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Suzuki K, Mizutani Y, Soga Y, Iida O, Kawasaki D, Yamauchi Y, Hirano K, Koshida R, Kamoi D, Tazaki J, Higashitani M, Shintani Y, Yamaoka T, Okazaki S, Suematsu N, Tsuchiya T, Miyashita Y, Shinozaki N, Takahashi H, Inoue N. Efficacy and Safety of Endovascular Therapy for Aortoiliac TASC D Lesions. Angiology 2016; 68:67-73. [DOI: 10.1177/0003319716638005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Although there is increasing evidence of the effectiveness of endovascular therapy for complex aortoiliac (AI) occlusive disease, it is not universally applied to TASC D lesions. Methods: A total of 2096 patients, 2601 limbs with AI occlusive disease, were enrolled. The lesions were categorized as TASC D (395) or TASC A-C (2206), and we compared baseline data, procedure, and follow-up result between the 2 groups. Results: The success rate of the procedure was significantly lower in the TASC D group (91.6% vs 99.3%, P < .01), and more procedure complications occurred in the TASC D group (11.1% vs 5.2%, P < .01). The results of a 5-year follow-up revealed no significant difference in primary patency (77.9% vs 77.1%, P = .17) and major adverse cardiovascular and limb events (MACLE; 30.5% vs 33.4%, P = .42) between the 2 groups. A multivariate analysis revealed complications and critical limb ischemia are independent predictors of MACLE in the TASC D group. Conclusion: The success rate of the procedure was lower in the TASC D group. Complications were more frequent in the TASC D group, and they were related to MACLE.
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Affiliation(s)
- Kenji Suzuki
- Department of cardiology, Saiseikai Central Hospital, Minato-ku, Tokyo, Japan
| | - Yukiko Mizutani
- Cardiovascular Center, Sendai Kousei Hospital, Sendai, Miyagi, Japan
| | | | - Osamu Iida
- Cardiovascular Division, Kansai Rosai Hospital, Nishinomiya, Hyogo, Japan
| | | | | | - Keisuke Hirano
- Saiseikai Yokohama-City Eastern Hospital, Yokohama, Kanagawa, Japan
| | | | | | | | | | | | | | - Shinya Okazaki
- Juntendo University Nerima Hospital, Nerima, Tokyo, Japan
| | | | | | | | | | | | - Naoto Inoue
- Cardiovascular Center, Sendai Kousei Hospital, Sendai, Miyagi, Japan
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202
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Soden PA, Zettervall SL, Curran T, Vouyouka AG, Goodney PP, Mills JL, Hallett JW, Schermerhorn ML. Regional variation in patient selection and treatment for lower extremity vascular disease in the Vascular Quality Initiative. J Vasc Surg 2016; 65:108-118. [PMID: 27692467 DOI: 10.1016/j.jvs.2016.06.105] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 06/21/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Prior studies on the cause and effect of surgical variation have been limited by utilization of administrative data. The Vascular Quality Initiative (VQI), a robust national clinical registry, provides anatomic and perioperative details allowing a more robust analysis of variation in surgical practice. METHODS The VQI was used to identify all patients undergoing infrainguinal open bypass or endovascular intervention from 2009 to 2014. Asymptomatic patients were excluded. The 16 regional groups of the VQI were used to compare variation in patient selection, operative indication, technical approach, and process measures. χ2 analysis was used to assess for differences across regions where appropriate. RESULTS A total of 52,373 interventions were included (31%). Of the 16,145 bypasses, 5% were performed for asymptomatic disease, 26% for claudication, 56% for chronic limb-threatening ischemia (CLI) (61% of these for tissue loss), and 13% for acute limb-threatening ischemia. Of the 35,338 endovascular procedures, 4% were for asymptomatic disease, 40% for claudication, 46% for CLI (73% tissue loss), and 12% for acute limb-threatening ischemia. Potentially unwarranted variation included proportion of prosthetic conduit for infrapopliteal bypass in claudication (13%-41%, median, 29%; P < .001), isolated tibial endovascular intervention for claudication (0.0%-5.0%, median, 3.0%; P < .001), discharge on antiplatelet and statin (bypass: 62%-84%; P < .001; endovascular: 63%-89%; P < .001), and ultrasound guidance for percutaneous access (claudication: range, 7%-60%; P < .001; CLI: 5%-65%; P < .001). Notable areas needing further research with significant variation include proportion of CLI vs claudication treated by bypass (38%-71%; P < .001) and endovascular intervention (28%-63%; P < .001), and use of closure devices in percutaneous access (claudication; 26%-76%; P < .001; CLI: 30%-78%; P < .001). CONCLUSIONS Significant variation exists both in areas where evidence exists for best practice and, therefore, potentially unwarranted variation, and in areas of clinical ambiguity. Quality improvement efforts should be focused on reducing unwarranted variation. Further research should be directed at identifying best practice where no established guidelines and high variation exists.
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Affiliation(s)
- Peter A Soden
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Thomas Curran
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Ageliki G Vouyouka
- Division of Vascular Surgery, Mount Sinai Health Systems, Icahn School of Medicine, New York, NY
| | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Dartmouth Medical School, Hanover, NH
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - John W Hallett
- Division of Cardiovascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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203
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Abstract
Critical limb ischemia (CLI), the most advanced form of peripheral artery disease, is associated with significant morbidity, mortality, and health care resource utilization. It is also associated with physical, as well as psychosocial, consequences such as amputation and depression. Importantly, after a major amputation, patients are at heightened risk of amputation on the contralateral leg. However, despite the technological advances to manage CLI with minimally invasive technologies, this condition often remains untreated, with significant disparities in revascularization and amputation rates according to race, socioeconomic status, and geographic region. Care remains disparate across medical specialties in this rapidly evolving field. Many challenges persist, including appropriate reimbursement for treating complex patients with difficult anatomy. This paper provides a comprehensive summary that includes diagnostic assessment and analysis, endovascular versus open surgical treatment, regenerative and adjunctive therapies, and other important aspects of CLI.
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204
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Zeller T, Beschorner U, Pilger E, Bosiers M, Deloose K, Peeters P, Scheinert D, Schulte KL, Rastan A, Brodmann M. Paclitaxel-Coated Balloon in Infrapopliteal Arteries: 12-Month Results From the BIOLUX P-II Randomized Trial (BIOTRONIK'S-First in Man study of the Passeo-18 LUX drug releasing PTA Balloon Catheter vs. the uncoated Passeo-18 PTA balloon catheter in subjects requiring revascularization of infrapopliteal arteries). JACC Cardiovasc Interv 2016; 8:1614-22. [PMID: 26493253 DOI: 10.1016/j.jcin.2015.07.011] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/23/2015] [Accepted: 07/17/2015] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The aim of BIOLUX P-II (BIOTRONIK'S-First in Man study of the Passeo-18 LUX drug releasing PTA Balloon Catheter vs. the uncoated Passeo-18 PTA balloon catheter in subjects requiring revascularization of infrapopliteal arteries) trial was to compare the safety and efficacy of a novel paclitaxel-coated drug-eluting balloon (DEB) versus an uncoated balloon (percutaneous transluminal angioplasty [PTA]) in de novo or native restenotic lesions of the infrapopliteal arteries in patients with claudication and critical limb ischemia. BACKGROUND DEB have shown promising results in femoropopliteal lesions, but data for infrapopliteal lesions are scarce. METHODS In this prospective, multicenter, randomized first-in-man study, 72 patients were randomized 1:1 to either a Passeo-18 Lux DEB (Biotronik AG, Buelach, Switzerland) (n = 36) or Passeo-18 PTA (n = 36). Follow-up assessments were scheduled at 1, 6, and 12 months, with angiographic assessment at 6 months. Adverse events were adjudicated by an independent clinical events committee, and angiographic parameters were assessed by an independent core laboratory. RESULTS The primary safety endpoint (a composite of all-cause mortality, target extremity major amputation, target lesion thrombosis, and target vessel revascularization at 30 days) was 0% in the DEB group versus 8.3% in the PTA group (p = 0.239). The primary performance endpoint (patency loss at 6 months) was 17.1% in the DEB group versus 26.1% in the PTA group (p = 0.298), and major amputations of the target extremity occurred in 3.3% versus 5.6% of the patients at 12 months, respectively. CONCLUSIONS The Passeo-18 Lux DEB has been proven to be safe and effective in infrapopliteal lesions with comparable outcomes to PTA.
