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Miranda JA, Pallister Z, Sharath S, Ferrer L, Chung J, Lepow B, Mills JL, Montero-Baker M. Early Experience with Venous Arterialization for Limb Salvage in No-Option Patients with Chronic Limb-Threatening Ischemia. J Vasc Surg 2022; 76:987-996.e3. [PMID: 35705119 DOI: 10.1016/j.jvs.2022.05.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 04/14/2022] [Accepted: 05/09/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Chronic limb-threatening ischemia (CLTI) is associated with adverse limb outcomes and increased mortality. In a small subset of the CLTI population, there are no feasible conventional means of revascularization. In such cases, venous arterialization (VA) provides an alternative for limb salvage. The objective of this study was to review the outcomes of venous arterialization (VA) at our institution. METHODS This is a single institution review of 41 patients followed prospectively who underwent either superficial or deep VA. Data collected included: patient demographics, co-morbidities, VA technique (endovascular vs. hybrid) and WIfI (wound ischemia foot infection) limb staging. Data were collected at 1 month, 6 months and 1-year intervals and included the following outcomes: patency, wound healing, major adverse limb event (MALE), major amputation and death. Descriptive statistics were used for analysis. RESULTS The study group includes 41 patients who underwent successful open hybrid superficial or deep endovascular VA; 21 (51.2%) underwent a purely endovascular procedure and 20 (48.8%) had hybrid VA. The WIfI clinical stages were as follows: 33 (80.5%) stage 4, 6 (14.6%) stage 3, and 1 (2.4%) stage 2. Twenty-four (58.5%) patients completed follow-up at 6 months and 16 (39%) at 1 year. VA primary patency at 12 months was 28.6% (95% CI 0.15-0.43), primary assisted patency at 12 months was 44.3% (95% CI 0.27-0.60) and secondary patency at 12 months was 67% (95% CI 0.49-0.80). Complete wound healing rates were 2.7% (1) at 1 month; 62.5% (15) at 6 months; and 18.8% (3) at 1 year. Overall wound healing at 1 year was 46.3% (19). MALE rate at 1 year was 36.5% (15) comprised of 19.5% (8) re-interventions and 17% (7) major amputations. There were 0 (0%) deaths at 1 month and 4 (19%) deaths at 6 months; 2 (9.5%) deaths were attributed to COVID-19. There were no further deaths within 1 year. The limb salvage survival probability at 1 year was 81%. CONCLUSIONS These findings suggest that for a select subset of CLTI patients presenting with high WIfI clinical limb stage CLTI and no viable options for conventional open or endovascular arterial revascularization, superficial and deep venous arterialization are feasible options to achieve limb salvage.
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Affiliation(s)
- Jorge A Miranda
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Zachary Pallister
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Sherene Sharath
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Lucas Ferrer
- Division of Vascular Surgery, Dell Seton Medical Center, University of Texas at Austin, Austin, TX
| | - Jayer Chung
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Brian Lepow
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Miguel Montero-Baker
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
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El Khoury R, Wu B, Kupiec-Weglinski SA, Liu IH, Edwards CT, Lancaster EM, Hiramoto JS, Vartanian SM, Schneider PA, Conte MS. Limb-based patency as a measure of effective revascularization for chronic limb-threatening ischemia. J Vasc Surg 2022; 76:997-1005.e2. [PMID: 35697305 DOI: 10.1016/j.jvs.2022.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/12/2022] [Accepted: 04/24/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE In 2019, the Global Vascular Guidelines on chronic limb-threatening ischemia (CLTI) introduced the concept of limb-based patency (LBP) defined as maintained patency of a target artery pathway (TAP) following intervention. The purpose of this study was to investigate the relationship between LBP and major adverse limb events following infrainguinal revascularization for CLTI. METHODS Consecutive patients undergoing revascularization for CLTI between 2016 and 2019 at a single tertiary institution with a dedicated limb preservation team were included. Subjects with aorto-iliac disease, prior infrainguinal stents or existing bypass grafts were excluded. Demographics, Global Limb Anatomic Staging System (GLASS) scores, Wound, Ischemia, foot Infection (WIfI) stages, revascularization details, and limb-specific outcomes were reviewed. LBP was defined by the absence of re-intervention, occlusion, critical stenosis (>70%), or hemodynamic compromise with ongoing symptoms of CLTI. Major adverse limb events (MALE) included thrombectomy or thrombolysis, new bypass, open surgical graft revision and/or major amputation. RESULTS 184 unique limbs in 163 patients were analyzed. This cohort was composed of 66.9% male patients with a mean age of 72. Baseline characteristics included diabetes (66%), tissue loss (91%) and advanced WIfI stages (30% stage 3, 51% stage 4). GLASS stage 3 anatomic patterns were common (n=119; 65%). 60 limbs were treated with open bypass (65% involving tibial targets) while 124 underwent endovascular intervention (70% including infrapopliteal targets). 12-month freedom from MALE and loss of LBP were 74.0%±3.7% and 48.6%±4.2%, respectively. Diabetes (HR=2.56 [1.13-5.83]; p=.025) and loss of LBP (4.12 [1.96-8.64]; p<.001) were independent predictors of MALE in a Cox proportional hazard model. Loss of LBP was the sole independent predictor of major limb amputation after revascularization (HR=4.97 [1.89-13.09]; p=.001). Loss of LBP impacted both intermediate-risk limbs (HR=2.85 [1.02-7.97]; p=.047 in WIfI stages 1-3) and high-risk limbs (HR=3.99 [1.32-12.11]; p=.014 in WIfI stage 4). However, loss of LBP had the greatest impact on patients presenting with WIfI stage 4 disease (31% vs. 8% major limb amputation at 12-months in limbs without vs. with maintained LBP). CONCLUSIONS Anatomic durability of revascularization, as measured by LBP, is a key determinant of treatment outcomes in CLTI regardless of the initial mode of intervention undertaken. Loss of LBP is most detrimental in patients presenting with advanced limb threat (WIfI stage 4).
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Affiliation(s)
- Rym El Khoury
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Bian Wu
- Department of Surgery, Division of Vascular Surgery, Kaiser Permanente San Francisco Medical Center, CA
| | | | - Iris H Liu
- School of Medicine, University of California San Francisco, CA
| | - Ceazon T Edwards
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Elizabeth M Lancaster
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Jade S Hiramoto
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Shant M Vartanian
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Peter A Schneider
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Michael S Conte
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA.
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Provance JB, Spertus JA, Jones PG, Hoffman MA, Bunte MC, Vogel TR, Mena-Hurtado C, Smolderen KG. Variability in 30-day major amputation rates following endovascular peripheral vascular intervention for critical limb ischemia. Vasc Med 2022; 27:350-357. [PMID: 35603755 DOI: 10.1177/1358863x221098097] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Patients with critical limb ischemia (CLI) can undergo endovascular peripheral vascular intervention (PVI) to restore blood flow and decrease risk of amputation. As a potential indicator of quality for CLI care, we sought to describe 30-day major amputation rates following PVI. We also examined rate variability, and patient-level and site-level factors predicting amputations, using a national electronic health record (EHR) database. Methods: Using the Cerner Health Facts de-identified EHR database, patients with CLI diagnosis codes undergoing PVI were identified. The rate of amputation within 30 days of PVI was calculated. Risk ratios predicting amputation were derived using a mixed effects Poisson regression model adjusting for 16 patient and clinical factors. Median risk ratios (MRRs) were calculated to quantify site-level variability in amputations. Results: A total of 20,204 PVI procedures for CLI from 179 healthcare sites were identified. Mean age at procedure was 69.0 ± 12.6 years, 58.0% were male, and 29.6% were persons of color. Amputation within 30 days of PVI occurred after 570 (2.8%) procedures. Malnutrition, previous amputation, diabetes, and being of Black race were predictors of amputation. Amputation rates across sites ranged from 0.0% to 10.0%. The unadjusted MRR was 1.40 (95% CI 1.35-1.46), which was attenuated after adjusting for patient-level factors (MRR 1.30, 95% CI 1.26-1.34) and site characteristics (MRR 1.11, 95% CI 1.09-1.13). Conclusions: Among PVI procedures for CLI treatment, 30-day amputation rates varied across institutions. Although patient-level factors explained some variability, site-level factors explained most variation in the rates of these outcomes.
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Affiliation(s)
- Jeremy B Provance
- Vascular Medicine Outcomes (VAMOS) Research Group, Department of Internal Medicine, Cardiovascular Medicine Section, Yale University, New Haven, CT, USA
| | - John A Spertus
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Saint Luke's Mid-America Heart Institute, Kansas City, MO, USA
| | - Philip G Jones
- Saint Luke's Mid-America Heart Institute, Kansas City, MO, USA
| | - Mark A Hoffman
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Children's Mercy Research Institute, Children's Mercy Hospital, Kansas City, MO, USA
| | - Matthew C Bunte
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Saint Luke's Mid-America Heart Institute, Kansas City, MO, USA
| | - Todd R Vogel
- Division of Vascular Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Research Group, Department of Internal Medicine, Cardiovascular Medicine Section, Yale University, New Haven, CT, USA
| | - Kim G Smolderen
- Vascular Medicine Outcomes (VAMOS) Research Group, Department of Internal Medicine, Cardiovascular Medicine Section, Yale University, New Haven, CT, USA.,Department of Psychiatry, Yale University, New Haven, CT, USA
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Nienaber JJ, Smith CY, Cha S, Correa M, Rowse PG, Bailey KR, Kalra M. Population-Based Trends in Amputations and Revascularizations for Peripheral Artery Disease From 1990 to 2009. Mayo Clin Proc 2022; 97:919-930. [PMID: 35177249 PMCID: PMC9081231 DOI: 10.1016/j.mayocp.2021.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 09/23/2021] [Accepted: 10/14/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine trends in amputations and revascularizations for peripheral artery disease (PAD) in a well-defined population. METHODS A population-based cohort study of Olmsted County, Minnesota, residents with PAD undergoing amputation or revascularization was conducted between January 1, 1990, and December 31, 2009. Population-level 5-year incidence trends for endovascular, open surgical, and hybrid revascularizations and major and minor amputations were determined. Limb-specific outcomes after revascularization, including major adverse limb events and amputation-free survival, were compared between initial surgical and endovascular or hybrid revascularization groups using Kaplan-Meier analysis. RESULTS We identified 773 residents who underwent 1906 limb-procedures, including 689 open revascularizations, 685 endovascular or hybrid revascularizations, and 220 major amputations. During the 20-year study period, the incidence of endovascular and hybrid revascularizations increased, whereas the incidence of open surgical revascularizations and major amputations decreased. Incidence of revascularizations for chronic limb-threatening ischemia (CLTI) did not change. Among residents with CLTI undergoing their first revascularization on a limb, endovascular revascularization was associated with more major adverse limb events and major amputations compared with surgical revascularization during the ensuing 15 years. CONCLUSION The rising incidence of endovascular and hybrid revascularizations and the decreasing incidence of open surgical revascularizations for PAD were associated with a decreasing incidence of major amputations in this population between 1990 and 2009, despite a stable incidence of revascularizations for CLTI. With more major adverse limb events and major amputations after endovascular revascularization, these trends suggest that additional emphasis should be placed on improving limb salvage efforts beyond just mode of revascularization.
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Affiliation(s)
| | - Carin Y Smith
- Division of Biomedical Statistics, Mayo Clinic, Rochester, MN. J.J.N. is currently at the Charles George VA Medical Center, Asheville, NC. M.C. is currently at Instituto Vascular, Passo Fundo, Brazil. P.G.R. is currently in the Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Stephen Cha
- Division of Biomedical Statistics, Mayo Clinic, Rochester, MN. J.J.N. is currently at the Charles George VA Medical Center, Asheville, NC. M.C. is currently at Instituto Vascular, Passo Fundo, Brazil. P.G.R. is currently in the Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | | | - Kent R Bailey
- Division of Biomedical Statistics, Mayo Clinic, Rochester, MN. J.J.N. is currently at the Charles George VA Medical Center, Asheville, NC. M.C. is currently at Instituto Vascular, Passo Fundo, Brazil. P.G.R. is currently in the Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery.
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Kim M, Yang YS, Ko YG, Choi M. Major Adverse Events in Patients with Peripheral Artery Disease after Endovascular Revascularization: A Retrospective Study. J Clin Med 2022; 11:2547. [PMID: 35566674 PMCID: PMC9102344 DOI: 10.3390/jcm11092547] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/19/2022] [Accepted: 04/28/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE For peripheral artery disease (PAD) patients, after endovascular revascularization, it is crucial to manage associated factors that can affect the risk of major adverse events. We aimed to investigate the associated factors of major adverse events in these patients. MATERIALS AND METHODS We conducted a retrospective longitudinal analysis using the electronic medical records from a tertiary hospital in Korea and included the data of 1263 patients. Eligible patients were categorized into four groups based on diabetes mellitus (DM) and regular exercise. The major adverse events included major adverse limb events and major adverse cardiovascular events. Major adverse events-free survival was assessed using the Kaplan-Meier method, and associated factors of major adverse events were analyzed using Cox proportional hazards analyses. RESULTS Kaplan-Meier survival curves showed that patients with DM and non-regular exercise had a shorter major adverse events-free survival. The Cox regression analysis showed that for patients with critical limb ischemia or chronic kidney disease, the risk of major adverse events increased, while group variables were not significant. CONCLUSION Target management of patients with DM, critical limb ischemia, and chronic kidney disease is essential to reduce major adverse events after endovascular revascularization in patients with PAD.
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Affiliation(s)
- Mihui Kim
- College of Nursing, Brain Korea 21 FOUR Project, Yonsei University, Seoul 03722, Korea; (M.K.); (Y.S.Y.)
| | - Yong Sook Yang
- College of Nursing, Brain Korea 21 FOUR Project, Yonsei University, Seoul 03722, Korea; (M.K.); (Y.S.Y.)
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea;
| | - Mona Choi
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul 03722, Korea
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Feldman ZM, Mohapatra A. Endovascular Management of Complex Tibial Lesions. Semin Vasc Surg 2022; 35:190-199. [DOI: 10.1053/j.semvascsurg.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 11/11/2022]
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Shirasu T, Takagi H, Gregg A, Kuno T, Yasuhara J, Kent KC, Clouse WD. Predictability of the Global Limb Anatomic Staging System (GLASS) for technical and limb-related outcomes: systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2022; 64:32-40. [DOI: 10.1016/j.ejvs.2022.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 03/09/2022] [Accepted: 03/31/2022] [Indexed: 11/03/2022]
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Below the ankle orbital atherectomy in chronic limb-threatening ischemia patients as a bailout strategy for limb salvage: Early clinical experience. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 42:121-126. [DOI: 10.1016/j.carrev.2022.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/14/2022] [Accepted: 03/21/2022] [Indexed: 11/17/2022]
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Team-Based Care in Patients with Chronic Limb-Threatening Ischemia. Curr Cardiol Rep 2022; 24:217-223. [PMID: 35129740 DOI: 10.1007/s11886-022-01643-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Team-based care has been proposed as a tool to improve health care delivery, especially for the treatment of complex medical conditions. Chronic limb-threatening ischemia (CLTI) is a complex disease associated with significant morbidity and mortality which often involves the care of multiple specialty providers. Coordination of efforts across the multiple physician specialists, nurses, wound care specialists, and administrators is essential to providing high-quality and efficient care. The aim of this review is to discuss the multiple facets of care of the CLTI patient and to describe components important for a team-based care approach. RECENT FINDINGS Observational studies have reported improved outcomes when using a team-based care approach in the care of the patients with CLTI, including reduction in mean wound healing times, decreasing rate of amputations, and readmissions. Team-based care can streamline care of CLTI patients by raising awareness, facilitating early recognition, and providing prompt vascular assessment, revascularization, and surveillance. This approach has the potential to improve patient outcomes and reduce downstream health care costs.
