity Peripheral Arterial Revascularization? A Critical Overview. Ann Vasc Surg 2008; 22:481-91. [DOI: 10.1016/j.avsg.2007.12.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Accepted: 12/26/2007] [Indexed: 10/21/2022]
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DeRubertis BG, Pierce M, Ryer EJ, Trocciola S, Kent KC, Faries PL. Reduced primary patency rate in diabetic patients after percutaneous intervention results from more frequent presentation with limb-threatening ischemia. J Vasc Surg 2008; 47:101-8. [DOI: 10.1016/j.jvs.2007.09.018] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Revised: 09/07/2007] [Accepted: 09/08/2007] [Indexed: 11/27/2022]
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Bakken AM, Palchik E, Hart JP, Rhodes JM, Saad WE, Davies MG. Impact of diabetes mellitus on outcomes of superficial femoral artery endoluminal interventions. J Vasc Surg 2007; 46:946-958; discussion 958. [DOI: 10.1016/j.jvs.2007.06.047] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2007] [Accepted: 06/25/2007] [Indexed: 11/26/2022]
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McCaslin JE, Hafez HM, Stansby G. Lower-limb revascularization and major amputation rates in England. Br J Surg 2007; 94:835-9. [PMID: 17330931 DOI: 10.1002/bjs.5668] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The aim was to establish national data for lower-limb revascularization and major amputation procedures performed in England. METHODS Data for lower-limb revascularization procedures and major amputations were collected from the Hospital Episode Statistics (finished consultant episodes) which is published yearly by the Department of Health. Transluminal procedures were analysed from 1998 onwards. Age adjustment was performed according to figures for the resident population of England in the interval studied. RESULTS In all age groups, revascularization rates initially increased to a peak in the mid-1990 s. This was followed by a steady decline in procedures to the present day. However, amputations gradually increased in the 45-64-years age group and showed only a slight decline in the 65-74-years age group. Among patients aged over 75 years there was a marked decline from the mid-1990 s to present-day. Data for diabetics showed similar trends. CONCLUSION The national rate of amputation initially rose despite an increasing number of vascular interventions. It is significant, however, that among patients aged over 75 years this has been followed by a decrease in both revascularization procedures and amputation rates to present levels, the lowest for 14 years.
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Affiliation(s)
- J E McCaslin
- Department of Surgery, Queen Elizabeth Hospital, Gateshead, UK
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Becker F, Loppinet A. [Chronic critical ischemia of the legs. Definition and management]. Ann Cardiol Angeiol (Paris) 2007; 56:63-9. [PMID: 17484089 DOI: 10.1016/j.ancard.2006.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The term "Chronic critical ischemia ", CCI, of lower limb defines a very advanced state of chronic LL arterial insufficiency with deleterious effect of low perfusion pressure rate. This diagnosis has serious consequences for the patient (high risk of major amputation, high risk of cardiovascular events and death, high risk of reduced quality of life for survivals even non-amputated). The diagnosis must be precise. We discuss the evolution of the concept and the definitions of CCI from Fontaine classification, the epidemiology of CCI and its risk factors, the diagnosis of CCI (clinical, haemodynamical, anatomical) and the treatment of CCI which the main goal is to increase as much as possible the arterial pressure in the foot.
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Affiliation(s)
- F Becker
- Medecine vasculaire, Université de Franche-Comté, UF de médecine vasculaire, Hôpital Jean-Minjoz, CHU, 25030 Besançon, France.
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