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Affiliation(s)
- Thomas Zeller
- Department of Angiology, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany.
| | | | - Ernst Pilger
- Department of Angiology, Medical University Graz, Graz, Austria
| | - Marc Bosiers
- Department of Vascular Surgery, A.Z. Sint-Blasius, Dendermonde, Belgium
| | - Koen Deloose
- Department of Vascular Surgery, A.Z. Sint-Blasius, Dendermonde, Belgium
| | - Patrick Peeters
- Department of Cardiovascular & Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium
| | - Dierk Scheinert
- Department of Angiology, Park-Krankenhaus Leipzig, Leipzig, Germany
| | - Karl-Ludwig Schulte
- Vascular Center Berlin, Ev. Krankenhaus Königin Elisabeth Herzberge, Berlin, Germany
| | - Aljoscha Rastan
- Department of Angiology, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
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205
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Morisaki K, Matsumoto T, Matsubara Y, Inoue K, Aoyagi Y, Matsuda D, Tanaka S, Okadome J, Maehara Y. Prognostic factor of the two-year mortality after revascularization in patients with critical limb ischemia. Vascular 2016; 25:123-129. [DOI: 10.1177/1708538116651216] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purposes The aim of this study was to evaluate the risk factors for the two-year survival after revascularization of critical limb ischemia. Methods Between 2008 and 2012, 142 patients underwent revascularization. A retrospective analysis was performed to measure the risk factor. Results A total 85 patients underwent surgical revascularization, 31 patients underwent endovascular therapy while 26 patients underwent hybrid therapy. By multivariate analysis, the following variables were considered to be risk factors: ejection fraction <50 % (HR, 3.14; 95% CI, 1.22–7.95; P = 0.02), serum albumin level <2.5 g/dL (HR, 3.45; 95% CI, 1.01–11.7; P = 0.04) and nonambulatory status (HR, 4.11; 95% CI, 1.79–9.70; P < 0.01). The two-year survival rate of the patients with no risk factors was 85.5%, while the patients with at least one risk factor had an unfavorable prognosis (one; 56.7%, two; 45.4%). Conclusions The nonambulatory status, serum albumin level <2.5 g/dL and ejection fraction <50% were the risk factors for the two-year mortality after revascularization in critical limb ischemia patients. These risk factors may be useful for the treatment strategy of critical limb ischemia patients.
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Affiliation(s)
- Koichi Morisaki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takuya Matsumoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yutaka Matsubara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kentaro Inoue
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yukihiko Aoyagi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daisuke Matsuda
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinichi Tanaka
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun Okadome
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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206
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Menard MT, Farber A, Assmann SF, Choudhry NK, Conte MS, Creager MA, Dake MD, Jaff MR, Kaufman JA, Powell RJ, Reid DM, Siami FS, Sopko G, White CJ, Rosenfield K. Design and Rationale of the Best Endovascular Versus Best Surgical Therapy for Patients With Critical Limb Ischemia (BEST-CLI) Trial. J Am Heart Assoc 2016; 5:JAHA.116.003219. [PMID: 27402237 PMCID: PMC5015366 DOI: 10.1161/jaha.116.003219] [Citation(s) in RCA: 133] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Critical limb ischemia (CLI) is increasing in prevalence, and remains a significant source of mortality and limb loss. The decision to recommend surgical or endovascular revascularization for patients who are candidates for both varies significantly among providers and is driven more by individual preference than scientific evidence. METHODS AND RESULTS The Best Endovascular Versus Best Surgical Therapy for Patients With Critical Limb Ischemia (BEST-CLI) Trial is a prospective, randomized, multidisciplinary, controlled, superiority trial designed to compare treatment efficacy, functional outcomes, quality of life, and cost in patients undergoing best endovascular or best open surgical revascularization. Approximately 140 clinical sites in the United States and Canada will enroll 2100 patients with CLI who are candidates for both treatment options. A pragmatic trial design requires consensus on patient eligibility by at least 2 investigators, but leaves the choice of specific procedural strategy within the assigned revascularization approach to the individual treating investigator. Patients with suitable single-segment of saphenous vein available for potential bypass will be randomized within Cohort 1 (n=1620), while patients without will be randomized within Cohort 2 (n=480). The primary efficacy end point of the trial is Major Adverse Limb Event-Free Survival. Key secondary end points include Re-intervention and Amputation-Free-Survival and Amputation Free-Survival. CONCLUSIONS The BEST-CLI trial is the first randomized controlled trial comparing endovascular therapy to open surgical bypass in patients with CLI to be carried out in North America. This landmark comparative effectiveness trial aims to provide Level I data to clarify the appropriate role for both treatment strategies and help define an evidence-based standard of care for this challenging patient population. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02060630.
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Affiliation(s)
- Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA
| | | | - Niteesh K Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Mark A Creager
- Dartmouth-Hitchcock Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Michael D Dake
- Department of Cardiothoracic Surgery, Stanford Hospital and Clinics, Stanford, CA
| | - Michael R Jaff
- Fireman Vascular Center, Massachusetts General Hospital, Boston, MA
| | | | - Richard J Powell
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Diane M Reid
- National Heart, Lung and Blood Institute, Bethesda, MD
| | | | - George Sopko
- National Heart, Lung and Blood Institute, Bethesda, MD
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Reporting standards of the Society for Vascular Surgery for endovascular treatment of chronic lower extremity peripheral artery disease. J Vasc Surg 2016; 64:e1-e21. [DOI: 10.1016/j.jvs.2016.03.420] [Citation(s) in RCA: 204] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 03/12/2016] [Indexed: 12/13/2022]
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208
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Reed GW, Salehi N, Giglou PR, Kafa R, Malik U, Maier M, Shishehbor MH. Time to Wound Healing and Major Adverse Limb Events in Patients with Critical Limb Ischemia Treated with Endovascular Revascularization. Ann Vasc Surg 2016; 36:190-198. [PMID: 27354323 DOI: 10.1016/j.avsg.2016.02.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 02/12/2016] [Accepted: 02/14/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND There are few studies that quantify the impact of time to wound healing on outcomes after endovascular revascularization of critical limb ischemia (CLI). METHODS In this retrospective study, 179 patients with CLI and tissue loss were assessed for adverse events after endovascular therapy. Associations between time to wound healing and outcomes were determined via Cox proportional hazards analysis. The long-term probability of events was assessed with Kaplan-Meier analysis. The primary end point was major adverse limb events (MALE-major amputation, surgical endarterectomy, or bypass). Secondary end points were major amputation, need for repeat endovascular therapy, and mortality. RESULTS After multivariable adjustment for time-dependent wound healing, age, renal function, diabetes, and Rutherford class, independent predictors of MALE included the presence of an unhealed wound (hazard ratio [HR], 5.2; 95% confidence interval (CI), 2.3-11.8; P < 0.0001) and creatinine ≥ 2.0 (HR, 2.4; 95% CI, 1.4-4.3; P = 0.003). On Kaplan-Meier analysis, the probability of MALE was greater in patients with unhealed wounds compared with healed wounds (log-rank P < 0.0001). Patients whose wounds healed within 4 months had a lower probability of MALE than patients who did not heal by 4 months (log-rank, P = 0.04). Unhealed wounds were also independently associated with major amputation (HR, 9.0; 95% CI, 2.6-31.1; P = 0.0004), and patients whose wounds healed by 3 months had less major amputation (log-rank, P = 0.04). Unhealed wounds were independently associated with increased risk of mortality (HR, 42.7; 95% CI, 5.7-319.0; P = 0.002) but not repeat revascularization. CONCLUSIONS Unhealed wounds are an independent risk factor for MALE, major amputation, and mortality after endovascular treatment of CLI. Wound healing within 3 months is associated with less risk of major amputation, and within 4 months less risk of MALE. A focus should be on achieving wound healing as fast as possible in this population.
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Affiliation(s)
- Grant W Reed
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Negar Salehi
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Pejman R Giglou
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH
| | - Rami Kafa
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH
| | - Umair Malik
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH
| | - Michael Maier
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Mehdi H Shishehbor
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.