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Kumada Y, Kawai N, Ishida N, Mori A, Ishii H, Ohshima S, Ito R, Umemoto N, Takahashi H, Murohara T. Impact of Hemodialysis on Clinical Outcomes in Patients Undergoing Lower Extremity Bypass Surgery for Peripheral Artery Disease-10-year Follow-Up Study. Angiology 2022; 73:744-752. [PMID: 35108110 DOI: 10.1177/00033197211070882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We investigated the clinical impact of hemodialysis on long-term outcomes of bypass surgery in patients with peripheral artery disease. We evaluated 660 consecutive patients who underwent successful bypass surgery (392 hemodialysis and 268 non-hemodialysis). The endpoint was amputation-free survival (AFS). To minimize differences in clinical characteristics between the 2 groups, propensity score matching was performed. The AFS rates for 10-year follow-up were 39.3% and 67.7% in hemodialysis and non-hemodialysis patients [hazard ratio (HR) 2.21, 95% confidence interval (CI) 1.65-3.01, P < .0001]. Cumulative incidence of amputation was higher in the hemodialysis group than in the non-hemodialysis group [(19.4 vs 8.4%, HR 2.15, 95% CI 1.29-3.74, P = .0027). In a matched cohort (n = 210 each), AFS was still lower in the hemodialysis patients (53.1 vs 66.3%, HR 1.94, 95% CI 1.36-2.82, P = .0003). However, there was no significant difference in amputation rate between the groups (10.5 vs 10.6%, HR .97, 95% CI 0.49-1.87, P = .93). In a sub-analysis of patients with critical limb ischemia, similar results were obtained. The 10-year AFS was consistently lower in the hemodialysis group than in the non-hemodialysis group. However, the amputation rate was comparable between the groups when matched for the differences in clinical characteristics.
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Affiliation(s)
- Yoshitaka Kumada
- Department of Cardiovascular Surgery, 73505Matsunami General Hospital, Kasamatsu, Japan
| | - Norikazu Kawai
- Department of Cardiovascular Surgery, 73505Matsunami General Hospital, Kasamatsu, Japan
| | - Narihiro Ishida
- Department of Cardiovascular Surgery, 73505Matsunami General Hospital, Kasamatsu, Japan
| | - Akihiro Mori
- Department of Cardiovascular Surgery, 73505Matsunami General Hospital, Kasamatsu, Japan
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Satoru Ohshima
- Department of Cardiology, 469749Nagoya Kyoritsu Hospital, Nagoya, Japan
| | - Ryuta Ito
- Department of Cardiology, 469749Nagoya Kyoritsu Hospital, Nagoya, Japan
| | - Norio Umemoto
- Department of Cardiology, 469749Nagoya Kyoritsu Hospital, Nagoya, Japan
| | - Hiroshi Takahashi
- Department of Nephrology, 12695Fujita Health University School of Medicine, Toyoake, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Wang C, Rosner GL, Bao T, Lu N, Chen WC, Li H, Tiwari R, Xu Y, Yue LQ. Leveraging real-world evidence for determining performance goals for medical device studies. Stat Med 2021; 40:6577-6589. [PMID: 34561895 DOI: 10.1002/sim.9199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/11/2021] [Accepted: 08/27/2021] [Indexed: 11/11/2022]
Abstract
Performance goals are numerical target values pertaining to effectiveness or safety endpoints in single-arm medical device clinical studies. Typically, performance goals are determined at the planning stage of the investigational study under consideration based on summarized outcome information from existing relevant clinical trials. In recent years, there is a growing interest in leveraging real-world evidence in medical product development. In this article, we introduce a new method for proposing performance goals by leveraging real-world evidence. The method applies entropy balancing to address possible patient dissimilarities between the study's target patient population and existing real-world patients, and can take into account operation differences between clinical studies and real-world clinical practice. An illustrative example is provided to demonstrate how to implement the proposed method for performance goal determination while leveraging real-world evidence.
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Affiliation(s)
- Chenguang Wang
- Oncology Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gary L Rosner
- Oncology Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tingting Bao
- Data Science Institute, Fu Foundation School of Engineering and Applied Science, Columbia University, New York, New York, USA
| | - Nelson Lu
- Division of Biostatistics, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Wei-Chen Chen
- Division of Biostatistics, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Heng Li
- Division of Biostatistics, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Ram Tiwari
- Division of Biostatistics, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yunling Xu
- Division of Biostatistics, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lilly Q Yue
- Division of Biostatistics, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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Choke E, Tang TY, Peh E, Damodharan K, Cheng SC, Tay JS, Finn AV. MagicTouch PTA Sirolimus Coated Balloon for Femoropopliteal and Below the Knee Disease: Results From XTOSI Pilot Study Up To 12 Months. J Endovasc Ther 2021; 29:780-789. [PMID: 34911383 DOI: 10.1177/15266028211064816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Sirolimus coated balloon (SCB) is a promising treatment option to prevent restenosis for peripheral arterial occlusive disease (PAOD). This is a pilot first-in-human study of MagicTouch percutaneous transluminal angioplasty (PTA) SCB for treatment of PAOD for both femoropopliteal and below the knee arteries (BTK). MATERIAL AND METHODS Xtreme Touch-Neo [MagicTouch PTA] Sirolimus Coated Balloon (XTOSI) pilot study is a prospective, single-arm, open-label, single-center trial evaluating MagicTouch PTA SCB for symptomatic PAOD. Primary endpoint was defined as primary patency at 6 months (duplex ultrasound peak systolic velocity ratio ≤2.4). Secondary endpoints included clinically driven target lesion revascularization (CD-TLR), amputation free survival (AFS), all-cause mortality, and limb salvage success. RESULTS Fifty patients were recruited. The mean age was 67 (n=31 [62%] males). SCB was applied to femoropopliteal in 20 patients (40%) and BTK in 30 patients (60%). Majority of treatments (94%) were performed for limb salvage indications (Rutherford scores 5 or 6). This was a high risk cohort, in which 90% had diabetes, 36% had coronary artery disease, 20% had end stage renal failure, and American Society of Anaesthesiologists (ASA) score was 3 or more in 80%. Mean lesion length treated was 227±81 mm, of which 36% were total occlusions. Technical and device success were both 100%. At 30 days, mortality was 2% and major limb amputation was also 2%. Six-month primary patency was 80% (88.2% for femoropopliteal; 74% for BTK). At 12 months, freedom from CD-TLR was 89.7% (94.1% for femoropopliteal; 86.3% for BTK), AFS was 81.6% (90.0% for femoropopliteal; 75.9% for BTK), all-cause mortality was 14.3% (10.0% for femoropopliteal; 17.2% for BTK), and limb salvage success was 92.9% (94.4% for femoropopliteal; 91.7% for BTK). There was a statistically significant increase between baseline and 6-month toe pressures for both femoropopliteal (57.3±23.3 mm Hg vs 82.5±37.8 mm Hg; p<.001) and BTK lesions (52.8±19.2 mm Hg vs 70.7±37 mm Hg; p<.037). At 12 months, wound healing rate was 33/39 (84.6%). CONCLUSIONS MagicTouch PTA SCB in the XTOSI study showed promising 6-month primary patency and encouraging 12-month freedom from CD-TLR, AFS, and limb salvage rates. No early safety concerns were raised. Randomized trials are needed to investigate the safety and efficacy of SCB for treatment of PAOD.
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Affiliation(s)
| | - Tjun Yip Tang
- Sengkang General Hospital, Singapore.,Singapore General Hospital, Singapore
| | | | | | | | | | - Aloke V Finn
- CVPath Institute Inc., Gaithersburg, MD, USA.,University of Maryland School of Medicine, Baltimore, MD, USA
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Lakhter V, Weinberg MD, Galmer A, Mishra S, Dalsania R, Das S, Geraghty PJ, Jaff MR, Schneider PA, Weinberg I. Objective Outcome Measures for Trials in Patients With Chronic Limb-Threatening Ischemia Across 2 Decades: Analysis and Recommendations. JACC Cardiovasc Interv 2021; 14:2584-2597. [PMID: 34887050 DOI: 10.1016/j.jcin.2021.08.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/13/2021] [Accepted: 08/17/2021] [Indexed: 11/30/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) is prevalent and associated with morbidity and mortality. The published research concerning CLTI therapeutics is evolving. The goals of this review are to: 1) summarize the endpoints that are being used in trials assessing interventions for patients with CLTI; and 2) review gaps and discrepancies in current outcome definitions. A search was conducted of the PubMed database and ClinicalTrials.gov to identify studies published between January 2000 and March 2020 that evaluated treatment options for patients with CLTI. Meta-analyses, case series, case reports, abstracts, and expert opinion were excluded. Forty-nine studies (n = 11,667) were identified that fulfilled the inclusion criteria. Most trials reported clinical outcomes (mortality, 69.4%; limb events, 87.8%; target lesion revascularization, 83.7%). Mean follow-up duration was 23.7 months. In investigational device exemption trials, total follow-up and follow-up to primary outcomes were discordant (12 months vs 6 months; P = 0.0018). Hemodynamic testing was reported in 71.4%, usually ankle-brachial index. Patency was assessed in 89.8% of trials; ultrasound was used in 65.3% and invasive angiography in 85.7%, at baseline and/or during follow-up. Wound assessment was performed in 49.0% of studies, qualitative in 28.6% and quantitative in 20.4%. Finally, quality of life assessment was performed in 55% of studies. Definitions for many outcomes varied across studies. Consensus regarding which outcomes to study, uniform definitions, and optimal methods to measure some of these outcomes are yet to be established. A comprehensive effort by all stakeholders is needed to move the field of CLTI forward.
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Affiliation(s)
- Vladimir Lakhter
- Cardiology Division, Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Mitchell D Weinberg
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, New York, USA
| | - Andrew Galmer
- Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Suraj Mishra
- Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Raj Dalsania
- Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Shinjita Das
- VASCORE, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Patrick J Geraghty
- Department of Surgery, Washington University Medical School, St. Louis, Missouri, USA
| | - Michael R Jaff
- Boston Scientific, Marlboro, Massachusetts, USA; Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Ido Weinberg
- VASCORE, Massachusetts General Hospital, Boston, Massachusetts, USA.
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Kobayashi T, Kodama A, Okazaki T, Honma T, Yamada T, Ishibashi H, Komori K. Prognostic Significance of Preoperative Functional Independence Measure (FIM) on Long-Term Outcomes in Patients with Chronic Limb-Threatening Ischemia (CLTI). Ann Vasc Surg 2021; 83:275-283. [PMID: 34902471 DOI: 10.1016/j.avsg.2021.10.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the effect of preoperative motor and cognitive activities of daily living (ADL) on long-term outcomes of patients with chronic limb-threatening ischemia (CLTI) after distal bypass. METHODS A retrospective review was performed for patients who underwent distal bypass for CLTI from 2013 to 2019 at multiple centers in Japan. Comparisons were made among patients with high and low motor and cognitive ADL based on the functional independence measure (FIM). The primary endpoint was limb salvage and the secondary endpoints were survival, amputation free survival (AFS), major adverse limb events (MALE), readmission, and wound healing. RESULTS A total of 226 distal bypasses were performed in 185 patients (169 males; median age, 76 years; diabetes mellitus, 70%; end-stage renal disease with hemodialysis, 40%). The patients were divided into high (n = 93, 50%) and low (n = 92, 50%) FIM-motor cases, and high (n = 157, 85%) and low (n = 28, 15%) FIM-cognitive cases. FIM-motor (high vs. low) and FIM-cognitive (high vs. low) were not significantly associated with limb salvage, freedom from MALE, freedom from readmission, and wound healing. The 1- and 3-year survival rates were significantly lower in low FIM-motor cases (93% vs. 70% at 1 year, 73% vs. 46% at 3 years, P = 0.0011); and in low FIM-cognitive cases (87% vs. 50% at 1 year, 63% vs. 45% at 3 years, P < 0.001). The 1- and 3-year AFS rates were significantly lower in low FIM-motor cases (92% vs. 67% at 1 year, 69% vs. 44% at 3 years, P < 0.001); and in low FIM-cognitive cases (85% vs. 49% at 1 year, 59% vs. 44% at 3 years, P < 0.001). In multivariate analysis, independent risk factors for survival were hemodialysis (HR = 2.17; 95% confidence interval (CI), 1.23-3.83; P = .0078), low FIM-cognitive (HR = 3.45; 95% CI, 1.78-6.71; P < 0.001), and ejection fraction (HR = 0.98; 95% CI, 0.95-0.99; P = 0.019). CONCLUSIONS FIM-motor and FIM-cognitive were predictive factors for long-term survival and AFS of CLTI patients after distal bypass, but had no influence on limb salvage, MALE, readmission, and wound healing. These results suggest that the motor and cognitive status of ADL should be assessed using FIM before distal bypass for patients with CLTI.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima Japan.; Department of Rehabilitation, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima Japan..
| | - Akio Kodama
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University School of Medicine, Showa-ku, Nagoya, Aichi Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima Japan
| | - Tomoaki Honma
- Department of Rehabilitation, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima Japan
| | | | | | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University School of Medicine, Showa-ku, Nagoya, Aichi Japan
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Yan Q, Prasla S, Carlisle DC, Rajesh A, Treffalls J, Davies MG. Deep Venous Arterialization for Chronic Limb Threatening Ischemia in Atherosclerosis Patients - A meta-analysis. Ann Vasc Surg 2021; 81:1-21. [PMID: 34883231 DOI: 10.1016/j.avsg.2021.10.059] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/09/2021] [Accepted: 10/23/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Venous arterialization is an upcoming and novel alternative in chronic limb threatening ischemia (CLTI) patients in the absence of standard revascularization options. The aim of this study is to systematically review and analyze outcomes of venous arterialization. STUDY DESIGN A systematic literature search was performed in 5 databases using the PRISMA methodology. Inclusion criteria were English language original research papers on CLTI patients treated with venous arterialization. EXCLUSION CRITERIA absence of CLTI due to atherosclerosis, duplicate study or reporting of patients, meeting abstract only. Quality and risk of bias were evaluated. Meta-analysis was performed using random effects model on articles that have a sample size of equal or greater than 10. RESULTS Twelve studies included 442 patients that underwent treatment for 445 limbs (374 patients and 377 limbs underwent venous arterialization while remainder underwent traditional bypass and served as control subjects). Average age was 66 [18 studies, range 37-91 years], 68% were male [271/366, 15 studies] and 67% diabetic [271/406, 16 studies]). Most limbs (88%, 352/398, 16 studies) had tissue loss. Pooled 30-day mortality was 3.7% (95%-confidence interval [CI] 0.8-6.6%), 30-day morbidity was 15.5% (95%-CI 3.2-27.8%), 30-day major adverse cardiovascular event was 5.2% (95%-CI 1.7-8.6%) and 30-day major adverse limb event was 16.7% (95%-CI 1.5-31.9%). Pooled 1-year limb-salvage rate was 79.0% (95%-CI 68.7-90.7) and 1-year survival rate was 85.7% (95%-CI 76.2-96.4). Studies quality varied significantly across studies. CONCLUSION Venous arterialization has an acceptable a 1-year limb salvage rate of 79%, however, this is based on low levels of evidence. More randomized controlled trials or high-quality cohort studies are needed to further define the effectiveness of this procedure for CLTI.