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Heideman PP, Rajebi MR, McKusick MA, Bjarnason H, Oderich GS, Friese JL, Fleming MD, Stockland AH, Harmsen WS, Mandrekar J, Misra S. Impact of Chronic Kidney Disease on Clinical Outcomes of Endovascular Treatment for Femoropopliteal Arterial Disease. J Vasc Interv Radiol 2016; 27:1204-14. [PMID: 27321888 DOI: 10.1016/j.jvir.2016.04.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 04/28/2016] [Accepted: 04/30/2016] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To evaluate effect of chronic kidney disease (CKD) on all-cause mortality, major adverse limb event (MALE), MALE and postoperative death (MALE + POD), and amputation after endovascular treatment of femoropopliteal disease. MATERIALS AND METHODS A retrospective review from January 2002 to October 2011 was performed of 440 patients who underwent endovascular treatment of symptomatic femoropopliteal disease for claudication (n = 251) or critical limb ischemia (CLI) (n = 267). CKD stage was divided based on Kidney Dialysis Outcomes Quality Initiative classification. Outcomes and factors associated with amputation, MALE, and MALE + POD were determined. RESULTS Patients with diabetes (hazard ratio [HR] = 2.2; 95% confidence interval [CI], 1.3-3.6; P = .002) and runoff score of 0 or 1 (HR = 2.0; 95% CI, 1.2-3.4; P = .01) relative to runoff score of 3 were at increased risk of amputation. Patients with baseline glomerular filtration rate < 45 mL/min/1.73 m(2) had a 17% increase in amputation for every 5-point decrease < 45 mL/min/1.73 m(2) (95% CI, 1.09-1.26; P < .001). Increase of 10 years in age (HR = 1.9; 95% CI, 1.5-2.3; P < .001), TransAtlantic Inter-Society Consensus class of C/D relative to A/B (HR = 1.6; 95% CI, 1.1-2.2; P = .01), and CLI (HR = 2.4; 95% CI, 0.5-0.9; P < .001) were associated with increased mortality. Female sex was associated with decreased risk of mortality (HR = 0.7; 95% CI, 0.5-0.9; P = .01). CONCLUSIONS Worsening CKD is associated with higher amputation rates, all-cause mortality, and MALE + POD in patients undergoing endovascular treatment of femoropopliteal disease.
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Affiliation(s)
- Paul P Heideman
- Division of Vascular and Interventional Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Mohammad Reza Rajebi
- Division of Vascular and Interventional Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Michael A McKusick
- Division of Vascular and Interventional Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Haraldur Bjarnason
- Division of Vascular and Interventional Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Gustavo S Oderich
- Department of Radiology, Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Jeremy L Friese
- Division of Vascular and Interventional Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Mark D Fleming
- Department of Radiology, Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Andrew H Stockland
- Division of Vascular and Interventional Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - William S Harmsen
- Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Jay Mandrekar
- Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Sanjay Misra
- Division of Vascular and Interventional Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; Vascular and Interventional Radiology Translational Laboratory, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
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210
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Reed GW, Raeisi-Giglou P, Kafa R, Malik U, Salehi N, Shishehbor MH. Hospital Readmissions Following Endovascular Therapy for Critical Limb Ischemia: Associations With Wound Healing, Major Adverse Limb Events, and Mortality. J Am Heart Assoc 2016; 5:JAHA.115.003168. [PMID: 27207964 PMCID: PMC4889187 DOI: 10.1161/jaha.115.003168] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The significance of hospital readmission after endovascular therapy for critical limb ischemia (CLI) is not well established. We sought to investigate the incidence, timing, and causes of readmissions after endovascular therapy for CLI and whether readmission is associated with major adverse limb events (MALE) or mortality. METHODS AND RESULTS This was a retrospective study of 252 patients treated with endovascular therapy for CLI. During median follow-up of 381 days (interquartile range [IQR], 115-718), 140 (56%) were readmitted, with median time to readmission of 83 days (IQR, 33-190). Readmission within 30 days occurred in 14% of patients (n=35; 25% of readmissions). Most readmissions occurred between 30 and 180 days (n=67; 48% of readmissions). The most frequent reason for readmission was unhealed wounds (n=63; 45% of readmissions). Independent predictors of readmission by Cox proportional hazards analysis were unhealed wounds, presence of multiple wounds, age ≥70, female sex, hemodialysis, and history of heart failure (P<0.05 for each). By Kaplan-Meier analysis, readmission was greatest in patients with unhealed wounds, followed by patients who never had a wound, and lowest in patients whose wounds completely healed (P<0.0001 overall, and P<0.01 between groups). After multivariable adjustment, readmission remained an independent predictor of composite MALE (major amputation, bypass, or endarterectomy) or mortality (adjusted hazard ratio, 3.1; 95% CI, 1.5-6.5; P=0.002). CONCLUSIONS Most readmissions occur 30 and 180 days after endovascular therapy for nonprocedural reasons. Unhealed wounds are an independent risk factor for readmission. Readmission is associated with increased MALE and mortality after endovascular therapy for CLI.
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Affiliation(s)
- Grant W Reed
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | | | - Rami Kafa
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH
| | - Umair Malik
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH
| | - Negar Salehi
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Mehdi H Shishehbor
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
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211
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Maldonado TS, Westin GG, Jazaeri O, Mewissen M, Reijnen MMPJ, Dwivedi AJ, Garrett HE, Dias Perera A, Shimshak T, Mantese V, Smolock CJ, Arthurs ZM. Treatment of Aortoiliac Occlusive Disease with the Endologix AFX Unibody Endograft. Eur J Vasc Endovasc Surg 2016; 52:64-74. [PMID: 27162000 DOI: 10.1016/j.ejvs.2016.04.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 04/06/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE/BACKGROUND Aorto-bifemoral bypass remains the gold standard for treatment of aortoiliac occlusive disease (AIOD) in patients with advanced (TASC D) lesions, but has significant associated morbidity and mortality. Treatment with a unibody stent-graft positioned at the aortic bifurcation is a potential endovascular option for the treatment of AIOD. The current study examines the safety, efficacy, and early patency rates of the Endologix AFX unibody stent-graft for treatment of AIOD. METHODS A multicenter retrospective review was conducted of patients treated exclusively for AIOD with the AFX device. Primary, assisted primary, and secondary patency rates were noted. Clinical improvement was assessed using Rutherford classification and ankle brachial index. Mean duration of follow-up was 22.2 ± 11.2 months. Ninety-one patients (56 males [62%]) were studied. RESULTS Sixty-seven patients (74%) presented with lifestyle-limiting intermittent claudication and the remaining 24 (26%) had critical limb ischemia. Technical success was 100%. Complications included groin infection (n = 4 [4%]), groin hematoma (n = 4 [4%]), common iliac rupture (n = 4 [4%]), iliac dissection (n = 4 [4%]), and thromboembolic event (n = 3 [3%]; one femoral, one internal iliac artery, and one internal iliac with bilateral popliteal/tibial thromboemboli). Thirty-day mortality was 1% (1/91) resulting from a case of extensive pelvic thromboembolism. At 1 year, 73% of patients experienced improvement in Rutherford stage of -3 or greater compared with baseline. Nine patients (10%) required 16 secondary interventions. At all time points, primary patency rates were > 90%, assisted patency rates were > 98%, and secondary patency rates were 100%. CONCLUSION This is the largest study to examine the use of the Endologix AFX unibody stent-graft for the treatment of AIOD. Use of the AFX stent-graft appears to be a safe and effective endovascular treatment for complex AIOD.
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Affiliation(s)
- T S Maldonado
- New York University Langone Medical Center, New York, NY, USA.
| | - G G Westin
- New York University Langone Medical Center, New York, NY, USA
| | - O Jazaeri
- University of Colorado Denver, Denver, CO, USA
| | - M Mewissen
- Vascular Center at St. Luke's Medical Center, Milwaukee, WI, USA
| | | | - A J Dwivedi
- University of Louisville, Louisville, KY, USA
| | - H E Garrett
- University of Tennessee, Baptist Memorial Hospital Memphis, Memphis, TN, USA
| | - A Dias Perera
- University of Tennessee, Cardiovascular Surgery Clinic, PLLC, Memphis, TN, USA
| | - T Shimshak
- Wheaton Franciscan Healthcare, Milwaukee, WI, USA
| | - V Mantese
- Mercy Clinic Vascular Specialists, St. Louis, MO, USA
| | | | - Z M Arthurs
- San Antonio Military Medical Center, Uniformed Services University of the Health Sciences, San Antonio, TX, USA
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212
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The efficacy of a multidisciplinary team approach in critical limb ischemia. Heart Vessels 2016; 32:55-60. [PMID: 27106919 DOI: 10.1007/s00380-016-0840-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 04/15/2016] [Indexed: 10/21/2022]
Abstract
The aim of the present study was to clarify the characteristics of Japanese critical limb ischemia (CLI) patients and analyze the rates of real-world mortality and amputation-free survival (AFS) in all patients with Fontaine stage IV CLI who were treated with/without revascularization therapy by an intra-hospital multidisciplinary care team. All consecutive patients who presented with CLI at Showa University Fujigaoka Hospital between April 2008 and March 2014 were prospectively registered. The intra-hospital committee consisted of cardiologists, plastic surgeons, dermatologists, diabetologists, nephrologists, cardiovascular surgeons, and vascular technologists. The primary endpoint of this study was all-cause mortality and AFS during the follow-up period. The present study included 145 patients with Fontaine stage IV CLI. The mean age was 76.5 ± 10.2 years. The all-cause mortality rate during the follow-up period (15.5 ± 16.1 months) was 21.4 %. The AFS rate during the follow-up period (14.1 ± 16.4 months) was 58.6 %. A multivariate Cox proportional hazards regression analysis found that age >75 years and hemodialysis were significantly associated with all-cause mortality; and that age >75 years, Rutherford 6, and wound infection were significantly associated with AFS. A multidisciplinary approach and comprehensive care may improve the outcomes and optimize the collaborative treatment of CLI patients. However, all-cause mortality remained high in patients with Fontaine stage IV CLI and early referral to a hospital that can provide specialized treatment for CLI, before the occurrence of major tissue loss or infection, is necessary to avoid primary amputation.
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213
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Abstract
Critical limb ischemia (CLI) has a high rate of major amputation and mortality due to advance systemic cardiovascular disease. The goals of treating patients with CLI not only include the prevention of limb loss but also to relieve pain, improve quality of life, and prevent death. A multidisciplinary team approach to treating patients with CLI improves limb salvage rates by helping to tailor the best intervention for these patients. In addition, a multidisciplinary team can help address cardiovascular risk modification and wound management to help in decreasing mortality and increase amputation-free survival. This review article intends to summarize the current trends and data in the team approach to CLI care. In addition, we will review the large multidisciplinary study evaluating surgical and endovascular treatments for CLI.
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Affiliation(s)
- Rahul S Patel
- Department of Radiology, The Mount Sinai Medical Center, New York, NY.
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214
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Single-Center Experience With Lutonix Drug-Coated Balloons in Infrapopliteal Arteries. J Endovasc Ther 2016; 23:417-23. [DOI: 10.1177/1526602816645080] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To examine patient outcomes following the use of the Lutonix drug-coated balloon (DCB) in patients undergoing endovascular intervention in below-the-knee (BTK) arteries. Methods: A retrospective chart review identified 248 patients who were treated for symptomatic peripheral artery disease with the Lutonix DCB between May 2013 and October 2014. Forty patients were lost to follow-up, leaving 208 patients (mean age 74.1±9.7 years; 138 men) with evaluable data for outcome analysis. The patient cohort suffered from either severe claudication (38.6%) or critical limb ischemia (CLI; 61.4%) in 220 limbs. Almost two-thirds (140, 63.6%) of the 220 target lesions were total occlusions, and 37 (17.8%) of all patients had occlusion of all 3 BTK vessels before intervention. Results: Over a median 9-month follow-up, target lesion revascularization occurred in 15.9% of patients with an average time to first reintervention of 8 months. In total, 39 amputations were performed in 31 limbs. However, 17 of these amputations were preplanned minor amputations below the ankle; only 9 (4.1%) major amputations occurred corresponding to 6.6% of the CLI cohort. Freedom from the composite of death or major amputation was estimated as 92% and 85% at 6 and 12 months, respectively, by Kaplan-Meier analysis. In the full cohort, improvement of at least 1 Rutherford category was seen in 130 (59.1%) limbs after 1 year or at the last follow-up, with 104 (80.0%) of those limbs showing an improvement of ≥2 categories. Conclusion: From this single-center experience, the Lutonix DCB shows therapeutic promise in a disease state where new treatment options are needed.
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215
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Peripheral Artery Disease Therapies May Perform Differently in Practice Than in Randomized Trials. JACC Cardiovasc Interv 2016; 9:725-7. [DOI: 10.1016/j.jcin.2016.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 01/19/2016] [Indexed: 11/17/2022]
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216
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Laird JR, Singh GD, Armstrong EJ. Contemporary Management of Critical Limb Ischemia. J Am Coll Cardiol 2016; 67:1914-6. [DOI: 10.1016/j.jacc.2016.02.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 02/29/2016] [Indexed: 10/22/2022]
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217
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Liang TW, Jester A, Motaganahalli RL, Wilson MG, G'Sell P, Akingba GA, Fajardo A, Murphy MP. Autologous bone marrow mononuclear cell therapy for critical limb ischemia is effective and durable. J Vasc Surg 2016; 63:1541-5. [PMID: 27021379 DOI: 10.1016/j.jvs.2016.01.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 01/13/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We have previously shown that autologous bone marrow mononuclear cell (ABMNC) therapy improves measures of limb perfusion, rest pain, wound healing, and amputation-free survival (AFS) at 1 year in patients with critical limb ischemia (CLI). Long-term durability of ABMNC therapy for CLI remains unknown. The objective of the current study was to evaluate long-term clinical outcomes 5 years after treatment. METHODS Data were retrospectively gathered from a database and via a patient survey and review of medical records of patients previously enrolled in this phase I/II trial. AFS, freedom from major amputation, and freedom from major adverse limb events (MALE) were calculated using the product-limit estimate. The incidence of cardiac, malignant, and other medical events relevant to the safety of cell therapy were tabulated during the time from treatment to follow-up. RESULTS Twenty-one of the 24 patients (88%) who completed the initial 1-year phase I/II trial were available for the 5-year analysis; AFS was 74% (95% confidence interval [CI], 0.53-0.87), freedom from major amputation was 78% (95% CI, 0.58-0.90), and freedom from MALE was 65% (95% CI, 0.45-0.80). Three patients (14%) had major cardiac events. There were no incidences of malignancies or diagnoses of clinically significant proliferative retinopathy. Fifteen patients (71%) report continued improvement in pain-free walking. Nineteen (90%) patients believed that the study was of significant medical value and would participate again. CONCLUSIONS ABMNC therapy provides long-term freedom from AFS, major amputation, and MALE that are comparable with other reports of patients who underwent surgical and endovascular interventions for CLI. Furthermore, no patients developed tumorigenesis or clinically significant retinopathy. Because of the limited number of patients studied, our findings will need to be followed up in a larger phase III trial.
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Affiliation(s)
- Tiffany W Liang
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Andrea Jester
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael G Wilson
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Ind
| | - Patricia G'Sell
- Indiana Center for Vascular Biology and Medicine, Indiana University School of Medicine, Indianapolis, Ind
| | - George A Akingba
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Andres Fajardo
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael P Murphy
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind.
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Abstract
Endovascular treatment of infrapopliteal disease is focused on the treatment of patients with rest pain or critical limb ischemia (CLI) due to severe atherosclerotic disease. While the evidence base surrounding the comparative effectiveness of endovascular intervention vs. surgery is lacking, many operators have adopted an "endovascular first" approach to the treatment of infrapopliteal atherosclerotic disease due to the lower morbidity of these procedures. This manuscript reviews current data on the endovascular treatment of CLI, including a comparison of endovascular and surgical approaches, current indications for and outcomes with balloon angioplasty of infrapopliteal PAD, angiosome-guided revascularization, and emerging technologies to improve long-term vessel patency after endovascular intervention.
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Affiliation(s)
- Ehrin J Armstrong
- VA Eastern Colorado Healthcare System and Division of Cardiology, University of Colorado, Denver, CO, USA.
| | - Kalkidan Bishu
- VA Eastern Colorado Healthcare System and Division of Cardiology, University of Colorado, Denver, CO, USA
| | - Stephen W Waldo
- VA Eastern Colorado Healthcare System and Division of Cardiology, University of Colorado, Denver, CO, USA
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219
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Affiliation(s)
- Martin Teraa
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands Department of Nephrology & Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Frans L Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marianne C Verhaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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220
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Okamoto S, Iida O, Takahara M, Yamauchi Y, Hirano K, Soga Y, Suzuki K, Uematsu M. Impact of Perioperative Complications After Endovascular Therapy in Diabetic Patients With Critical Limb Ischemia due to Isolated Infrapopliteal Lesions. J Endovasc Ther 2016; 23:371-7. [DOI: 10.1177/1526602816632712] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To investigate the thus far poorly defined impact of perioperative complications (POCs) on clinical outcomes after endovascular therapy (EVT) of diabetic patients with critical limb ischemia (CLI) due to isolated infrapopliteal lesions. Methods: A multicenter registry of CLI patients was interrogated to identify 780 consecutive diabetic patients (mean age 71±10 years; 553 men) who successfully underwent balloon angioplasty for isolated infrapopliteal lesions. More than half of the population (487 patients) was on dialysis. Independent predictors (logistic regression) and prognostic impact on outcomes (Cox proportional hazards model) of POC (ie, death, myocardial infarction, stroke, pseudoaneurysm, puncture site hemorrhage/hematoma, distal emboli, vascular rupture, transfusion, dialysis, and gastrointestinal hemorrhage) were investigated. Outcomes are presented as the odds ratio (OR) and hazard ratio (HR), respectively, with 95% confidence intervals (CI). Results: POCs occurred in 12.3% (96/780) of the population. Multivariate modeling identified body mass index (BMI) <18.5 kg/m2 (adjusted OR 1.71, 95% CI 1.01 to 2.89, p=0.047) and tissue loss (adjusted OR 2.43, 95% CI 1.14 to 5.15, p=0.021) as independent predictors of POCs. In a Cox regression model adjusted for baseline clinical characteristics, the occurrence of POCs was independently associated with major adverse limb events (HR 1.87, 95% CI 1.12 to 3.13, p=0.016) but not with mortality or wound healing. In follow-up, freedom from major adverse limb events was higher in the group without POC (85.2%) than with POC (69.7%, p=0.006) at up to 3 years. Conclusion: POCs within 30 days after balloon angioplasty for infrapopliteal disease in diabetics with CLI were more likely to occur in patients with low BMI and tissue loss. POC occurrence was associated with major adverse limb events in follow-up but not with mortality or wound healing.