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Affiliation(s)
- Qi Yan
- Division of Vascular and Endovascular Surgery, University of Texas Health at San Antonio, San Antonio, Texas; Department of Surgery, University of Texas Health at San Antonio, San Antonio, Texas.; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Texas
| | - Sanaa Prasla
- Department of Surgery, University of Texas Health at San Antonio, San Antonio, Texas
| | - Daniel C Carlisle
- Department of Surgery, University of Texas Health at San Antonio, San Antonio, Texas
| | - Aashish Rajesh
- Department of Surgery, University of Texas Health at San Antonio, San Antonio, Texas
| | - John Treffalls
- Department of Surgery, University of Texas Health at San Antonio, San Antonio, Texas
| | - Mark G Davies
- Center for Quality, Effectiveness and Outcomes in Cardiovascular Diseases, University of Texas Health at San Antonio, San Antonio, Texas; Division of Vascular and Endovascular Surgery, University of Texas Health at San Antonio, San Antonio, Texas; Department of Surgery, University of Texas Health at San Antonio, San Antonio, Texas.; South Texas Center for Vascular Care, South Texas Medical Center, San Antonio, Texas..
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Verwer MC, Waissi F, Mekke JM, Dekker M, Stroes ESG, de Borst GJ, Kroon J, Hazenberg CEVB, de Kleijn DPV. High lipoprotein(a) is associated with major adverse limb events after femoral artery endarterectomy. Atherosclerosis 2021; 349:196-203. [PMID: 34857353 DOI: 10.1016/j.atherosclerosis.2021.11.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/25/2021] [Accepted: 11/17/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUNDS AND AIMS Elevated lipoprotein(a) (Lp[a]) has been identified as a causal risk factor for cardiovascular disease including peripheral arterial disease (PAD). Although Lp(a) is associated with the diagnosis of PAD, it remains elusive whether there is an association of Lp(a) with cardiovascular and limb events in patients with severe PAD. METHODS Preoperative plasma Lp(a) levels were measured in 384 consecutive patients that underwent iliofemoral endarterectomy and were included in the Athero-Express biobank. Our primary objective was to assess the association of Lp(a) levels with Major Adverse Limb Events (MALE). Our secondary objective was to relate Lp(a) levels to Major Adverse Cardiovascular Events (MACE) and femoral plaque composition that was acquired from baseline surgery. RESULTS During a median follow-up time of 5.6 years, a total of 225 MALE were recorded in 132 patients. Multivariable analysis, including history of peripheral intervention, age, diabetes mellitus, end stage renal disease and PAD disease stages, showed that Lp(a) was independently associated with first (HR of 1.36 (95% CI 1.02-1.82) p = .036) and recurrent MALE (HR 1.36 (95% CI 1.10-1.67) p = .004). A total of 99 MACE were recorded but Lp(a) levels were not associated with MACE.sLp(a) levels were significantly associated with a higher presence of smooth muscle cells in the femoral plaque, although this was not associated with MALE or MACE. CONCLUSIONS Plasma Lp(a) is independently associated with first and consecutive MALE after iliofemoral endarterectomy. Hence, in patients who undergo iliofemoral endarterectomy, Lp(a) could be considered as a biomarker to enhance risk stratification for future MALE.
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Affiliation(s)
- Maarten C Verwer
- Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands.
| | - Farahnaz Waissi
- Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands; Netherlands Heart Institute, Moreelsepark 1, 3511, EP, Utrecht, the Netherlands; Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
| | - Joost M Mekke
- Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands
| | - Mirthe Dekker
- Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands; Netherlands Heart Institute, Moreelsepark 1, 3511, EP, Utrecht, the Netherlands; Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands
| | - Jeffrey Kroon
- Department of Experimental Vascular Medicine, Amsterdam Cardiovascular Sciences, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
| | - Constantijn E V B Hazenberg
- Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands
| | - Dominique P V de Kleijn
- Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands; Laboratory of Experimental Cardiology, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands; Netherlands Heart Institute, Moreelsepark 1, 3511, EP, Utrecht, the Netherlands.
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Lynch TG. What are the right questions? If it were easy, someone would have done it already. J Vasc Surg 2021; 74:1956-1957. [PMID: 34809811 DOI: 10.1016/j.jvs.2021.07.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/15/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Thomas G Lynch
- Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC.
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Moreira R, Duarte-Gamas L, Pereira-Macedo J, Pereira-Neves A, Domingues-Monteiro D, Jácome F, Andrade JP, Marreiros A, Rocha-Neves J. Contralateral Carotid Stenosis is a Predictor of Long-term Adverse Events in Carotid Endarterectomy. Ann Vasc Surg 2021; 79:247-255. [PMID: 34699941 DOI: 10.1016/j.avsg.2021.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/06/2021] [Accepted: 07/09/2021] [Indexed: 11/29/2022]
Abstract
Contralateral carotid stenosis (clCS) has been described as a perioperative predictor of mortality after carotid endarterectomy (CEA). However, its predictive value on long-term cardiovascular events remains controversial. The study aims to assess the potential role of clCS as a long-term predictor of major adverse cardiovascular events (MACE) in patients who underwent CEA. From January 2012 to July 2020, patients undergoing CEA under regional anesthesia for carotid stenosis in a tertiary care and referral center were eligible from a prospective database, and a post hoc analysis was performed. The primary outcome consisted in the occurrence of long-term MACE. Secondary outcomes included all-cause mortality, stroke, myocardial infarction, acute heart failure, and major adverse limb events. A total of 192 patients were enrolled. With a median 50 months follow-up, chronic kidney disease (CKD) (mean survival time (MST) 51.7 vs. 103.3, p<0.010) and peripheral artery disease (PAD) (MST 75.1 vs. 90.3, p=0.001) were associated with decreased survival time. After propensity score matching (PSM), CKD (MST 49.1 vs. 106.0, p=0.001) and PAD (MST 75.7 vs. 94.0, p=0.001) maintained this association. On multivariate Cox regression analysis, contralateral stenosis was associated with higher MACE (hazard ratio (HR) = 2.035; 95% CI: 1.113-3.722, p=0.021 and all-cause mortality (HR = 2.564; 95% CI: 1.276-5,152 p=0.008). After PSM, only all-cause mortality (HR 2.323; 95% CI: 0.993-5.431, p=0.052) maintained a significant association with clCS. On multivariable analysis, clCS (aHR 2.367; 95% CI: 1.174-4.771, p=0.016), age (aHR 1.039, 95% CI: 1.008-1.070), CKD (aHR 2.803; 95% CI: 1.409-5.575, p=0.003) and PAD (aHR 3.225, 95% CI: 1.695-6.137, p<0.001) were independently associated with increased all-cause mortality. Contrary to MACE, clCS is a strong predictor of long-term all-cause mortality after CEA. However, MACE risk may compromise CEA benefits by other competitive events. Therefore, further studies are needed to establish the role of clCS on postoperative events and on patients' specific assessments in order to determine the best medical treatment and easy access to surgical intervention.
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Affiliation(s)
- Rita Moreira
- Faculdade de Medicina e Ciências Biomédicas da Universidade do Algarve, Portugal; ABC, Algarve Biomedical Center, Faro, Portugal.
| | - Luís Duarte-Gamas
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal
| | - Juliana Pereira-Macedo
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal
| | - António Pereira-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal; Department of Biomedicine - Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal
| | - Diogo Domingues-Monteiro
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal
| | - Filipa Jácome
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal
| | - José P Andrade
- Department of Biomedicine - Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal; Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - Ana Marreiros
- Faculdade de Medicina e Ciências Biomédicas da Universidade do Algarve, Portugal; ABC, Algarve Biomedical Center, Faro, Portugal
| | - João Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Portugal; Department of Biomedicine - Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Portugal
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Evaluation of Long-Term Outcomes of Femoropopliteal Bypass Surgery in Patients With Chronic Limb-Threatening Ischemia in an Endovascular Era. Ann Vasc Surg 2021; 79:191-200. [PMID: 34644653 DOI: 10.1016/j.avsg.2021.06.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 06/28/2021] [Accepted: 06/30/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND To investigate the long-term outcomes of femoropopliteal bypass surgery in patients with chronic limb-threatening ischemia (CLTI) and TransAtlantic Inter-Society Consensus II (TASC II), type D (TASC D) femoropopliteal disease. METHODS A retrospective analysis was performed for all consecutive patients undergoing above-knee (AK) femoropopliteal bypass surgery at an academic vascular centre between January 2007 and March 2019. Patients with claudication (IC) and patients with CLTI were included. Patency rates and freedom from major adverse limb events (MALE) after 5 years were analysed. RESULTS In total, 432 femoropopliteal grafts were performed. Indications for surgery were claudication and CLTI in 232 (53.7%) and 200 (46.3%) patients, respectively. Graft material was autologous vein in 186 patients (43.1%), polytetrafluoroethylene (PTFE) in 128 patients (29.6%), and heparin-bonded expanded polytetrafluoroethylene (HePTFE) in 118 patients (27.3%). At the 5-year follow-up, the primary patency rate was 58.1% and 58.3% in patients with CLTI and claudication, respectively. Secondary patency rates were 74.1% and 68.6%, respectively. Freedom from MALE was 64.5% and 61.9%, respectively. Analyses of graft material in the CLTI group showed that, at 5 years, autologous vein grafts had better long-term patency rates than PTFE and HePTFE grafts. At 5 years, the primary and secondary patency rate for autologous vein grafts were 63.2% (P= 0.324) and 83.2% (P = 0.020), respectively. Freedom from MALE was 72.0% with the use of autologous vein grafts, 47.9% using PTFE and, 52.9% using HePTFE, respectively (P= 0.021). CONCLUSIONS Our study shows that femoropopliteal bypass surgery in patients with TASC D lesions is safe and effective in the long term. Autologous vein grafts remain the first choice for patients with CLTI, also for bypasses in AK position. However, prosthetic grafts in AK the position are an acceptable alternative for revascularisation when the saphenous vein is not available.
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AbuRahma AF, Beasley M, AbuRahma ZT, Davis M, Adams E, Dean LS, Shapiro J, Scott G, Davis E. Clinical Outcome of Drug-Eluted Stenting (Zilver PTX) in Patients With Femoropopliteal Occlusive Disease a Single Center Experience. J Endovasc Ther 2021; 29:350-360. [PMID: 34622706 DOI: 10.1177/15266028211049339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Few industry sponsored trials reported satisfactory outcomes in the use of drug-eluting stents (DES) for treatment of femoropopliteal arterial disease. This study analyzed the early/late clinical outcome from a real world single center. PATIENT POPULATIONS/METHODS A total of 115 limbs treated with Zilver PTX were analyzed for: major adverse limb event (MALE: above ankle limb amputation/major intervention at 1 year), major adverse events (MAEs; death, amputation, and target lesion thrombosis/reintervention), primary patency (based on duplex ultrasound ± ankle brachial indexes), limb salvage, and amputation free survival rates (AFS) at 1 and 2 years. RESULTS Indications included claudication in 32% and critical limb threatening ischemia (CLTI) in 68%. Lesions treated included: superficial femoral artery (SFA) 66%, both SFA and popliteal artery (PA) 19% and PA 15%. Mean lesion length was 21 cm and 68% had total occlusion. 45% were Trans-Atlantic Inter-Society Consensus (TASC) TASC II D lesions and 55% A-C lesions. Mean follow-up was 18.4 months (1-76 months). Perioperative major morbidity rate was 8.7% with 0% mortality. MALE rate at 1 year was 17% (13.5% for claudication vs 19.2% for CLTI, p=0.4499). MAE rate was 30% for claudication versus 52% for CLTI (p=0.0392). Overall primary patency rates at 1 and 2 years were 75% and 54% (86% and 71% for claudication vs 70% and 46% for CLTI, respectively, p=0.0213). Primary patency rates at 1 and 2 years were 94% and 88% for TASC A-C lesions versus 50% and 16% for TASC D lesions (p<0.0001). Overall freedom from MALE rate at 1 and 2 years were 85% and 79% (86% and 86% for claudication vs 84% and 74% for CLTI, p=0.2391). These rates were 96% and 93% for TASC A-C lesions versus 70% and 50% for D lesions, respectively (p<0.0001). Limb salvage rates at 1 and 2 years were 93% and 86% (100% and 100% for claudication vs 89% and 78% for CLTI, p=0.012). Overall AFS rates at 1 and 2 years were 79% and 71% (93% and 82% for TASC A-C vs 59% and 59% for D lesions, p=0.001). CONCLUSION Clinical outcomes after DES (Zilver PTX) in femoropopliteal arterial lesions were satisfactory for TASC A-C lesions but inferior/unsatisfactory for TASC D lesions.
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Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV, USA
| | - Matthew Beasley
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV, USA
| | - Zachary T AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV, USA
| | - Meghan Davis
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV, USA
| | - Elliot Adams
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV, USA
| | - L Scott Dean
- CAMC Institute for Academic Medicine, Charleston, WV, USA
| | | | | | - Elaine Davis
- CAMC Institute for Academic Medicine, Charleston, WV, USA
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Tay S, Abdulnabi S, Saffaf O, Harroun N, Yang C, Semenkovich CF, Zayed MA. Comprehensive Assessment of Current Management Strategies for Patients With Diabetes and Chronic Limb-Threatening Ischemia. Clin Diabetes 2021; 39:358-388. [PMID: 34866779 PMCID: PMC8603325 DOI: 10.2337/cd21-0019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Chronic limb-threatening ischemia (CLTI) is the most severe form of peripheral artery disease. It is estimated that 60% of all nontraumatic lower-extremity amputations performed annually in the United States are in patients with diabetes and CLTI. The consequences of this condition are extraordinary, with substantial patient morbidity and mortality and high socioeconomic costs. Strategies that optimize the success of arterial revascularization in this unique patient population can have a substantial public health impact and improve patient outcomes. This article provides an up-to-date comprehensive assessment of management strategies for patients afflicted by both diabetes and CLTI.
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Affiliation(s)
- Shirli Tay
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Sami Abdulnabi
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Omar Saffaf
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Nikolai Harroun
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Chao Yang
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
| | - Clay F. Semenkovich
- Department of Internal Medicine, Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, MO
| | - Mohamed A. Zayed
- Department of Surgery, Section of Vascular Surgery, Washington University School of Medicine, St. Louis, MO
- Division of Molecular Cell Biology, Washington University School of Medicine, St. Louis, MO
- Department of Biomedical Engineering, Washington University McKelvey School of Engineering, St. Louis, MO
- Veterans Affairs St. Louis Health Care System, St. Louis, MO
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The Society for Vascular Surgery Objective Performance Goals for Critical Limb Ischemia are attainable in select patients with ischemic wounds managed with wound care alone. Ann Vasc Surg 2021; 78:28-35. [PMID: 34543715 DOI: 10.1016/j.avsg.2021.06.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/28/2021] [Accepted: 06/30/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND To set therapeutic benchmarks, in 2009 the Society for Vascular Surgery defined objective performance goals (OPG) for treatment of patients with chronic limb threatening ischemia (CLTI) with either open surgical bypass or endovascular intervention. The goal of these OPGs are to set standards of care from a revascularization standpoint and to provide performance benchmarks for 1 year patency rates for new endovascular therapies. While OPGs are useful in this regard, a critical decision point in the treatment of patients with CLTI is determining when revascularization is necessary. There is little guidance in the comprehensive treatment of this patient population, especially in the nonoperative cohort. Guidelines are needed for the CLTI patient population as a whole and not just those revascularized, and our aim was to assess whether CLTI OPGs could be attained with nonoperative management alone. METHODS Our cohort included patients with an incident diagnosis of CLTI (by hemodynamic and symptomatic criteria) at our institution from 2013-2017. The primary outcome measured was mortality. Secondary outcomes were limb loss and failure of amputation-free survival. Descriptive statistics were used to define the 2 groups - patients undergoing primary revascularization and patients undergoing primary wound management. The risk difference in outcomes between the 2 groups was estimated using collaborative-targeted maximum likelihood estimation. RESULTS Our cohort included 349 incident CLTI patients; 60% male, 51% white, mean age 63 +/- 13 years, 20% Rutherford 4, and 80% Rutherford 5. Most patients (277, 79%) underwent primary revascularization, and 72 (21%) were treated with wound care alone. Demographics and presenting characteristics were similar between groups. Although the revascularized patients were more likely to have femoropopliteal disease (72% vs. 36%), both groups had a high rate of infrapopliteal disease (62% vs. 57%). Not surprisingly, the patients in the revascularization group were less likely to have congestive heart failure (34% vs. 42%), complicated diabetes (52% vs. 79%), obesity (19% vs. 33%), and end stage renal disease (14% vs. 28%). In the wound care group, 2-year outcomes were 65% survival, 51% amputation free survival, 19% major limb amputation, and 17% major adverse cardiac event. The wound care cohort had a 13% greater risk of death at 2 years; however, the risk of limb loss at 2 years was 12% less in the wound care cohort. CONCLUSIONS A comprehensive set treatment goals and expected amputation free survival outcomes can guide revascularization, but also assure that appropriate outcomes are achieved for patients treated without revascularization. The 2-year outcomes achieved in this cohort provide an estimate of outcomes for nonrevascularized CLTI patients. Although multi-center or prospective studies are needed, we demonstrate that equal, even improved, limb salvage rates are possible.
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Geraghty PJ, Conte MS. A critical appraisal of registry-based objective performance goals in peripheral arterial disease. J Vasc Surg 2021; 74:1008-1012. [PMID: 34425942 DOI: 10.1016/j.jvs.2021.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/16/2021] [Indexed: 11/25/2022]
Abstract
The multidisciplinary Superficial Femoral Artery-Popliteal EvidencE Development (SPEED) Study Group, under the auspices of the Registry Assessment of Peripheral Interventional Devices (RAPID) partnership, recently published objective performance goals for peripheral vascular interventions in the femoropopliteal arteries. Retrospective outcomes from the Vascular Quality Initiative provided the sole study data source. Strengths and weaknesses of this landmark effort are examined. Critical concerns include the substantial risks of ascertainment bias, flawed end point selection, sparse and variable capture of midterm follow-up data, and lack of expected discrimination between treatment modalities. The current Vascular Quality Initiative registry data thus appear insufficiently robust for the generation of objective performance goals and practice benchmarks; suggestions for redesign are provided. The impact of the statutory framework of the US Food and Drug Administration on device approval pathways and the maturation of an evidence-based approach to peripheral vascular intervention is explored.
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Affiliation(s)
- Patrick J Geraghty
- Department of Surgery, Section of Vascular Surgery, Washington University Medical School, St. Louis, Calif.
| | - Michael S Conte
- Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco Medical School, University of California, San Francisco, Calif
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Bertges DJ, Eldrup-Jorgensen J, Drozda J, Jones WS, Sedrakyan A, Krucoff MW, Cronenwett JL. Toward a better system for the sustainable development of objective performance goals for peripheral vascular interventions. J Vasc Surg 2021; 74:1013-1014. [PMID: 34425943 DOI: 10.1016/j.jvs.2021.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 06/01/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Daniel J Bertges
- Division of Vascular Surgery, University of Vermont Medical Center, Burlington, Vt
| | - Jens Eldrup-Jorgensen
- Division of Vascular Surgery and Endovascular Therapy, Maine Medical Center, Portland, Me
| | - Joseph Drozda
- Department of Cardiology, Mercy Health, Chesterfield, Mo
| | - W Schuyler Jones
- Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Art Sedrakyan
- Department of Population Health Sciences and Department of Cardiothoracic Surgery, Weill Cornell College of Medicine, New York, NY
| | - Mitchell W Krucoff
- Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Jack L Cronenwett
- Section of Vascular Surgery and the Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Debus ES, Nehler MR, Govsyeyev N, Bauersachs RM, Anand SS, Patel MR, Fanelli F, Capell WH, Brackin T, Hinterreiter F, Krievins D, Nault P, Piffaretti G, Svetlikov A, Jaeger N, Hess CN, Sillesen HH, Conte M, Mills J, Muehlhofer E, Haskell LP, Berkowitz SD, Hiatt WR, Bonaca MP. Effect of Rivaroxaban and Aspirin in Patients with Peripheral Artery Disease Undergoing Surgical Revascularization: Insights from the VOYAGER PAD Trial. Circulation 2021; 144:1104-1116. [PMID: 34380322 DOI: 10.1161/circulationaha.121.054835] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Patients with peripheral artery disease (PAD) requiring lower extremity revascularization (LER) are at high risk of adverse limb and cardiovascular events. VOYAGER PAD demonstrated that rivaroxaban significantly reduced this risk. The efficacy and safety of rivaroxaban has not been described in patients who underwent surgical LER. Methods: The VOYAGER PAD trial randomized patients with PAD after surgical and endovascular LER to rivaroxaban 2.5mg twice daily plus aspirin or matching placebo plus aspirin and followed for a median of 28 months. The primary endpoint was a composite of acute limb ischemia, major vascular amputation, myocardial infarction, ischemic stroke, or cardiovascular death. The principal safety outcome was Thrombolysis in Myocardial Infarction (TIMI) major bleeding. International Society on Thrombosis and Haemostasis (ISTH) bleeding was a secondary safety outcome. All efficacy and safety outcomes were adjudicated by a blinded independent committee. Results: Of the 6564 randomized, 2185 (33%) underwent surgical LER and 4379 (67%) endovascular. Compared to placebo, rivaroxaban reduced the primary endpoint consistently regardless of LER method (p-interaction 0.43). Following surgical LER, the primary efficacy outcome occurred in 199 (18.4%) patients in the rivaroxaban group and 242 (22.0%) patients in the placebo group with a cumulative incidence at 3 years of 19.7% and 23.9%, respectively (HR 0.81, 95% CI 0.67 - 0.98; p=0.026). In the overall trial, TIMI major bleeding and ISTH major bleeding were increased with rivaroxaban. There was no heterogeneity for TIMI major bleeding (p-interaction 0.17) or ISTH major bleeding (p-interaction 0.73) based on LER approach. Following surgical LER, the principal safety outcome occurred in 11 (1.0%) patients in the rivaroxaban group and 13 (1.2%) patients in the placebo group; 3-year cumulative incidence 1.3% and 1.4% respectively (HR 0.88, 95% CI 0.39-1.95; p=0.75) Among surgical patients, the composite of fatal bleeding or intracranial hemorrhage (p=0.95) and postprocedural bleeding requiring intervention (p=0.93) were not significantly increased. Conclusions: The efficacy of rivaroxaban is associated with a benefit in surgical LER patients. While bleeding was increased with rivaroxaban plus aspirin, the incidence was low, with no significant increase in fatal bleeding, intracranial hemorrhage or postprocedural bleeds requiring intervention. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT02504216.
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Affiliation(s)
- E Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery-Angiology-Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Mark R Nehler
- CPC Clinical Research, Aurora, CO; Department of Surgery, Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Nicholas Govsyeyev
- CPC Clinical Research, Aurora, CO; Department of Surgery, Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Rupert M Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt, Darmstadt, and Center for Thrombosis and Hemostasis, University of Mainz, Mainz, Germany
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Manesh R Patel
- Duke Clinical Research Institute, Division of Cardiology, Duke University, Durham, NC
| | - Fabrizio Fanelli
- Vascular and Interventional Radiology Department, Careggi University Hospital, University of Florence, Florence, Italy
| | - Warren H Capell
- CPC Clinical Research, Aurora, CO; Department of Medicine, Division of Endocrinology, University of Colorado School of Medicine, Aurora, CO
| | | | - Franz Hinterreiter
- Department for Vascular Surgery KH BHB Linz, Seilerstätte 2, 4020, Austria
| | | | - Patrice Nault
- Vascular and Endovascular Surgery, McGill University Montreal, Canada
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Alexei Svetlikov
- The I.I. Mechnikov North-Western State Medical University, Department of Cardio-Vascular surgery, St-Petersburg, Russia
| | | | - Connie N Hess
- CPC Clinical Research, Aurora, CO; Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO
| | - Henrik H Sillesen
- Department of Vascular Surgery, Rigshospitalet, Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Michael Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Joseph Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX
| | | | | | - Scott D Berkowitz
- Thrombosis Group Head, Clinical Development, Bayer U.S., Whippany, NJ
| | - William R Hiatt
- CPC Clinical Research, Aurora, CO; Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO; Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO
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Use of drug-eluting stents in patients with critical limb ischemia and infrapopliteal arterial disease: a real-world single-center experience. J Vasc Surg 2021; 74:1619-1625. [PMID: 34182023 DOI: 10.1016/j.jvs.2021.06.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/16/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Although no drug-eluting stent (DES) has been approved by the Food and Drug Administration to treat infrapopliteal arterial disease, several industry-sponsored trials have reported the outcomes with the use of paclitaxel or sirolimus DESs. To the best of our knowledge, only one study to date has reported on the use of everolimus DESs for infrapopliteal arterial disease. In the present study, we analyzed the clinical outcomes with everolimus DESs in our real-world, single-center experience. METHODS A total of 107 limbs with critical limb threatening ischemia (98 patients; 118 lesions) treated with DESs (Xience; Abbott Vascular, Santa Clara, Calif) were analyzed. The postoperative early outcomes, major adverse limb events (above the ankle limb amputation or major intervention at 1 year), and major adverse events (death, amputation, target lesion thrombosis or reintervention) were analyzed. Kaplan-Meier analysis was used to estimate the primary patency rates (using duplex ultrasound), amputation-free rates, and amputation-free survival rates. RESULTS Of the 118 lesions treated, 33% were in the anterior tibial artery, 28% were in the tibioperoneal (TP) artery, 21% were in the posterior tibial artery, 8% were in the peroneal artery, 5% were in the TP/posterior tibial artery, 4% were in the TP artery/PA, and 1% were in the TP/anterior tibial artery. The mean lesion length was 41 mm, and 59% were totally occluded (41% stenotic). The mean follow-up was 18.5 months (range, 1-70 months). The overall postoperative complication rate was 11% (2% major amputations), with 2% mortality. Late symptom improvement of one or more Rutherford category was obtained in 71%. The major adverse events rate at 30 days and 1 year was 12% and 45%, respectively. The major adverse limb events rate at 1 year was 15%. The overall primary patency rate was 42%. The primary patency rate at 1, 2, and 3 years was 57%, 45%, and 33%, respectively. The major amputation-free and overall amputation-free survival rates were 87%, 80%, and 77% and 76%, 65%, and 61% at 1, 2, and 3 years, respectively. CONCLUSIONS The clinical outcomes after DES (Xience; Abbott Vascular) for infrapopliteal lesions were somewhat satisfactory at 1 year but inferior to the previously reported outcomes, especially at 3 years. Further data with long-term follow-up are needed.
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Hata Y, Iida O, Takahara M, Asai M, Masuda M, Okamoto S, Ishihara T, Nanto K, Kanda T, Tsujumura T, Matsuda Y, Yanaka K, Mano T. Saphenous vein size as a surrogate marker for mortality of patients with chronic limb-threatening ischemia undergoing endovascular therapy. J Cardiol 2021; 78:341-346. [PMID: 34039466 DOI: 10.1016/j.jjcc.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The size of the autologous vein graft is an important determinant of prognosis in patients with chronic limb-threatening ischemia (CLTI) undergoing bypass surgery. However, it is unclear whether reconstruction using a small vein graft would directly affect prognosis, or a subgroup having small veins would be subject to a poor prognosis. If the latter is true, having small veins would work as a marker for a poor prognosis even in patients with CLTI undergoing endovascular therapy (EVT). Therefore, we investigated the association between the size of saphenous veins and prognosis in patients with CLTI undergoing EVT. METHODS This study included 209 consecutive patients with CLTI who primarily underwent EVT between January 2017 and December 2018. The diameter of the saphenous vein was measured at three locations (saphenous-femoral junction, knee, and ankle joint) per limb before EVT by ultrasonography. A small saphenous vein was defined as the mean diameter <3.0 mm. RESULTS All-cause mortality rate was significantly higher in patients with a small saphenous vein than in those with non-small one (46.3% versus 10.7% at 2 years, p<0.001). The multivariate Cox regression analysis revealed that a small saphenous vein was independently associated with an increased risk of all-cause mortality. CONCLUSIONS Having a small saphenous vein was an independent marker for all-cause mortality in patients with CLTI undergoing EVT.
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Affiliation(s)
- Yosuke Hata
- Kansai Rosai Hospital Cardiovascular Center, Inabaso, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan.
| | - Osamu Iida
- Kansai Rosai Hospital Cardiovascular Center, Inabaso, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Mitsutoshi Asai
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masaharu Masuda
- Kansai Rosai Hospital Cardiovascular Center, Inabaso, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Shin Okamoto
- Kansai Rosai Hospital Cardiovascular Center, Inabaso, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Takayuki Ishihara
- Kansai Rosai Hospital Cardiovascular Center, Inabaso, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Kiyonori Nanto
- Kansai Rosai Hospital Cardiovascular Center, Inabaso, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Takashi Kanda
- Kansai Rosai Hospital Cardiovascular Center, Inabaso, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Takuya Tsujumura
- Kansai Rosai Hospital Cardiovascular Center, Inabaso, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Yasuhiro Matsuda
- Kansai Rosai Hospital Cardiovascular Center, Inabaso, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Koji Yanaka
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Toshiaki Mano
- Kansai Rosai Hospital Cardiovascular Center, Inabaso, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
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Clinical Impact of Stent Graft Thrombosis in Femoropopliteal Arterial Lesions. JACC Cardiovasc Interv 2021; 14:1137-1147. [PMID: 34016412 DOI: 10.1016/j.jcin.2021.03.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 02/26/2021] [Accepted: 03/16/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVES This study sought to elucidate the clinical impact and prognosis of stent graft (SG) thrombosis. BACKGROUND The VIABAHN SG offers a favorable outcome in long peripheral artery occlusive disease (PAOD) lesions in the femoropopliteal artery. One concern after SG deployment is the incidence of stent thrombosis and consequent acute limb ischemia (ALI). METHODS In this retrospective multicenter study, we collected the clinical data of PAOD patients treated with VIABAHN SG who subsequently experienced SG thrombosis. The clinical symptoms of SG thrombosis, patency after reintervention, and predictors of loss of patency after reintervention were examined. RESULTS VIABAHN SGs were used for 1,215 patients; SG thrombosis occurred in 159 (13%) patients at a median of 6.4 months (interquartile range: 2.8 to 13.5 months) after SG implantation; 21 (13%) patients presented with ALI. A total of 131 (82%) patients underwent reintervention for SG thrombosis, whereas 2 (1%) underwent primary major amputation and the remaining 26 (16%) were treated conservatively. The patency rate 1 year after reintervention, freedom from major adverse limb events, and limb salvage after reintervention were 54.9%, 73.6%, and 92.5%, respectively. Critical limb-threatening ischemia at SG implantation and ALI presentation at SG thrombosis were positively associated with an increased risk of rethrombosis, whereas distal stent diameter was negatively associated with the risk of rethrombosis. CONCLUSIONS SG thrombosis is associated with a considerable risk of ALI, but the risk of primary major amputation was not high. Clinical outcomes after reinterventions for thrombosed SGs were suboptimal.