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Affiliation(s)
- Shin Okamoto
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Mitsuyoshi Takahara
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | | | - Keisuke Hirano
- Division of Cardiology, Saiseikai Yokohama-City Eastern Hospital, Kanagawa, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Kenji Suzuki
- Department of Cardiology, Sendai Kousei Hospital, Miyagi, Japan
| | - Masaaki Uematsu
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
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221
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Treatment with cilostazol improves clinical outcome after endovascular therapy in hemodialysis patients with peripheral artery disease. J Cardiol 2016; 67:199-204. [DOI: 10.1016/j.jjcc.2015.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 04/17/2015] [Accepted: 05/01/2015] [Indexed: 11/24/2022]
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222
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Retrograde Pedal Access and Endovascular Revascularization: A Safe and Effective Technique for High-Risk Patients with Complex Tibial Vessel Disease. Ann Vasc Surg 2016; 31:91-8. [DOI: 10.1016/j.avsg.2015.09.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 08/24/2015] [Accepted: 09/07/2015] [Indexed: 11/21/2022]
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223
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Affiliation(s)
- Aaron Liew
- Newcastle University; Institute of Cellular Medicine; 4th Floor, William Leech Building Framlington Place Newcastle upon Tyne UK NE2 4HH
- National University of Ireland Galway (NUIG), Portiuncula University Hospital & Galway University Hospital, Saolta University Health Care Group; Galway Ireland
| | - Vish Bhattacharya
- Queen Elizabeth Hospital; Department of General and Vascular Surgery; Queen Elizabeth Avenue Sheriff Hill Gateshead Tyne and Wear UK NE9 6SX
| | - James Shaw
- Newcastle University; Institute of Cellular Medicine; 4th Floor, William Leech Building Framlington Place Newcastle upon Tyne UK NE2 4HH
| | - Gerard Stansby
- Freeman Hospital; Northern Vascular Centre; Newcastle upon Tyne UK NE7 7DN
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224
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Zimmermann A, Ludwig U, Eckstein HH. [Indications and results of endovascular therapy of critical limb ischemia]. Radiologe 2016; 56:216-22. [PMID: 26796338 DOI: 10.1007/s00117-015-0070-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Critical limb ischemia (CLI) is the most severe form of peripheral artery occlusive disease and is characterized by high amputation, morbidity and mortality rates. Therefore, revascularization is the essential step in therapy for retention of the affected limb. OBJECTIVES Although for a long time bypass surgery represented the gold standard in the treatment of CLI, in recent years there has been a disproportionate increase of endovascular treatment despite the lack of level-data. In this review the indications and results of endovascular therapy of CLI are presented on the basis of published data. METHODS A literature search was carried out to identify publications that compared the results of endovascular and surgical therapy as well as observational studies about different endovascular techniques. RESULTS The BASIL study provided the highest quality data comparing endovascular and surgical treatment of CLI. The long-term data of the BASIL trial showed that apart from patients with a suitable vein and a life expectancy of more than 2 years, first line endovascular therapy is equivalent to surgical treatment. The equivalence could also be demonstrated in a meta-analysis comparing operative and endovascular treatment of CLI. CONCLUSION The CLI is a disease with high mortality and morbidity risks. Due to the comparable amputation-free survival times with lower complication rates in the published data, in most patients an endovascular first strategy in experienced centers can be justified.
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Affiliation(s)
- A Zimmermann
- Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - U Ludwig
- Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - H-H Eckstein
- Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
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225
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Brothers TE, Zhang J, Mauldin PD, Tonnessen BH, Robison JG, Vallabhaneni R, Hallett JW. Predicting outcomes for infrapopliteal limb-threatening ischemia using the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg 2016; 63:114-24.e5. [DOI: 10.1016/j.jvs.2015.08.063] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 08/11/2015] [Indexed: 10/23/2022]
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226
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Clinical effect of wound depth in critical limb ischemia with tissue loss after endovascular treatment. J Vasc Surg 2015; 62:1564-74. [DOI: 10.1016/j.jvs.2015.06.230] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 06/04/2015] [Indexed: 11/22/2022]
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227
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Costs of Real-Life Endovascular Treatment of Critical Limb Ischemia: Report from Poland-A European Union Country with a Low-Budget Health Care System. Ann Vasc Surg 2015; 31:111-23. [PMID: 26616505 DOI: 10.1016/j.avsg.2015.08.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 07/28/2015] [Accepted: 08/05/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND To analyze the costs of inhospital, percutaneous treatment of patients with critical limb ischemia (CLI) carried out in Poland, a European Union country with a low-budget national health system. METHODS A retrospective analysis of prospectively collected data on all patients admitted to a tertiary care hospital for endovascular treatment of CLI over 1 year. SETTING A single, large volume, tertiary angiology center located in Southern Poland. PARTICIPANTS CLI patients due to aortoiliac, femoropopliteal, or infrapopliteal arterial stenoses or occlusions with indications for first-line endovascular therapy or similar patients who refused open surgical procedure despite having primary indications for vascular surgery. INTERVENTIONS Direct stenting using bare-metal stents was the primary mode of treatment for lesions located within the aortoiliac and femoropopliteal arterial segments. Plain old balloon angioplasty (POBA) was the second most commonly used technique. For below-the-knee arteries, POBA was the mainstay of treatment, which was occasionally supported by drug-eluting stent angioplasty. Directional atherectomy, scoring balloon angioplasty, or local fibrinolysis was used infrequently. Drug-eluting balloon percutaneous transluminal angioplasty was not used. MAIN OUTCOME MEASURES The main outcome measures were the mean reimbursement of costs provided by the Polish National Health Fund (NHF) for inhospital treatment of patients for whom endovascular procedures were performed as initial treatment for CLI and the inhospital costs of endovascular treatment calculated by the caregiver in the 2 years since the first procedure. The average total number of days spent in hospital, amputation-free survival (AFS), overall survival (OS), and limb salvage rate (LSR) according to a life-table method were also calculated for the 2 years. RESULTS In the first year, there were 496 endovascular and 15 surgical hospitalizations for revascularization procedures to treat 340 limbs in 327 patients, with a further 53 revascularization procedures in the second year. There were an additional 90 hospitalizations over the first year and 38 over the second year for CLI-associated cardiovascular comorbidities. The mean reimbursement for hospitalizations of patients included into observation, provided by the NHF, was $4901.94 per patient for the first year and $833.57 per patient alive to the second year. The mean cost of hospitalization for percutaneous revascularization treatment was $3804.25 per patient for the first year and $3340.30 per patient requiring revascularization within the second year. All costs were calculated in constant 2011 USD. The average total number of days spent in hospital was 8.4 days for the first year and 1.97 days per patient alive to the second year. At 1 and 2 years, the AFS was 76.8% and 66.6%, the OS was 86.5% and 77.3%, and the LSR was 89.4% and 86%, respectively. CONCLUSIONS Endovascular therapy using the currently available techniques can be performed in almost all patients suffering from CLI at relatively low costs, and satisfactory results can be obtained. Physicians play a pivotal role in ensuring quality of treatment and the reduction of treatment cost in these patients.