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Zaghloul MS, Andraska EA, Leake A, Chaer R, Avgerinos ED, Hager ES, Makaroun MS, Eslami MH. Poor runoff and distal coverage below the knee are associated with poor long-term outcomes following endovascular popliteal aneurysm repair. J Vasc Surg 2021; 74:153-160. [PMID: 33347999 DOI: 10.1016/j.jvs.2020.12.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/05/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Reports of good short-term outcomes for endovascular repair of popliteal artery aneurysms have led to an increased use of the technique. However, data are lacking on long-term limb-related outcomes and factors associated with the failure of endovascular repair. METHODS All patients who underwent endovascular popliteal aneurysm repair (EPAR) at a single institution from January 2006 to December 2018 were included in the study. Demographics, indications, anatomic and operative details, and outcomes were reviewed. Long-term patency, major adverse limb event-free survival (MALE-FS) and graft loss/occlusion were analyzed with multivariable cox regression analysis and Kaplan-Meier curves. RESULTS We included 117 limbs from 101 patients with a mean follow-up of 55.6 months (range, 0.43-158 months). The average age was 73 ± 9.3 years. Thirty-two patients (29.1%) were symptomatic (claudication, rest pain, tissue loss, or rupture). The stent grafts crossed the knee joint in 91.4% of cases. In all, 36.8% of procedures used one stent graft, 41.0% used two stent grafts, and 22.2% of procedures used more than two stent grafts. The median arterial length covered was 100 mm, with an average length of stent overlap of 25 mm. Tapered configurations were used in 43.8% of cases. The majority of limbs (62.8%) had a three-vessel runoff, 20.2% had a two-vessel runoff, and 17% has a one-vessel runoff. The Kaplan-Meier estimates of graft occlusion at 1 and 3 years were 6.3% and 16.2%, respectively. The 1- and 3-year primary patency rates were 88.2% and 72.6%, and the 1- and 3-year major adverse limb event-free survival (MALE-FS) rates were 82% and 57.4%. The 1- and 3-year survival rates were 92.9% and 76.2%, respectively. On multivariable Cox regression, aneurysm size, one-vessel runoff, and coverage below the knee were associated with a lower 3-year MALE-FS. Coverage below the knee was also associated with a lower 3-year MALE-FS. Other anatomic or technical details were not associated with limb-related events or patency. CONCLUSIONS This study is the largest single center analysis to describe the predictors of poor outcomes after EPAR. EPAR is a safe and effective way to treat popliteal artery aneurysms. Factors associated with poor MALE-FS after EPAR include single-vessel tibial runoff and coverage below the knee.
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Affiliation(s)
- Mohamed S Zaghloul
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pa
| | - Elizabeth A Andraska
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pa
| | - Andrew Leake
- Vascular Surgery Associates of Richmond, PC, Richmond, Va
| | - Rabih Chaer
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pa
| | - Efthymios D Avgerinos
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pa
| | - Eric S Hager
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pa
| | - Michel S Makaroun
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pa
| | - Mohammad H Eslami
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pa.
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Moussa Pacha H, Mir T, Al-Khadra Y, Sattar Y, Ullah W, Zaher N, Ahmad B, M Suleiman AR, Darmoch F, Soud M, Faraz H, Hakim Z, Alraies MC. Trends and causes of readmission following peripheral vascular intervention in patients with peripheral vascular disease. Catheter Cardiovasc Interv 2021; 98:540-548. [PMID: 33860990 DOI: 10.1002/ccd.29698] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/01/2021] [Accepted: 03/19/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To study the risk factors associated with 30-readmission postperipheral vascular intervention (PVI) in peripheral artery disease (PAD). BACKGROUND There has been a paucity of data regarding the trend and predictors of PVI readmission. METHODS We performed an observational cohort study of patients admitted with peripheral vascular disease for PVI using the NRD for the years 2010-2014. PVI was defined as angioplasty, atherectomy, and/or stenting of lower limb vessels. RESULTS A total of 453,278 patients (30-day readmission n = 97,235). The mean age of study population was 68.6 ± 12.2 years and included 43.8% women. The 30-day readmission post-PVI was 21.5% (p = .034). Cardiovascular causes constitute 44% of readmission. Chronic limb ischemia and intermittent claudication were two most common cardiovascular causes constituting 11.7 and 4.9% cases of readmissions. Other cardiac causes of readmissions included heart failure (4.64%), dysrhythmias (1.4%), and acute myocardial infarction (1.7%). The high-risk factors for of all-cause 30-day readmission were hypertension, CLI, diabetes, renal failure, dyslipidemia, smoking, chronic pulmonary disease, and atrial fibrillation (p < .005). Length-of-stay was greater than 5 days for 56.2 and 75.4% paid by Medicare. CONCLUSIONS Our study shows an average yearly readmission rate of 21.5% post-PVI. Chronic comorbidities and prolonged hospitalization were associated with higher risk of readmission.
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Affiliation(s)
- Homam Moussa Pacha
- McGovern Medical School, Memorial Hermann Heart & Vascular Institute, University of Texas Health Science Center, Houston, Texas, USA
| | - Tanveer Mir
- Detroit Medical Center, Wayne State University, Detroit, Michigan, USA
| | | | - Yasar Sattar
- Icahn School of Medicine, Mount Sinai-Elmhurst Hospital Queens, New York, New York, USA
| | - Waqas Ullah
- Abington Jefferson Health, Abington, Pennsylvania, USA
| | - Nathan Zaher
- Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | - Bachar Ahmad
- Detroit Medical Center, Wayne State University, Detroit, Michigan, USA
| | | | - Fahed Darmoch
- Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
| | | | - Haroon Faraz
- Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Zaher Hakim
- Detroit Medical Center, Wayne State University, Detroit, Michigan, USA
| | - M Chadi Alraies
- Detroit Medical Center, Wayne State University, Detroit, Michigan, USA
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Alrohimi A, Jickling G, Jeerakathil T, Shuaib A, Khan K, Kate M, Hill MD, Buck B, Butcher K. Protocol for LASER: A Randomized Evaluation and an Associated Registry of Early Anticoagulation With Edoxaban After Ischemic Stroke in Patients With Atrial Fibrillation. Front Neurol 2021; 12:645822. [PMID: 33868150 PMCID: PMC8044522 DOI: 10.3389/fneur.2021.645822] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 03/08/2021] [Indexed: 01/01/2023] Open
Abstract
Background: The optimal timing of anticoagulation after stroke in patients with atrial fibrillation (AF) is unknown. Aim and Hypothesis: Our primary aim is to demonstrate the safety of edoxaban initiation within 5 days of AF related stroke. Our secondary aim is to determine predictors of hemorrhagic transformation (HT) after AF related stroke. We hypothesize that the rate of radiological HT will not be increased in patients starting edoxaban within 5 days of AF related stroke, relative to those in whom initiation is delayed. We hypothesize that the risk of HT in patients treated with edoxaban can be predicted using RNA expressed in leukocytes at time of stroke. Methods and Design: LASER (Lixiana Acute Stroke Evaluation Registry) is a randomized controlled trial with an associated registry (clinicaltrials.gov NCT03494530). One hundred and fifty patients with ischemic stroke and AF will undergo baseline Computed Tomography (CT) scan and will be randomized 2:1 within 5 days of symptom onset to early (≤5 days, n = 100) or delayed (6–14 days, n = 50) edoxaban initiation. Participants will undergo clinical assessment and repeat CT at 7 days and clinical assessment at 90 days. Study Outcomes: The primary outcome is the rate of incident radiological HT. Secondary outcomes include symptomatic HT, recurrent ischemic stroke, recurrent sub-clinical infarcts on follow up CT, systemic hemorrhagic complication rate, National Institute of Health Stroke Scale and modified Rankin Scale at day 7 and 90, mortality within 90 days, quality of life assessments at day 90, and predictors of HT, including RNA expression by 6 pre-selected candidate genes. Discussion: Event rates for both HT and recurrent ischemic events, in patients treated with early vs. delayed edoxaban initiation are unknown. The primary study endpoint of LASER is an objective performance criterion relevant to clinical decision making in patients with AF related stroke. This study will provide data required for a definitive safety/efficacy study sample size power calculation.
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Affiliation(s)
- Anas Alrohimi
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Glen Jickling
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | | | - Ashfaq Shuaib
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Khurshid Khan
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Mahesh Kate
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Michael D Hill
- Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Brian Buck
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ken Butcher
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
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Kim C, Yang YS, Ryu GW, Choi M. Risk factors associated with amputation-free survival for patients with peripheral arterial disease: a systematic review. Eur J Cardiovasc Nurs 2021; 20:295-304. [PMID: 33786599 DOI: 10.1093/eurjcn/zvaa022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/01/2020] [Accepted: 11/09/2020] [Indexed: 12/24/2022]
Abstract
AIMS Peripheral arterial disease (PAD) is associated with morbidity and mortality, comprising a significant percentage of amputations. As it affects the quality of life of patients with PAD, it is an important health issue. Therefore, the risk factors affecting the outcomes of limb salvage after revascularization should be well investigated. The aim of this review is to summarize risk factors of amputation-free survival (AFS) after interventions targeting patients with PAD to develop evidence-based intervention for improving patient outcomes. METHODS AND RESULTS A systematic review following PRISMA guidelines was conducted, and the protocol was registered on PROSPERO (CRD42020183076). PubMed, CINAHL, EMBASE, Cochrane Library, and Web of Science were searched for observational studies published between 2008 and 2019. Search terms included 'peripheral arterial disease', 'risk factors', and 'amputation-free survival'. The quality of the studies was evaluated using the Joanna Briggs Institute's Critical Appraisal Tools. Seventeen cohort studies were included in our study, and 16 risk factors were identified. Risk factors exemplifying a significant influence on decreased AFS were divided into three categories: sociodemographic (e.g. older age, male gender, African-American race, low body mass index, high nutritional risk, frailty), disease-related characteristics (e.g. severity of the disease, intervention site), and comorbidities (e.g. cardiovascular disease, kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, dementia, wide pulse pressure). CONCLUSION We found that managing modifiable risk factors, as well as addressing high-risk populations, has the potential to improve outcomes of PAD interventions. More high-quality cohort studies are needed to confirm these findings.
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Affiliation(s)
- Changhwan Kim
- Department of Critical Care Nursing, Samsung Medical Center, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
| | - Yong Sook Yang
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1 Yonsei-ro, College of Nursing Yonsei University, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Gi Wook Ryu
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1 Yonsei-ro, College of Nursing Yonsei University, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Mona Choi
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1 Yonsei-ro, College of Nursing Yonsei University, Seodaemun-gu, Seoul 03722, Republic of Korea.,Yonsei Evidence Based Nursing Centre of Korea, JBI Centre of Excellence, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
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83
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Adami D, Marconi M, Piaggesi A, Mocellin DM, Berchiolli RN, Ferrari M. Bifurcated bypass in severe chronic limb threatening ischaemia. Vascular 2021; 30:63-71. [PMID: 33691547 DOI: 10.1177/1708538121999856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Revascularization according to the angiosome concept is of proven importance for limb salvage in chronic limb threatening ischaemia but it is not always practicable. Bifurcated bypasses could be considered as an option when an endovascular approach is not feasible or has already failed and a single bypass would not allow direct revascularization of the ischaemic area. Bifurcated bypasses are characterized by landing on two different arteries, the main artery (in direct continuity with the foot vessels) and the secondary one (perfusing the angiosome district). The aim of this study is to evaluate the safety and effectiveness of bifurcated bypass in chronic limb threatening ischaemia. METHODS Thirty-five patients were consecutively treated with a bifurcated bypass for chronic limb threatening ischaemia from January 2014 to December 2019 in a single vascular surgery centre. Data from clinical records and operative registers were collected prospectively in an electronic database and retrospectively analysed. Primary and primary assisted bypass patency, amputation-free survival, morbidity and mortality rates at 12 and 24 months were analysed. RESULTS Mean follow-up period was 25.1 months (range 2-72 months). Thirty-six bifurcated bypasses were performed on 35 patients (age 75.3 ± 7.2 years; 69.4% were male). According to Wound, Ischemia, foot Infection classification 22.2% belonged to stage 3 and 77.8% to stage 4 and the mean Rutherford's class was 5.1 ± 0.7. Immediate technical success was 100%. Early mortality and morbidity rates were respectively 5.5%, and 33.3%; foot surgery was performed in 50% of cases with wound healing in all patients. Primary patency and primary assisted bypass patency were 96.7% and 100% at 6 months; 85.2% and 92% at 12 months, 59.9% and 73.4% at 24 months, respectively. Amputation-free survival at 12 and 24 months was, respectively, 95.6% and 78.8%. Overall survival rates at 12 and 24 months were respectively 94.4% and 91.6%. CONCLUSIONS Bifurcates bypass can provide good results in patients with chronic limb threatening ischaemia without endovascular option, especially in diabetic ones. Bifurcated bypass is a complex surgical solution, both to be planned and performed, and it is quite invasive for frail patients that should be accurately selected.
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Affiliation(s)
- Daniele Adami
- Vascular Surgery Unit, Cardio Thoracic and Vascular Department, Pisa University Hospital, Pisa, Italy
| | - Michele Marconi
- Vascular Surgery Unit, Cardio Thoracic and Vascular Department, Pisa University Hospital, Pisa, Italy
| | - Alberto Piaggesi
- Diabetic Foot Section, Endocrinology and Metabolism Department, Pisa University Hospital, Pisa, Italy
| | - Davide M Mocellin
- Vascular Surgery Unit, Cardio Thoracic and Vascular Department, Pisa University Hospital, Pisa, Italy
| | - Raffaella N Berchiolli
- Vascular Surgery Unit, Cardio Thoracic and Vascular Department, Pisa University Hospital, Pisa, Italy
| | - Mauro Ferrari
- Vascular Surgery Unit, Cardio Thoracic and Vascular Department, Pisa University Hospital, Pisa, Italy
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84
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Chua K, Lim FP, Lee VKM, Phan TT, Tai BC, Tan YK. Cord Lining Mesenchymal Stem Cells Have a Modest Positive Effect on Angiogenesis in Hindlimb Ischemia. Front Cell Dev Biol 2021; 8:596170. [PMID: 33763413 PMCID: PMC7982459 DOI: 10.3389/fcell.2020.596170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/21/2020] [Indexed: 01/01/2023] Open
Abstract
Purpose: We investigated the use of human Cord Lining Mesenchymal Stem Cells (CL-MSCs) (US Patent number 9,737,568), in a rabbit hindlimb ischemia model, and evaluated their potential in stimulating neovascularization. Allogenic human CL- MSCs could potentially be used to treat patients with lower limb ischemia and non-healing wounds. Methods: Twenty rabbits were divided into two separate groups. We created a hindlimb ischemia model surgically. At 21 and 49 days post-operatively, animals in the treatment group were injected with CL-MSCs (500,000 cells per 0.2 ml on each site) at 10 different sites (Quadriceps- 4 sites, Hamstrings- 4 sites and Calf--2 sites) in the hindlimb muscles. The control group received only saline injection to the corresponding sites at the same time point as the treatment group. We then evaluated the effects of treatment on neovascularization by angiography, laser doppler perfusion imaging, as well as by histology. We evaluated the tissue samples for any signs of local immune reaction to the cell implantation. We also observed the rabbit clinically for any adverse effects after treatment. Results: We found a higher number of CD31 positive cells in the treatment group, with a greater number of capillaries found in the treated muscles. The Rectus Femoris demonstrated a median vessel count/muscle fiber of 0.121 for the treatment group, compared to 0.076 in the control group (median difference 0.04; 95% CI 0.001-0.11; p = 0.041). The Gastrocnemius demonstrated a median vessel count/muscle fiber of 0.175 for the treatment group, compared to 0.089 in the control group (median difference 0.087; 95% CI -0.006 to 0.234; p = 0.07). Blood perfusion quantification through Laser Doppler Perfusion Imaging (LDPI) also demonstrated a non-statistically significant increase in perfusion in favor of the treatment group. CL-MSCs demonstrated no toxicity associated morbidity and minimal local immune reaction to implantation. Conclusion: CL-MSCs have a positive effect on angiogenesis in a rabbit hindlimb ischemia model. This preliminary data is encouraging and paves the way for future large animal studies or for clinical trials.
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Affiliation(s)
- Kenon Chua
- Programme in Cancer and Stem Cell Biology, Duke-NUS Medical School, Singapore, Singapore
| | - Fui Ping Lim
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore, Singapore
| | - Victor Kwan Min Lee
- Department of Pathology, National University Hospital, Singapore, Singapore.,National University Cancer Institute, Singapore, Singapore.,Department of Pathology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Toan Thang Phan
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bee Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Yih Kai Tan
- Novena Vascular and Varicose Vein Centre, Mount Elizabeth Novena Specialist Centre, Singapore, Singapore.,Department of Surgery (Vascular), Changi General Hospital, Singapore, Singapore
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85
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Miyata T, Mii S, Kumamaru H, Takahashi A, Miyata H. Risk prediction model for early outcomes of revascularization for chronic limb-threatening ischaemia. Br J Surg 2021; 108:941-950. [PMID: 33693591 DOI: 10.1093/bjs/znab036] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/15/2020] [Accepted: 01/17/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Quantifying the risks and benefits of revascularization for chronic limb-threatening ischaemia (CLTI) is important. The aim of this study was to create a risk prediction model for treatment outcomes 30 days after revascularization in patients with CLTI. METHODS Consecutive patients with CLTI who had undergone revascularization between 2013 and 2016 were collected from the JAPAN Critical Limb Ischemia Database (JCLIMB). The cohort was divided into a development and a validation cohort. In the development cohort, multivariable risk models were constructed to predict major amputation and/or death and major adverse limb events using least absolute shrinkage and selection operator logistic regression. This developed model was applied to the validation cohort and its performance was evaluated using c-statistic and calibration plots. RESULTS Some 2906 patients were included in the analysis. The major amputation and/or mortality rate within 30 days of arterial reconstruction was 5.0 per cent (144 of 2906), and strong predictors were abnormal white blood cell count, emergency procedure, congestive heart failure, body temperature of 38°C or above, and hemodialysis. Conversely, moderate, low or no risk in the Geriatric Nutritional Risk Index (GNRI) and ambulatory status were associated with improved results. The c-statistic value was 0.82 with high prediction accuracy. The rate of major adverse limb events was 6.4 per cent (185 of 2906), and strong predictors were abnormal white blood cell count and body temperature of 38°C or above. Moderate, low or no risk in the GNRI, and age greater than 84 years were associated with improved results. The c-statistic value was 0.79, with high prediction accuracy. CONCLUSION This risk prediction model can help in deciding on the treatment strategy in patients with CLTI and serve as an index for evaluating the quality of each medical facility.
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Affiliation(s)
- T Miyata
- Office of Medical Education, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - S Mii
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Fukuoka, Japan
| | - H Kumamaru
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - A Takahashi
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - H Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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86
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Latz CA, Boitano L, Wang LJ, Pendleton AA, DeCarlo C, Sumpio B, Schwartz S, Srivastava S, Dua A. Contemporary Endovascular 30-Day Outcomes for Critical Limb Threatening Ischemia Relative to Surgical Bypass Grafting. Vasc Endovascular Surg 2021; 55:441-447. [PMID: 33602047 DOI: 10.1177/1538574421989516] [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: 11/15/2022]
Abstract
OBJECTIVES Data from 2011-2014 showed lower extremity bypass(LEB) outperforming infrainguinal endovascular intervention(IEI) regarding major adverse limb events(MALE) but noted no significant difference in major adverse cardiac events(MACE) in propensity matched cohorts. This study aimed to determine if more recent(2015-2018) endovascular outcomes data have improved relative to surgical bypass. METHODS Patients who underwent intervention for chronic limb threatening ischemia (CLTI) from 2015-2018 were identified using the American College of Surgeons National Quality Improvement Program(NSQIP) Vascular Surgery module. The cohort was categorized as undergoing lower extremity bypass(LEB) or infrainguinal endovascular intervention(IEI). Primary 30-day outcomes included major adverse cardiac events(MACE), major adverse limb events(MALE), and major amputation. Inverse probability weighting was used for multivariable analysis. RESULTS A total of 10,783 patients underwent an infrainguinal intervention for CLTI from 2015-2018. Of these, 6,003(55.7%) underwent LEB and 4,780(44.3%) underwent IEI. Forty percent of the cohort was considered "high anatomic risk" by Objective Performance Goals(OPG) standards, and 13.6% were considered "high clinical risk." The IEI cohort vs. the LEB cohort experienced a Myocardial infarction(MI)/Stroke rate of 1.8% vs. 3.6%(p < .001), and had a mortality rate of 2.0% vs. 1.7%(p = .22), which yielded a composite MACE of 3.4% vs. 4.8%(p = .001). The rate of reintervention for IEI vs LEB was 4.4% vs. 5.3%(p = .04), the loss of patency (without re-intervention) rate was 1.8% vs. 1.8%(p = 1.0), and the major amputation rate was 4.1% vs. 3.5%(p = .15), which resulted in a MALE rate of 9.1% vs. 8.8%(p = .50). Following inverse probability weighting, comparing the IEI to the referent LEB, MALE AOR = 1.17, 95% CI[1.01 -1.36], p = .036, MACE AOR = 0.61, 95% CI[0.49-0.74], p < .001, and major amputation AOR = 1.31, 95% CI[1.05 -1.62], p = .016. CONCLUSION Endovascular outcomes continue to demonstrate inferiority in major amputation and overall MALE. However, endovascular intervention has a significantly reduced incidence of MACE. Overall, these results demonstrate an improvement in endovascular MACE rates in recent years relative to surgical bypass.
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Affiliation(s)
- Christopher Alan Latz
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Laura Boitano
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Linda J Wang
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Anna A Pendleton
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Brandon Sumpio
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Samuel Schwartz
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Sunita Srivastava
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
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El Khoury R, Wu B, Edwards CT, Lancaster EM, Hiramoto JS, Vartanian SM, Schneider PA, Conte MS. The Global Limb Anatomic Staging System is associated with outcomes of infrainguinal revascularization in chronic limb threatening ischemia. J Vasc Surg 2021; 73:2009-2020.e4. [PMID: 33548444 DOI: 10.1016/j.jvs.2020.12.094] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/29/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The Global Limb Anatomic Staging System (GLASS) has been proposed to facilitate clinical decision-making regarding revascularization for chronic limb threatening ischemia (CLTI). The purpose of the present study was to define its relationship to the treatment outcomes in CLTI. METHODS Consecutive patients who had undergone peripheral angiography for rest pain or tissue loss from January 2017 to July 2019 at a tertiary referral center with a dedicated limb preservation program were reviewed. Subjects with significant aortoiliac disease, previous infrainguinal stenting or functioning bypass grafts, or GLASS stage 0 were excluded. The GLASS score was assigned from the preintervention angiography findings, and the treating surgeon determined the primary infrapopliteal target artery pathway for the limb at risk. The demographic data, procedural details, and clinical outcomes were analyzed. RESULTS The study cohort included 167 patients and 194 limbs, of which 175 of 194 limbs (90%) had presented with tissue loss and 149 of 182 limbs (83%) with WIfI (Wound, Ischemia and foot Infection) stage 3 or 4. The GLASS stage was GLASS 1 in 14%, GLASS 2 in 18%, and GLASS 3 in 68%. GLASS 3 anatomy was present in 85% of 52 limbs treated by bypass and 55% of 108 limbs treated by endovascular intervention (EVI; P < .001). Revascularization was not performed in 34 limbs, most of which were GLASS 3 (85%). Immediate technical failure for EVI (ie, failure to establish target artery pathway) occurred exclusively in the setting of GLASS 3 anatomy (n = 13; 22%). After a median follow-up of 10 months, limb-based patency after EVI was significantly lower in GLASS 3 than in GLASS 1 or 2 limbs (42% vs 59%; P = .018). GLASS 3 was associated with reduced major adverse limb events-free survival in both the EVI group (P = .002) and the overall revascularized cohort (P = .001). GLASS 3 was also associated with significantly reduced overall survival, amputation-free survival, and reintervention-free survival. In a Cox proportional hazards model, GLASS 3 (hazard ratio, 2.35; 95% confidence interval, 1.30-4.24; P = .005) and WIfI wound grade 3 (hazard ratio, 2.64; 95% confidence interval, 1.26-5.53; P = .010) were independent predictors of reduced major adverse limb events-free survival after revascularization. CONCLUSIONS GLASS stage 3 was strongly associated with major adverse clinical outcomes after revascularization in patients with CLTI.
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Affiliation(s)
- Rym El Khoury
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Bian Wu
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Ceazon T Edwards
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Elizabeth M Lancaster
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Jade S Hiramoto
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Shant M Vartanian
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Peter A Schneider
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif
| | - Michael S Conte
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, Calif.
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88
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Alrohimi A, Buck B, Jickling G, Shuaib A, Thirunavukkarasu S, Butcher KS. Early apixaban therapy after ischemic stroke in patients with atrial fibrillation. J Neurol 2021; 268:1837-1846. [PMID: 33392636 DOI: 10.1007/s00415-020-10335-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/16/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The optimal timing of anticoagulation after stroke in patients with atrial fibrillation (AF) is unknown. We aimed to objectively assess the rate of radiological hemorrhagic transformation (HT) associated with early anticoagulation. PATIENTS AND METHODS A prospective, open label study (NCT04435418) of patients with AF treated with apixaban within 14 days of ischemic stroke/TIA onset was conducted. Baseline and follow-up CT scans were assessed for HT and graded using European Cooperative Acute Stroke Study (ECASS) criteria. The primary endpoint was symptomatic HT. Incident HT rates were assessed as Objective Performance Criteria. RESULTS One-hundred AF stroke patients, with a mean age of 79 ± 11 years were enrolled. Median infarct volume was 4 (0.5-10.75) ml. Median time from index event onset to apixaban initiation was 2 (1-6) days, and median baseline NIHSS was 4 (1-9). Asymptomatic HT on baseline imaging was present in 15 patients. Infarct volume (OR = 1.1, [1.02-1.12], p < 0.0001) and NIHSS (OR = 1.11, [1.03-1.20], p = 0.007) were both associated with baseline HT. No patients developed symptomatic HT or systemic hemorrhage. Incident asymptomatic HT was seen on follow-up CT scan in 3 patients. Patients with incident HT were functionally independent (mRS = 0-2) at 90 days. Recurrent ischemic events occurred within 90 days in 13 patients, 4 of which were associated with severe disability (mRS 3-5) and 4 with death. DISCUSSION Early apixaban treatment did not precipitate symptomatic HT after stroke. All HT was asymptomatic identified on imaging. Recurrent ischemic events were common and clinically symptomatic. CONCLUSIONS Symptomatic HT rates are likely to be low in randomized trials of DOAC initiation post-stroke. Recurrent ischemic stroke may be the major clinical outcome. These data may be used as expected event rates when calculating sample size requirements for future safety/efficacy trials of early versus late DOAC initiation after AF-related stroke.
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Affiliation(s)
- Anas Alrohimi
- University of Alberta, Medicine, Edmonton, Canada
- King Saud University, Medicine, Riyadh, Saudi Arabia
| | - Brian Buck
- University of Alberta, Medicine, Edmonton, Canada
| | | | | | | | - Ken S Butcher
- University of Alberta, Medicine, Edmonton, Canada.
- Prince of Wales Clinical School, University of New South Wales, Level 1, South Wing, Edmund Blacket Building, Sydney, Australia.
- Prince of Wales Hospital, Randwick, NSW, 2031, Australia.
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89
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Iida O, Takahara M, Soga Y, Kodama A, Terashi H, Azuma N. The Association of Preoperative Characteristics with Reintervention Risk in Patients Undergoing Revascularization for Chronic Limb-Threatening Ischemia. J Atheroscler Thromb 2021; 28:52-65. [PMID: 32224557 PMCID: PMC7875141 DOI: 10.5551/jat.54866] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 02/27/2020] [Indexed: 12/24/2022] Open
Abstract
AIM To investigate the associations between preoperative characteristics and the risk of reintervention in patients undergoing revascularization for chronic limb-threatening ischemia (CLTI) in a contemporary real-world setting. METHODS We retrospectively analyzed data from a clinical database formed by the Surgical Reconstruction Versus Peripheral Intervention in Patients With Critical Limb Ischemia (SPINACH) study, which was a multicenter, prospective, observational study. The study population was composed of 520 CLTI patients with the wound, ischemia, and foot infection (WIfI) classes I-3 with resting pain or classes I-2/3 with ulcers/gangrene. Of the 520 patients, 192 had surgical reconstruction planned, whereas 328 had endovascular therapy (EVT) alone planned at the time of registration. The current analysis was conducted to explore the associations between preoperative characteristics and the risk of reintervention. RESULTS A total of 452 participants (87%) completed the 3-year follow-up regarding reintervention. The competing risk analysis estimated that the three-year cumulative incidence rates for reintervention and reintervention-free deaths were 44.0% and 28.7%, respectively. No preoperative characteristics had a significant interaction effect with EVT versus surgical reconstruction. The risk analysis identified the following independent risk factors for reintervention: 1) EVT instead of bypass reconstruction, 2) renal dysfunction, 3) history of revascularization after CLTI onset (i.e., requirement of redo revascularization for CLTI), and 4) bilateral CLTI. Patients with more than one of these risk factors had an increased risk of reintervention. CONCLUSIONS The current study identified preoperative characteristics associated with an increased risk of reintervention. No preoperative characteristics had any significant interactions with EVT or surgical reconstruction.