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228
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A comparative evaluation of risk-adjustment models for benchmarking amputation-free survival after lower extremity bypass. J Vasc Surg 2015; 63:990-7. [PMID: 26603547 DOI: 10.1016/j.jvs.2015.09.051] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 09/28/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Providing patients and payers with publicly reported risk-adjusted quality metrics for the purpose of benchmarking physicians and institutions has become a national priority. Several prediction models have been developed to estimate outcomes after lower extremity revascularization for critical limb ischemia, but the optimal model to use in contemporary practice has not been defined. We sought to identify the highest-performing risk-adjustment model for amputation-free survival (AFS) at 1 year after lower extremity bypass (LEB). METHODS We used the national Society for Vascular Surgery Vascular Quality Initiative (VQI) database (2003-2012) to assess the performance of three previously validated risk-adjustment models for AFS. The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL), Finland National Vascular (FINNVASC) registry, and the modified Project of Ex-vivo vein graft Engineering via Transfection III (PREVENT III [mPIII]) risk scores were applied to the VQI cohort. A novel model for 1-year AFS was also derived using the VQI data set and externally validated using the PIII data set. The relative discrimination (Harrell c-index) and calibration (Hosmer-May goodness-of-fit test) of each model were compared. RESULTS Among 7754 patients in the VQI who underwent LEB for critical limb ischemia, the AFS was 74% at 1 year. Each of the previously published models for AFS demonstrated similar discriminative performance: c-indices for BASIL, FINNVASC, mPIII were 0.66, 0.60, and 0.64, respectively. The novel VQI-derived model had improved discriminative ability with a c-index of 0.71 and appropriate generalizability on external validation with a c-index of 0.68. The model was well calibrated in both the VQI and PIII data sets (goodness of fit P = not significant). CONCLUSIONS Currently available prediction models for AFS after LEB perform modestly when applied to national contemporary VQI data. Moreover, the performance of each model was inferior to that of the novel VQI-derived model. Because the importance of risk-adjusted outcome reporting continues to increase, national registries such as VQI should begin using this novel model for benchmarking quality of care.
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229
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Nishibe T, Yamamoto K, Seike Y, Ogino H, Nishibe M, Koizumi J, Dardik A. Endovascular Therapy for Femoropopliteal Artery Disease and Association of Risk Factors With Primary Patency. Vasc Endovascular Surg 2015; 49:236-41. [DOI: 10.1177/1538574415614406] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The treatment of femoropopliteal artery disease remains controversial, without clear guidelines specifying the indications for endovascular therapy (EVT). Accordingly, we retrospectively examined our experience of using EVT to treat femoropopliteal artery disease. A total of 91 limbs in 82 patients underwent EVT for the treatment of femoropopliteal artery disease. Percutaneous transluminal angioplasty alone was performed in 20 limbs, and additional stenting was performed in 71 limbs. The 1-year primary patency, primary-assisted patency, limb salvage, and survival rates were 76%, 88%, 96%, and 92%, respectively. Multivariate Cox analysis of primary patency showed that critical limb ischemia (CLI; hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.08-5.33; P < .01) and TASC II C/D disease (HR, 2.70; 95% CI, 1.14-6.39; P < .05) were independent predictors of decreased primary patency. In conclusion, patients with CLI or extensive lesions have reduced patency after EVT for femoropopliteal artery disease.
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Affiliation(s)
- Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kiyohito Yamamoto
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yoshimasa Seike
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | | | - Jun Koizumi
- Department of Diagnostic Radiology, Tokai University School of Medicine, Isehara, Japan
| | - Alan Dardik
- Department of Vascular Surgery, Yale University School of Medicine, New Haven, CT, USA
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230
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Hernández Mateo MM, Martínez López I, Revuelta Suero S, Marqués de Marino P, Cernuda Artero I, Cabrero Fernández M, Serrano Hernando FJ. Clinical Outcomes after Endovascular Treatment Failure in Patients with Femoropopliteal Occlusive Disease. Ann Vasc Surg 2015; 30:299-304. [PMID: 26541966 DOI: 10.1016/j.avsg.2015.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 07/24/2015] [Accepted: 07/31/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND To analyze the clinical impact derived from endovascular treatment failure on patients with femoropopliteal occlusive disease (FPOD) regarding their preoperative clinical stage. METHODS Retrospective review for primary endovascular procedures for FPOD from 2008 to 2013. Primary end point included clinical deterioration defined as acute limb ischemia (ALI) or clinical worsening by, at least, one Rutherford's classification category, related to procedure's failure (restenosis >70% or occlusion). RESULTS Ninety procedures were analyzed in 85 patients, 87.8% operated due to critical limb ischemia. The lesion treated was classified as Trans-Atlantic Inter-Society Consensus (TASC)-A/B in 76.7%, with a mean length of 98.5 ± 54 mm. Covered stent graft (SG) was used in 31.1% of the cases. Median follow-up was 14.5 months and treatment failure occurred in 33.3% of cases (n = 30, 9 restenosis and 21 occlusions). Clinical worsening was assessed in 40% of treatment failures and 6 of 21 (28.6%) presented as ALI. Twenty-two major adverse limb events (MALEs) were recorded and 8 major amputations. Regarding the type of stent, more occlusions were recorded on patients treated with SG compared with bare metal stent (39.3% vs. 16%; P = 0.02). However, no differences were found between groups regarding clinical worsening attributable to treatment failure (HR, 1.33; CI 95%, 0.5-3.5; P = 0.5). On multivariate analysis, TASC-C/D lesions (HR, 5.5; CI 95%, 2.3-13.3; P < 0.001) and female sex (HR, 4.9; CI 95%, 1.9-12.5; P = 0.001) behaved as significant predictors for failure and dual-antiplatelet therapy as a protective factor (HR, 0.3; CI 95%, 0.3-0.13; P = 0.03). No predictors were obtained regarding clinical worsening and occurrence of MALEs in our series. CONCLUSIONS Patients with failure of endovascular procedures on FPOD appeared with clinical worsening in a no negligible number of cases in our sample regarding their preoperative clinical situation. Thus, we believe that endovascular treatment should be carefully deliberated.
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Affiliation(s)
| | - Isaac Martínez López
- Department of Angiology and Vascular Surgery, Hospital Clínico San Carlos, Madrid, Spain
| | - Sergio Revuelta Suero
- Department of Angiology and Vascular Surgery, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Iñaki Cernuda Artero
- Department of Angiology and Vascular Surgery, Hospital Clínico San Carlos, Madrid, Spain
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231
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Abu Dabrh AM, Steffen MW, Asi N, Undavalli C, Wang Z, Elamin MB, Conte MS, Murad MH. Nonrevascularization-based treatments in patients with severe or critical limb ischemia. J Vasc Surg 2015; 62:1330-9.e13. [DOI: 10.1016/j.jvs.2015.07.069] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 07/09/2015] [Indexed: 11/17/2022]
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232
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Jaff MR, White CJ, Hiatt WR, Fowkes GR, Dormandy J, Razavi M, Reekers J, Norgren L. An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries: A Supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II): The TASC Steering Comittee(.). Ann Vasc Dis 2015; 8:343-57. [PMID: 26730266 DOI: 10.3400/avd.tasc.15-01000] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were last updated in 2007 (TASC II) and represented the collaboration of international vascular specialties involved in the management of patients with peripheral arterial disease (PAD). Since the publication of TASC II, there have been innovations in endovascular revascularization strategies for patients with PAD. The intent of this publication is to provide a complete anatomic lower limb TASC lesion classification, including the infrapopliteal segment, and an updated literature review of new endovascular techniques and practice patterns employed by vascular specialists today.
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Affiliation(s)
| | - Christopher J White
- The Ochsner Clinical School-University of Queensland, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - William R Hiatt
- Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora, CO, USA
| | - Gerry R Fowkes
- Centre for Population Health Sciences, The University of Edinburgh, UK
| | | | | | - Jim Reekers
- Academic Medical Center, University Hospital, Amsterdam, The Netherlands
| | - Lars Norgren
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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233
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Saraidaridis JT, Patel VI, Lancaster RT, Cambria RP, Conrad MF. Applicability of the Society for Vascular Surgery's Objective Performance Goals for Critical Limb Ischemia to Current Practice of Lower-Extremity Bypass. Ann Vasc Surg 2015; 30:59-65. [PMID: 26476271 DOI: 10.1016/j.avsg.2015.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/17/2015] [Accepted: 09/09/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND In 2009, the Society for Vascular Surgery (SVS) established objective performance goals (OPGs) for critical limb ischemia (CLI) based on data from previous, randomized, controlled trials of lower-extremity bypass (LEB). These OPG sought to establish a benchmark of outcomes to which one could compare future endovascular therapy. However, the cohort used to develop the OPG excluded all patients who required prosthetic conduit and those with end-stage renal disease (ESRD), possibly limiting the generalizability of these results and the subsequent guidelines. The goal of this study was to determine if the SVS OPG are applicable to the current population of patients undergoing LEB. METHODS All patients who underwent infrainguinal LEB for CLI from January 2010 to December 2013 were identified in a prospectively maintained database. Patients were stratified into OPG eligible and ineligible (non-OPG) groups based on their demographic and operative characteristics. OPG eligible patients were further stratified into high risk and average risk. Outcomes included 30-day major adverse limb events (MALEs), 30-day major adverse cardiovascular events (MACE), 1-year survival, and 1-year freedom from amputation. RESULTS A total of 89 individual patients were identified. Only 43 (48%) patients met OPG inclusion criteria and 46 (52%) were not OPG eligible (non-OPG). The 30-day MALE was 8.7% (13.0% non-OPG vs. 7.0% OPG, P = 0.34). The 30-day MACE was 11.2% (13.0% non-OPG vs. 9.3% OPG, P = 0.58). One-year survival was 80.3% ± 4.5% (71.2% non-OPG vs. 90.0% OPG, P = 0.21). One-year freedom from amputation was 71.7% ± 5.5% (58.8% non-OPG vs. 84.0% OPG, P = 0.03). CONCLUSIONS The SVS OPG for LEB are likely not generalizable to current practice as 51% of patients would have been excluded from the SVS cohort because of ESRD and prosthetic conduit. Most SVS OPG (30-day MALE, 1-year survival, and 1-year limb salvage) were attainable in patients who met SVS OPG inclusion criteria; but for the patients who are not OPG eligible, new benchmarks are needed.