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Affiliation(s)
- Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine and Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University School of Medicine, Nagoya, Japan
| | - Hiroto Terashi
- Kobe University Graduate School of Medicine, Department of Plastic Surgery, Kobe, Japan
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Japan
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90
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Iida O, Takahara M, Soga Y, Kodama A, Terashi H, Azuma N. The Association of Preoperative Characteristics with Reintervention Risk in Patients Undergoing Revascularization for Chronic Limb-Threatening Ischemia. J Atheroscler Thromb 2021. [PMID: 32224557 DOI: 10.5551/jat.54866.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
AIM To investigate the associations between preoperative characteristics and the risk of reintervention in patients undergoing revascularization for chronic limb-threatening ischemia (CLTI) in a contemporary real-world setting. METHODS We retrospectively analyzed data from a clinical database formed by the Surgical Reconstruction Versus Peripheral Intervention in Patients With Critical Limb Ischemia (SPINACH) study, which was a multicenter, prospective, observational study. The study population was composed of 520 CLTI patients with the wound, ischemia, and foot infection (WIfI) classes I-3 with resting pain or classes I-2/3 with ulcers/gangrene. Of the 520 patients, 192 had surgical reconstruction planned, whereas 328 had endovascular therapy (EVT) alone planned at the time of registration. The current analysis was conducted to explore the associations between preoperative characteristics and the risk of reintervention. RESULTS A total of 452 participants (87%) completed the 3-year follow-up regarding reintervention. The competing risk analysis estimated that the three-year cumulative incidence rates for reintervention and reintervention-free deaths were 44.0% and 28.7%, respectively. No preoperative characteristics had a significant interaction effect with EVT versus surgical reconstruction. The risk analysis identified the following independent risk factors for reintervention: 1) EVT instead of bypass reconstruction, 2) renal dysfunction, 3) history of revascularization after CLTI onset (i.e., requirement of redo revascularization for CLTI), and 4) bilateral CLTI. Patients with more than one of these risk factors had an increased risk of reintervention. CONCLUSIONS The current study identified preoperative characteristics associated with an increased risk of reintervention. No preoperative characteristics had any significant interactions with EVT or surgical reconstruction.
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Affiliation(s)
- Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine and Department of Metabolic Medicine, Osaka University Graduate School of Medicine
| | | | - Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University School of Medicine
| | - Hiroto Terashi
- Kobe University Graduate School of Medicine, Department of Plastic Surgery
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
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91
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Duarte-Gamas L, Pereira-Neves A, Jácome F, Fragão-Marques M, Vaz RP, Andrade JP, Rocha-Neves JP. Red Blood Cell Distribution Width as a 5-Year Prognostic Marker in Patients Submitted to Carotid Endarterectomy. Cerebrovasc Dis Extra 2020; 10:181-192. [PMID: 33326971 PMCID: PMC7841742 DOI: 10.1159/000512587] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/16/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Patients submitted to carotid artery endarterectomy (CEA) have a long-term risk of major adverse cardiovascular events (MACE) of 6-9% at 2 years. Hematological parameters have been shown to have a predictive function in atherosclerotic diseases, namely the red blood cell distribution width-coefficient of variation (RDW-CV). This parameter has been associated with worse outcomes such as myocardial infarction (MI), stroke, and all-cause mortality. This study aims to evaluate the potential role of preoperative hematologic parameters such as RDW-CV in predicting perioperative and long-term cardiovascular adverse events and mortality in patients submitted to CEA. METHODS From January 2012 to January 2019, 180 patients who underwent CEA with regional anesthesia in a tertiary care and referral center were selected from a prospective cohort database. Blood samples were collected preoperatively 2 weeks before admission, including a full blood count. The primary outcome included long-term MACE. Secondary outcomes included all-cause mortality, stroke, MI, acute heart failure, and major adverse limb events (MALE). RESULTS At baseline, 27.2% of patients had increased RDW-CV. Increased RDW-CV was independently associated with baseline hemoglobin (adjusted odds ratio [aOR] 0.715, 95% CI 0.588-0.869, p = 0.001) and atrial fibrillation (aOR 4.028, 95% CI 1.037-15.639, p = 0.001). After a median follow-up of 50 months, log-rank univariate analysis of RDW-CV demonstrated a significant association between increased RDW-CV and long-term all-cause mortality (log-rank <0.001), MACE (log-rank <0.001), and MI (log-rank = 0.017). After multivariate Cox regression analysis, increased RDW-CV was associated with increased long-term mortality (adjusted hazard ratio [aHR] 2.455, 95% CI 1.231-4.894, p = 0.011) and MACE (aHR 2.047, 95% CI 1.202-3.487, p = 0.008). A decreased hemoglobin to platelet ratio (aHR 2.650e-8, 95% CI 9.049e-15 to 0.078, p = 0.019) was also associated with all-cause mortality. CONCLUSION RDW is a widely available and low-cost marker that independently predicts long-term mortality, MACE, and MI after CEA. This biomarker could prove useful in assessing which patients would likely benefit from CEA in the long term.
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Affiliation(s)
- Luís Duarte-Gamas
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal,
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal,
| | - António Pereira-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Department of Biomedicine, Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Filipa Jácome
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Mariana Fragão-Marques
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Department of Clinical Pathology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Cardiovascular R&D Unit, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Ricardo P Vaz
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - Jose Paulo Andrade
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - João P Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Department of Biomedicine, Unit of Anatomy, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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92
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Goldman MP, Corriere MA, Craven T, Davis RP, Sheehan M, Hurie JB, Velazquez G, Williams TK, Chang K, Edwards MS. Evaluation of Neuropathy, Glycemic Control, and Revascularization as Risk Factors for Future Lower Extremity Amputation among Diabetic Patients. Ann Vasc Surg 2020; 73:254-263. [PMID: 33248240 DOI: 10.1016/j.avsg.2020.10.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 06/22/2020] [Accepted: 10/09/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Diabetes mellitus is a major risk factor for progression to lower extremity amputation (LEA) due to progressive neuropathy and glycemia-induced vasculopathy. In this study, we evaluated risk factors for incident LEA type 2 diabetics during a randomized controlled trial and extended post-trial follow-up. METHODS The Action to Control Cardiovascular Risk in Diabetes trial randomized 10,251 type 2 diabetics to intensive glycemic control (Hemoglobin A1c (HbA1c) target <6.0%) versus standard glycemic control (HbA1c target 7.0-7.9%). Using backward elimination logistic regression models, we examined relationships between neuropathy using the Michigan Neuropathy Screening Instrument (MNSI) and glycemic control and incident LEA during the clinical trial and subsequent follow-up. RESULTS 9,746 patients were followed for a mean of 7.9 +/-3.1 (median 8.9) years after randomization. Ninety-eight (1%) participants underwent an incident LEA during the trial or post-trial follow-up period. Baseline demographics and traditional risk factors were examined by incident amputation status. Multivariable models revealed that abnormal 10 gm filament test (HR 4.50, 95% CI 2.92-6.95, P < 0.0001), presence of ulceration (HR 4.22, 95% CI 1.65-10.8, P = 0.0004), abnormal appearance on foot examination (HR 4.75, 95% CI 2.30-9.83, P < 0.0001), and mean postrandomization HbA1c (HR 1.65, 95% CI 1.35-2.00, P < 0.0001) were strongly predictive of LEA when accounting for other common risk factors for amputation. CONCLUSIONS In this post hoc analysis of a large randomized controlled population of diabetic patients, we found that components of the MNSI score including presence of ulceration, abnormal appearance of the foot, and 10 gm filament monofilament scoring were strongly predictive of LEA. This adds a valuable clinical tool in the risk stratification of diabetic patients for LEA.
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Affiliation(s)
- Matthew P Goldman
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC.
| | - Matthew A Corriere
- Department of Vascular Surgery, University of Michigan School of Medicine, Ann Arbor, MI
| | - Timothy Craven
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC
| | - Ross P Davis
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC
| | - Maureen Sheehan
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC
| | - Justin B Hurie
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC
| | - Gabriella Velazquez
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC
| | - Timothy K Williams
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC
| | - Kevin Chang
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC
| | - Matthew S Edwards
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC
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Lee KB, Macsata RA, Lala S, Sparks AD, Amdur RL, Ricotta JJ, Sidawy AN, Nguyen BN. Outcomes of open and endovascular interventions in patients with chronic limb threatening ischemia. Vascular 2020; 29:693-703. [PMID: 33190618 DOI: 10.1177/1708538120971972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Widespread adoption of endovascular therapy for the treatment of chronic limb-threatening ischemia has transformed the field of vascular surgery. In this modern era, we aimed to define where open surgical interventions are of greatest benefit for limb salvage. METHODS Patients who underwent interventions for chronic limb-threatening ischemia were identified in the vascular-targeted lower extremity National Surgical Quality Improvement Program database for open surgical interventions (OPEN) and endovascular surgical interventions (ENDO) from 2011 to 2017. Patients were further stratified based on the criteria of chronic limb-threatening ischemia (rest pain or tissue loss), and the location of the diseased arteries (femoropopliteal or tibioperoneal). The main outcomes measured included 30-day mortality, amputation, and major adverse cardiovascular events. RESULTS A total of 17,193 patients were revascularized for chronic limb-threatening ischemia: 10,532 were OPEN and 6661 were ENDO. OPEN had higher 30-day mortality, major adverse cardiovascular events, pulmonary, renal dysfunction, and wound complications. However, OPEN resulted in significantly lower 30-day major amputation (3.8% vs. 5.0%, odds ratio (OR): 0.83 [0.72-0.97], P = .018). Subgroup analysis revealed a higher mortality rate in OPEN was observed only in tibioperoneal intervention for tissue loss. Major adverse cardiovascular event was higher in OPEN for most subgroups. OPEN for patients with tissue loss had significantly lower amputation rate than ENDO in both femoropopliteal and tibioperoneal subgroups (3.7% vs. 5.1%, OR: 0.76 [0.59-0.98], P = .036, and 4.7% vs. 6.6%, OR: 0.74 [0.57-0.96], P = .024, respectively). The benefit of open surgery in reducing the amputation rate was not seen in patients with rest pain. CONCLUSIONS Open surgical intervention is associated with significantly better limb salvage than endovascular intervention in patients with tissue loss. Surgical options should be given more emphasis as the first-line option in this cohort of patients unless the cardiopulmonary risk is prohibitive.
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Affiliation(s)
- K Benjamin Lee
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Robyn A Macsata
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Salim Lala
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Andrew D Sparks
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Richard L Amdur
- Department of Surgery, George Washington University, Washington, DC, USA
| | - John J Ricotta
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Anton N Sidawy
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Bao-Ngoc Nguyen
- Department of Surgery, George Washington University, Washington, DC, USA
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Najafi B, Veranyan N, Zulbaran-Rojas A, Park C, Nguyen H, Nakahara QK, Elizondo-Adamchik H, Chung J, Mills JL, Montero-Baker M, Armstrong DG, Rowe V. Association Between Wearable Device-Based Measures of Physical Frailty and Major Adverse Events Following Lower Extremity Revascularization. JAMA Netw Open 2020; 3:e2020161. [PMID: 33211104 PMCID: PMC7677765 DOI: 10.1001/jamanetworkopen.2020.20161] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Physical frailty is a key risk factor associated with higher rates of major adverse events (MAEs) after surgery. Assessing physical frailty is often challenging among patients with chronic limb-threatening ischemia (CLTI) who are often unable to perform gait-based assessments because of the presence of plantar wounds. OBJECTIVE To test a frailty meter (FM) that does not rely on gait to determine the risk of occurrence of MAEs after revascularization for patients with CLTI. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 184 consecutively recruited patients with CLTI at 2 tertiary care centers. After 32 individuals were excluded, 152 participants were included in the study. Data collection was conducted between May 2018 and June 2019. EXPOSURES Physical frailty measurement within 1 week before limb revascularization and incidence of MAEs for as long as 1 month after surgery. MAIN OUTCOMES AND MEASURES The FM works by quantifying weakness, slowness, rigidity, and exhaustion during a 20-second repetitive elbow flexion-extension exercise using a wrist-worn sensor. The FM generates a frailty index (FI) ranging from 0 to 1; higher values indicate progressively greater severity of physical frailty. RESULTS Of 152 eligible participants (mean [SD] age, 67.0 [11.8] years; 59 [38.8%] women), 119 (78.2%) were unable to perform the gait test, while all could perform the FM test. Overall, 53 (34.9%), 58 (38.1%), and 41 (27.0%) were classified as robust (FI <0.20), prefrail (FI ≥0.20 to <0.35), or frail (FI ≥0.35), respectively. Within 30 days after surgery, 24 (15.7%) developed MAEs, either major adverse cardiovascular events (MACE; 8 [5.2%]) or major adverse limb events (MALE; 16 [10.5%]). Baseline demographic characteristics were not significantly different between frailty groups. In contrast, the FI was approximately 30% higher in the group that developed MAEs (mean [SD] score, 0.36 [0.14]) than those who were MAE free (mean [SD] score, 0.26 [0.13]; P = .001), with observed MAE rates of 4 patients (7.5%), 7 patients (12.1%), and 13 patients (31.7%) in the robust, prefrail and frail groups, respectively (P = .004). The FI distinguished individuals who developed MACE and MALE from those who were MAE free (MACE: mean [SD] FI score, 0.38 [0.16]; P = .03; MALE: mean [SD] FI score, 0.35 [0.13]; P = .004) after adjusting by body mass index. CONCLUSIONS AND RELEVANCE In this cohort study, measuring physical frailty using a wrist-worn sensor during a short upper extremity test was a practical method for stratifying the risk of MAEs following revascularization for CLTI when the administration of gait-based tests is often challenging.
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Affiliation(s)
- Bijan Najafi
- Interdisciplinary Consortium on Advanced Motion Performance, Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Narek Veranyan
- Keck School of Medicine, University of Southern California, Los Angeles
| | - Alejandro Zulbaran-Rojas
- Interdisciplinary Consortium on Advanced Motion Performance, Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Catherine Park
- Interdisciplinary Consortium on Advanced Motion Performance, Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Hung Nguyen
- Interdisciplinary Consortium on Advanced Motion Performance, Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Hector Elizondo-Adamchik
- Interdisciplinary Consortium on Advanced Motion Performance, Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Jayer Chung
- Interdisciplinary Consortium on Advanced Motion Performance, Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joseph L. Mills
- Interdisciplinary Consortium on Advanced Motion Performance, Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Miguel Montero-Baker
- Interdisciplinary Consortium on Advanced Motion Performance, Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Vincent Rowe
- Keck School of Medicine, University of Southern California, Los Angeles
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The Reintervention Index: A New Outcome Measure for Comparative Effectiveness of Lower Extremity Revascularization. Ann Vasc Surg 2020; 69:52-61. [DOI: 10.1016/j.avsg.2020.05.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 04/17/2020] [Accepted: 05/02/2020] [Indexed: 01/31/2023]
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Zavgorodnyaya D, Knight TB, Daley MJ, Teixeira PG. Antithrombotic therapy for postinterventional management of peripheral arterial disease. Am J Health Syst Pharm 2020; 77:269-276. [PMID: 31930282 DOI: 10.1093/ajhp/zxz315] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Evidence on the use of antithrombotic pharmacotherapy in patients undergoing revascularization of lower extremities for symptomatic peripheral arterial disease (PAD) is reviewed. SUMMARY Individuals with PAD can experience leg pain, intermittent claudication, critical limb ischemia, and acute limb ischemia. In such patients, revascularization may be indicated to improve the quality of life and to prevent amputations. Antithrombotic therapy is often intensified in the postrevascularization period to prevent restenosis of the index artery and to counteract the prothrombotic state induced by the intervention. Therapeutic modalities include dual antiplatelet therapy (DAPT), anticoagulation, a combination of antiplatelet and anticoagulation therapy, and addition of cilostazol to single antiplatelet therapy. Subgroup analyses of data from randomized clinical trials provided low-quality evidence for the use of DAPT in patients with a below-knee prosthetic bypass graft and anticoagulation for those with a venous bypass graft. Cilostazol, when added to aspirin therapy, has been shown to prevent index vessel reocclusion after an endovascular intervention in patients at low risk for thrombosis in several small randomized trials. CONCLUSION There is a considerable paucity of high-quality evidence on the optimal antithrombotic regimen for patients undergoing lower extremity revascularization, with no particular therapy shown to consistently improve patient outcomes. The decision to initiate intensified antithrombotic therapy should include a close examination of its risk-benefit profile. The demonstrated benefit of such treatment is restricted to the prevention of index artery reocclusion, while an increased risk of bleeding may lead to significant morbidity and mortality.
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Affiliation(s)
- Daria Zavgorodnyaya
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tamara B Knight
- Department of Pharmacy, Dell Seton Medical Center at the University of Texas, Ascension Seton, Austin, TX
| | - Mitchell J Daley
- Department of Pharmacy, Dell Seton Medical Center at the University of Texas, Ascension Seton, Austin, TX
| | - Pedro G Teixeira
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX
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Bertges DJ, White R, Cheng YC, Sun T, Ramkumar N, Goodney PP, Wilgus RW, Lottes AE, Smale JA, Drozda J, Raska M, Heise T, Jones WS, Tcheng JE, Eldrup-Jorgensen J, Sedrakyan A, Malone ML, Marinac-Dabic D, Thatcher R, Morales P, Krucoff MW, Cronenwett JL. Registry Assessment of Peripheral Interventional Devices objective performance goals for superficial femoral and popliteal artery peripheral vascular interventions. J Vasc Surg 2020; 73:1702-1714.e11. [PMID: 33080324 DOI: 10.1016/j.jvs.2020.09.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 09/10/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND The Superficial Femoral Artery-Popliteal EvidencE Development Study Group developed contemporary objective performance goals (OPGs) for peripheral vascular interventions (PVI) for superficial femoral artery (SFA)-popliteal artery disease using the Registry Assessment of Peripheral Interventional Devices. METHODS The Society for Vascular Surgery Vascular Quality Initiative PVI registry from January 2010 to October 2016 was used to develop OPGs based on SFA-popliteal procedures (n = 21,377) for intermittent claudication and critical limb ischemia (CLI). OPGs included 1-year rates for target lesion revascularization (TLR), major amputation, and 1 and 4-year survival rates. OPGs were calculated for the SFA and popliteal arteries and stratified by four treatments: angioplasty alone (percutaneous transluminal angioplasty [PTA]), self-expanding stenting, atherectomy, and any treatment type. Outcomes were illustrated by unadjusted Kaplan-Meier analyses. RESULTS Cohorts included PTA (n = 7505), stenting (n = 9217), atherectomy (n = 2510) and any treatment (n = 21,377). The mean age was 69 years, 58% were male, 79% were White, and 52% had CLI. The freedom from TLR OPGs at 1 year in the SFA were 80.3% (PTA), 83.2% (stenting), 83.9% (atherectomy), and 81.9% (any treatments). The freedom from TLR OPGs at 1 year in the popliteal were 81.3% (PTA), 81.3% (stenting), 80.2% (atherectomy), and 81.1% (any treatments). The freedom from major amputation OPGs at 1 year after SFA PVI were 93.4% (PTA), 95.7% (stenting), 95.1% (atherectomy), and 94.8% (any treatments). The freedom from major amputation OPG at 1 year after popliteal PVI were 90.5% (PTA), 93.7% (stenting), 91.8% (atherectomy), and 91.8%, (any treatments). The 4-year survival OPGs after SFA PVI were 76% (PTA), 80% (stenting), 82% (atherectomy), and 79% (any treatments), and for the popliteal artery were 72% (PTA), 77% (stenting), 82% (atherectomy), and 75% (any treatment). On a multivariable analysis, which included patient-level, leg-level, and lesion-level covariates, CLI was the single independent factor associated with increased TLR, amputation, and mortality. CONCLUSIONS The Superficial Femoral Artery-Popliteal EvidencE Development OPGs define a new, contemporary benchmark for SFA-popliteal interventions using a large subset of real-world evidence to inform more efficient peripheral device clinical trial designs to support regulatory and clinical decision-making. It is appropriate to discuss proposals intended for regulatory approval with the US Food and Drug Administration to refine the OPG to match the specific trial population. The OPGs may be updated using coordinated registry networks to assess long-term real-world device performance.
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Affiliation(s)
- Daniel J Bertges
- University of Vermont Medical Center, Division of Vascular Surgery, Burlington, VT.
| | | | | | - Tianyi Sun
- Departments of Cardiothoracic Surgery and Populations Health Sciences, Weill Cornell College of Medicine, New York, NY
| | - Niveditta Ramkumar
- Section of Vascular Surgery and the Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Philip P Goodney
- Section of Vascular Surgery and the Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Rebecca W Wilgus
- Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | | | | | | | | | | - W Schuyler Jones
- Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - James E Tcheng
- Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | | - Art Sedrakyan
- Departments of Cardiothoracic Surgery and Populations Health Sciences, Weill Cornell College of Medicine, New York, NY
| | | | | | | | | | - Mitchell W Krucoff
- Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Jack L Cronenwett
- Section of Vascular Surgery and the Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Lam A, Schwertner A, Katrivesis J, Fernando D, Nelson K, Abi-Jaoudeh N. Atherectomy with balloon angioplasty compared to balloon angioplasty alone for the treatment of chronic limb threatening ischemia: A national surgical quality improvement program database analysis. Vascular 2020; 28:747-755. [PMID: 33045944 DOI: 10.1177/1708538120932713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To compare perioperative outcomes related to atherectomy with percutaneous transluminal angioplasty versus percutaneous transluminal angioplasty alone for the treatment of lower extremity chronic limb threatening ischemia using a national patient database. METHODS Patients with chronic limb threatening ischemia treated with atherectomy and percutaneous transluminal angioplasty or percutaneous transluminal angioplasty alone from 2011 to 2016 in the National Surgical Quality Improvement Program database were identified. Primary outcomes were major adverse limb events (30-day untreated loss of patency, major reintervention, major amputation) and major adverse cardiac events (cardiac arrest, composite outcome of myocardial infarction or stroke). Secondary outcomes included 30-day mortality, length of stay, and any unplanned readmission within 30 days. Multivariate regression analyses were performed to determine independent predictors of outcome. Propensity score matched cohort analysis was performed. A p-value <0.05 was considered statistically significant. Subgroup analyses of femoropopliteal and infrapopliteal interventions were performed. RESULTS In total, 2636 (77.2%) patients were treated with percutaneous transluminal angioplasty and 778 (22.8%) were treated with atherectomy and percutaneous transluminal angioplasty. Multivariate analyses of the unadjusted cohort revealed no significant differences in major adverse cardiac events or major adverse limb events between the two groups (p-value >0.05). Subgroup analysis of femoropopliteal interventions demonstrated a significantly decreased likelihood of untreated loss of patency in 30 days in the atherectomy group compared to the percutaneous transluminal angioplasty group (1.1% vs. 2.7%, respectively; p-value = 0.034), which persisted on propensity score matched analysis (1.1% vs. 3.1%, respectively; p-value = 0.026). CONCLUSION Atherectomy with balloon angioplasty of femoropopliteal disease provides a significant decrease in untreated loss of patency compared to balloon angioplasty alone.
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Affiliation(s)
- Alexander Lam
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, School of Medicine, San Francisco, CA, USA
| | - Adam Schwertner
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, School of Medicine, San Francisco, CA, USA
| | - James Katrivesis
- Department of Radiological Sciences, University of California, Irvine, School of Medicine, Orange, CA, USA
| | - Dayantha Fernando
- Department of Radiological Sciences, University of California, Irvine, School of Medicine, Orange, CA, USA
| | - Kari Nelson
- Department of Radiological Sciences, University of California, Irvine, School of Medicine, Orange, CA, USA
| | - Nadine Abi-Jaoudeh
- Department of Radiological Sciences, University of California, Irvine, School of Medicine, Orange, CA, USA
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Brodmann M, Moscovic M, Wang JCC, Nano G, Dahm J, Zeller T, Christensen JK, Keirse K, Ghotbi R, Corpataux JM, Tepe G. Real-World Experience With a Paclitaxel-Coated Balloon in Critical Limb Ischemia: 24-Month Subgroup Outcomes of BIOLUX P-III. JACC Cardiovasc Interv 2020; 13:2289-2299. [PMID: 32950415 DOI: 10.1016/j.jcin.2020.06.059] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The aim of the BIOLUX P-III (A Prospective, International, Multi-Centre, Post-Market All-Comers Registry to Assess the Clinical Performance of the Passeo-18 Lux Paclitaxel Releasing Balloon Catheter in Infrainguinal Arteries - III) registry was to collect real-world data on the Passeo-18 Lux paclitaxel-coated balloon. BACKGROUND Critical limb ischemia (CLI) is a severe condition associated with high morbidity and mortality. Prospective data are needed to provide further insights on drug-eluting devices. METHODS BIOLUX P-III is a prospective, post-market, all-comers registry assessing the safety and performance of the Passeo-18 Lux. Clinical information was collected at 6, 12, and 24 months. The authors report 24-month outcomes of the CLI subgroup with patients in Rutherford classes 4 to 6. RESULTS The CLI subgroup included 328 patients with 422 lesions. Patients were 71.1 ± 10.5 years of age, and 61.0% had diabetes. Femoropopliteal lesions were present in 53.8% (n = 227), below-the-knee lesions were present in 27.0% (n = 114), and lesions were moderate or heavily calcified in 45.0% (n = 190). Major adverse events, defined as 30-day device- or procedure-related mortality, major target limb amputation, and clinically driven target lesion revascularization, occurred in 9.8% of patients through 6 months, in 14.9% through 12 months, and in 19.4% through 24 months. Clinically driven target lesion revascularization occurred in 4.4%, 8.5%, and 12.1%, major amputation in 4.9%, 5.2%, and 6.1%, and mortality in 8.1%, 11.1%, and 20.1%, respectively. Predictors of mortality were age ≥75 years and higher Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease class, and higher Rutherford class was associated with increased mortality and amputation rates. CONCLUSIONS In a large, multimorbid patient population with complex lesions and CLI, the safety and performance of the Passeo-18 Lux paclitaxel-coated balloon has been confirmed, with low rates of major amputation and target lesion revascularization.
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Affiliation(s)
| | - Matej Moscovic
- Angiology Clinic, Institute of Cardiovascular Diseases, Kosice, Slovakia
| | | | - Giovanni Nano
- 1st Vascular Surgery Department, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Johannes Dahm
- Department of Angiology and Cardiology, Herz- und Gefäßzentrum Neu-Bethlehem, Göttingen, Germany
| | - Thomas Zeller
- Clinic Cardiology and Angiology II, Universitäts-Herzzentrum Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | | | - Koen Keirse
- Department of Vascular Surgery, Regional Hospital Heilig Hart, Tienen, Belgium
| | - Reza Ghotbi
- Klinik für Gefäßchirurgie, Helios Klinikum München West, Munich, Germany
| | - Jean-Marc Corpataux
- Department of Thoracic and Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Gunnar Tepe
- Department of Interventional Radiology, Klinikum Rosenheim, Rosenheim, Germany
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Latz CA, Wang LJ, Boitano L, DeCarlo C, Sumpio B, Schwartz S, Lee CJ, Dua A. Contemporary Endovascular Outcomes for Critical Limb Ischemia Are Still Failing to Meet Society for Vascular Surgery Objective Performance Goals. Vasc Endovascular Surg 2020; 55:33-38. [PMID: 33030116 DOI: 10.1177/1538574420964623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The Society for Vascular Surgery (SVS) created Objective Performance Goals (OPGs) for critical limb ischemia (CLI) in 2009. It was previously shown that endovascular therapy for CLI was not meeting these benchmarks. The OPG for all peripheral interventions is <8% for major adverse cardiac events (MACE), <8% for major adverse limb events (MALE), and <3% for major amputation. The goal of this study is to evaluate if outcomes have improved for CLI in recent years, specifically 2015-2018. METHODS The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried to identify patients who underwent endovascular intervention for critical limb ischemia from 2011-2018. Cohorts were divided into 2011-2014 and 2015-2018. Primary 30-day outcomes were MACE, MALE, and major amputation. Univariate analyses were performed using the Fisher's exact test and the Wilcoxon rank-sum test. Multivariate analysis comparing groups was performed using inverse probability weights and trend over time analysis was performed using logistic regression with year of intervention as a continuous variable. RESULTS From 2011 to 2018, 7,168 patients underwent an endovascular intervention for CLI. 28% were classified as "OPG high anatomic risk," and 17% were classified as "OPG high clinical risk." The 2015-2018 cohort vs. the 2011-14 cohort experienced MACE in 3.3% vs. 2.7% (p = .23), MALE in 9.1% vs. 8.9% (p = 0.83), and amputation in 4.0% vs. 4.2% (p = 0.71). When only high anatomic risk patients were considered (n = 1988), MACE was experienced in 2.4% vs. 2.2% (p = 0.87), MALE by 9.5% vs. 10.6% (p = 0.47) and amputation by 5.1% vs. 6.0% (p = 0.40). When only high clinical risk patients were considered (n = 1224), MACE was experienced in 5.2% vs. 3.9% (p = 0.33), MALE by 8.0% vs. 7.4% (p = 0.74) and amputation by 3.9% vs. 3.7% (p = 0.88). Comparing 2015-2018 to the reference 2011-2014, MALE adjusted odds ratio (AOR) = 0.99, 95% CI [0.83-1.18], MACE AOR = 1.19 95% CI [0.88-1.60], and major amputation AOR = 0.91 95% CI [0.70-1.17]. There were no decreases in the trend over time for MALE (AOR per year 0.97, CI [.94-1.02], major amputation (AOR per year: 0.97, CI [0.91-1.03], nor for MACE (AOR per year: 1.05, CI [.98-1.13]). CONCLUSION Outcomes following endovascular interventions for CLI continue to underperform when compared to OPG benchmarks for MALE and amputations. There is no decrease over time for these target outcomes. Target MACE events remain acceptable despite the increasing clinical complexity of patients being treated.
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Affiliation(s)
- Christopher A Latz
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Linda J Wang
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Laura Boitano
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Brandon Sumpio
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Samuel Schwartz
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Cheong J Lee
- Division of Vascular Surgery, NorthShore University Health System, Evanston, IL, USA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, 2348Massachusetts General Hospital, Boston, MA, USA
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