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Affiliation(s)
| | - Virendra I Patel
- Department of Vascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Robert T Lancaster
- Department of Vascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Richard P Cambria
- Department of Vascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark F Conrad
- Department of Vascular Surgery, Massachusetts General Hospital, Boston, MA.
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234
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Bisdas T, Borowski M, Torsello G. Current practice of first-line treatment strategies in patients with critical limb ischemia. J Vasc Surg 2015; 62:965-973.e3. [PMID: 26187290 DOI: 10.1016/j.jvs.2015.04.441] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 04/28/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Theodosios Bisdas
- Clinic for Vascular and Endovascular Surgery, University Clinic of Muenster, and Department of Vascular Surgery, St. Franziskus Hospital, Muenster, Germany.
| | - Matthias Borowski
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Giovanni Torsello
- Clinic for Vascular and Endovascular Surgery, University Clinic of Muenster, and Department of Vascular Surgery, St. Franziskus Hospital, Muenster, Germany
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235
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Ziza V, Canaud L, Gandet T, Molinari N, Alonso W, Chastan R, Branchereau P, Picard E. Outcomes of cold-stored venous allograft for below-knee bypasses in patients with critical limb ischemia. J Vasc Surg 2015; 62:974-83. [DOI: 10.1016/j.jvs.2015.04.437] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 04/06/2015] [Indexed: 10/23/2022]
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237
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Davies MG, El-Sayed HF. Objective performance goals after endovascular intervention for critical limb ischemia. J Vasc Surg 2015; 62:1555-63. [PMID: 26409847 DOI: 10.1016/j.jvs.2015.06.228] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 06/30/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE During the last decade, primary endoluminal therapy for critical limb ischemia (CLI), assessed as rest pain and tissue loss of the lower extremity, has significantly increased. Reporting of patient-centered outcomes using the new Society for Vascular Surgery objective performance goals (OPGs) has been limited. This study examined the OPGs for infrainguinal endovascular management of CLI. METHODS A prospective database of patients undergoing endovascular treatment of the lower extremity for CLI between 2000 and 2011 was queried. Evaluated were clinical efficacy (absence of recurrent symptoms, maintenance of ambulation and absence of major amputation), amputation-free survival (survival without major amputation), and freedom from major adverse limb events (MALEs; above-ankle amputation of the index limb or major reintervention - new bypass graft, jump/interposition graft revision). RESULTS A total of 728 patients (60% male; age, 68 ± 14 years) underwent lower extremity interventions for CLI (66% tissue loss); of these, 39% had superficial femoral artery and tibial interventions. Diabetes mellitus was present in 71%, hyperlipidemia in 64%, and chronic renal insufficiency in 37%. Technical success was 96%. The overall rate at 30 days of major adverse cardiovascular events (MACEs) was 3% and MALEs was 12%. At 5 years, clinical efficacy was (mean ± standard error of the mean) 42% ± 5%, amputation-free survival was 41% ± 7%, and freedom from MALEs was 51% ± 4%. Clinical efficacy was significantly different in those presenting with rest pain and tissue loss and in the anatomic high-risk group compared with the clinical high-risk group, and both were worse compared with the group without clinical or high-risk criteria. CONCLUSIONS Endoluminal therapy for CLI is associated with early low MACE rates but high MALE rates. When the key outcome of amputation free survival is considered, predictors of a better outcome were absence of current smoking, a lower modified Edifoligide for the Prevention of Infrainguinal Vein Graft Failure (PREVENT III) amputation risk score, better preoperative ambulation status, lower MACEs, and discharge disposition to home. The presence of tissue loss and anatomic risk factors negatively affect outcomes. Longer-term outcomes after endovascular intervention for CLI remain relatively poor, with <40% success in objective performance outcomes at 5 years.
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Affiliation(s)
- Mark G Davies
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex.
| | - Hosam F El-Sayed
- Division of Vascular Diseases and Surgery, Department of Surgery, Ohio State University, Columbus, Ohio
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238
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Abu Dabrh AM, Steffen MW, Asi N, Undavalli C, Wang Z, Elamin MB, Conte MS, Murad MH. Bypass surgery versus endovascular interventions in severe or critical limb ischemia. J Vasc Surg 2015; 63:244-53.e11. [PMID: 26372187 DOI: 10.1016/j.jvs.2015.07.068] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 07/10/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Critical limb ischemia is associated with a significant morbidity and mortality. We systematically reviewed the evidence to compare bypass surgery with endovascular revascularization in patients with critical limb ischemia. METHODS We systematically searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and Scopus through October 2014 for comparative studies (randomized and nonrandomized). Predefined outcomes of interest were mortality, major amputation, patency, and wound healing. We pooled odds ratios (ORs) of the outcomes of interest using the random-effects model. RESULTS Nine studies that enrolled 3071 subjects were included. There was no significant difference in mortality (OR, 0.72; 95% confidence interval [CI], 0.44-1.16) or amputation (OR, 1.2; 95% CI, 0.87-1.65). Bypass surgery was associated with higher primary patency (OR, 2.50; 95% CI, 1.25-4.99) and assisted primary patency (OR, 3.39; 95% CI, 1.53-7.51). The quality of evidence was low for mortality and amputation outcomes and moderate for patency outcomes. CONCLUSIONS Low quality of evidence due to imprecision and heterogeneity suggests that bypass surgery and endovascular approaches may have similar effect on mortality and major amputations. However, better primary and primary assisted patency can be expected with surgery.
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Affiliation(s)
- Abd Moain Abu Dabrh
- Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, Minn; Knowledge Synthesis Unit, the Center for Healthcare Delivery, Mayo Clinic, Rochester, Minn
| | - Mark W Steffen
- Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, Minn
| | - Noor Asi
- Knowledge Synthesis Unit, the Center for Healthcare Delivery, Mayo Clinic, Rochester, Minn
| | - Chaitanya Undavalli
- Knowledge Synthesis Unit, the Center for Healthcare Delivery, Mayo Clinic, Rochester, Minn
| | - Zhen Wang
- Knowledge Synthesis Unit, the Center for Healthcare Delivery, Mayo Clinic, Rochester, Minn
| | - Mohamed B Elamin
- Knowledge Synthesis Unit, the Center for Healthcare Delivery, Mayo Clinic, Rochester, Minn
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, San Francisco, Calif
| | - Mohammad Hassan Murad
- Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, Minn; Knowledge Synthesis Unit, the Center for Healthcare Delivery, Mayo Clinic, Rochester, Minn.
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239
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Iida O, Nakamura M, Yamauchi Y, Fukunaga M, Yokoi Y, Yokoi H, Soga Y, Zen K, Suematsu N, Inoue N, Suzuki K, Hirano K, Shintani Y, Miyashita Y, Urasawa K, Kitano I, Tsuchiya T, Kawamoto K, Yamaoka T, Uesugi M, Shinke T, Oba Y, Ohura N, Uematsu M, Takahara M, Hamasaki T, Nanto S. 3-Year Outcomes of the OLIVE Registry, a Prospective Multicenter Study of Patients With Critical Limb Ischemia. JACC Cardiovasc Interv 2015; 8:1493-1502. [DOI: 10.1016/j.jcin.2015.07.005] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 06/18/2015] [Accepted: 07/02/2015] [Indexed: 10/23/2022]
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240
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Davies MG, El-Sayed HF. Outcomes of Isolated Tibial Endovascular Interventions for Tissue Loss in CLI Patients on Hemodialysis. J Endovasc Ther 2015; 22:681-9. [PMID: 26286072 DOI: 10.1177/1526602815602074] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To compare the objective performance goals (OPGs) and patient-centered outcomes of isolated tibial interventions in patients with tissue loss who were on hemodialysis (HD) to patients with tissue loss who were not on HD. METHODS Interrogation of a prospectively maintained database identified 242 critical limb ischemia (CLI) patients who underwent isolated tibial interventions for tissue loss in a single limb between 2007 and 2012. The 78 patients (mean age 66±12 years; 44 men) on HD were compared with 164 patients (mean age 50±13 years; 82 men) who were not on HD. There was an equal distribution of the tibial vessels treated; 152 (63%) patients had more than one treated tibial vessel. Patient-centered outcomes of clinical efficacy (absence of recurrent symptoms, maintenance of ambulation, and no major amputation), amputation-free survival (AFS), and freedom from major adverse limb events (MALE) were evaluated. The Society for Vascular Surgery OPGs were defined at 30 days and 1 year. RESULTS The 30-day major adverse cardiac events was significantly higher (p=0.004) in the HD group (5, 5%) compared with the no-HD group (0%), but both remained under the stated OPG of ≤10%. The 30-day MALE rates were significantly higher than the stated ≤9% OPG at 13% and 18% for the no-HD and HD groups, respectively. At 1 year, the rates for AFS, freedom from MALE, limb salvage, and survival did not achieve the stated Society for Vascular Surgery OPGs in the HD group. Clinical efficacy was 61% and 25% at 3 years for the no-HD and HD groups, respectively (p<0.01). Overall, AFS was 54% and 22% and freedom from MALE was 56% and 27% at 3 years for the no-HD and HD groups, respectively (both p<0.01). CONCLUSION Tibial intervention for tissue loss in patients on HD is a valid treatment option but is associated with a high MALE rate. Three-year outcomes remain relatively poor, with <25% success in terms of clinical efficacy and AFS.
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Affiliation(s)
- Mark G Davies
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, TX, USA
| | - Hosam F El-Sayed
- Division of Vascular Diseases and Surgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA
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241
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Jaff MR, White CJ, Hiatt WR, Fowkes GR, Dormandy J, Razavi M, Reekers J, Norgren L. An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries: A Supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Vasc Med 2015; 20:465-78. [DOI: 10.1177/1358863x15597877] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were last updated in 2007 (TASC II) and represented the collaboration of international vascular specialties involved in the management of patients with peripheral arterial disease (PAD). Since the publication of TASC II, there have been innovations in endovascular revascularization strategies for patients with PAD. The intent of this publication is to provide a complete anatomic lower limb TASC lesion classification, including the infrapopliteal segment, and an updated literature review of new endovascular techniques and practice patterns employed by vascular specialists today.
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Affiliation(s)
| | | | - Christopher J. White
- The Ochsner Clinical School–University of Queensland, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - William R. Hiatt
- Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora, CO, USA
| | - Gerry R. Fowkes
- Centre for Population Health Sciences, The University of Edinburgh, UK
| | | | | | - Jim Reekers
- Academic Medical Center, University Hospital, Amsterdam, The Netherlands
| | - Lars Norgren
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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242
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Jaff MR, White CJ, Hiatt WR, Fowkes GR, Dormandy J, Razavi M, Reekers J, Norgren L. An update on methods for revascularization and expansion of the TASC lesion classification to include below-the-knee arteries: A supplement to the inter-society consensus for the management of peripheral arterial disease (TASC II): The TASC steering commi. Catheter Cardiovasc Interv 2015; 86:611-25. [DOI: 10.1002/ccd.26122] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | - Christopher J. White
- The Ochsner Clinical School-University of Queensland, Ochsner Clinic Foundation; New Orleans LA USA
| | - William R. Hiatt
- Division of Cardiology; University of Colorado School of Medicine, and CPC Clinical Research; Aurora CO USA
| | - Gerry R. Fowkes
- Centre for Population Health Sciences, The University of Edinburgh; UK
| | | | | | - Jim Reekers
- Academic Medical Center, University Hospital; Amsterdam The Netherlands
| | - Lars Norgren
- Department of Surgery; Faculty of Medicine and Health, Örebro University; Örebro Sweden
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243
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Jaff MR, White CJ, Hiatt WR, Fowkes GR, Dormandy J, Razavi M, Reekers J, Norgren L. An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries. J Endovasc Ther 2015; 22:663-77. [DOI: 10.1177/1526602815592206] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were last updated in 2007 (TASC II) and represented the collaboration of international vascular specialties involved in the management of patients with peripheral arterial disease (PAD). Since the publication of TASC II, there have been innovations in endovascular revascularization strategies for patients with PAD. The intent of this publication is to provide a complete anatomic lower limb TASC lesion classification, including the infrapopliteal segment, and an updated literature review of new endovascular techniques and practice patterns employed by vascular specialists today.
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Affiliation(s)
| | | | - Christopher J. White
- The Ochsner Clinical School–University of Queensland, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - William R. Hiatt
- Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora, CO, USA
| | - Gerry R. Fowkes
- Centre for Population Health Sciences, The University of Edinburgh, UK
| | | | | | - Jim Reekers
- Academic Medical Center, University Hospital, Amsterdam, The Netherlands
| | - Lars Norgren
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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244
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Nakano M, Hirano K, Iida O, Yamauchi Y, Soga Y, Kawasaki D, Tazaki J, Suzuki K, Fujiwara M, Yamaoka T. Clinical Efficacy of Infrapopliteal Endovascular Procedures for Hemodialysis Patients with Critical Limb Ischemia. Ann Vasc Surg 2015; 29:1225-34. [DOI: 10.1016/j.avsg.2015.03.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 03/03/2015] [Accepted: 03/05/2015] [Indexed: 11/16/2022]
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245
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Saraidaridis JT, Ergul E, Patel VI, Stone DH, Cambria RP, Conrad MF. The Society for Vascular Surgery's objective performance goals for lower extremity revascularization are not generalizable to many open surgical bypass patients encountered in contemporary surgical practice. J Vasc Surg 2015; 62:392-400. [DOI: 10.1016/j.jvs.2015.03.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 03/19/2015] [Indexed: 10/23/2022]
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246
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Determinants of survival and major amputation after peripheral endovascular intervention for critical limb ischemia. J Vasc Surg 2015. [PMID: 26215708 DOI: 10.1016/j.jvs.2015.04.391] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Our objective was to analyze periprocedural and 1-year outcomes of peripheral endovascular intervention (PVI) for critical limb ischemia (CLI). METHODS We reviewed 1244 patients undergoing 1414 PVIs for CLI (rest pain, 29%; tissue loss, 71%) within the Vascular Study Group of New England (VSGNE) from January 2010 to December 2011. Overall survival (OS), amputation-free survival (AFS), and freedom from major amputation at 1 year were analyzed using the Kaplan-Meier method. Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS The number of arteries treated during each procedure were 1 (49%), 2 (35%), 3 (12%), and ≥4 (5%). Target arterial segments and TransAtlantic Inter-Society Consensus classifications were aortoiliac, 27% (A, 48%; B, 28%; C, 12%; and D, 12%); femoral-popliteal, 48% (A, 29%; B, 34%; C, 20%; and D, 17%); and infrapopliteal, 25% (A, 17%; B, 14%; C, 25%; D, 44%). Technical success was 92%. Complications included access site hematoma (5.0%), occlusion (0.3%), and distal embolization (2.4%). Mortality and major amputation rates were 2.8% and 2.2% at 30 days, respectively. Overall percutaneous or open reintervention rate was 8.0% during the first year. At 1-year, OS, AFS, and freedom from major amputation were 87%, 87%, and 94% for patients with rest pain and 80%, 71%, and 81% for patients with tissue loss. Independent predictors of reduced 1-year OS (C index = .74) included dialysis (HR, 3.8; 95% CI, 2.8-5.1; P < .01), emergency procedure (HR, 2.5; 95% CI, 1.0-6.2; P = .05), age >80 years (HR, 2.2; 95% CI, 1.7-2.8; P < .01), not living at home preoperatively (HR, 2.0; 95% CI, 1.4-2.8; P < .01), creatinine >1.8 mg/dL (HR, 1.9; 95% CI, 1.3-2.8; P < .01), congestive heart failure (HR, 1.7; 95% CI, 1.3-2.2; P < .01), and chronic β-blocker use (HR, 1.4; 95% CI, 1.0-1.9; P = .03), whereas independent preoperative ambulation (HR, 0.7; 95% CI, 0.6-0.9; P = .014) was protective. Independent predictors of major amputation (C index = .69) at 1 year included dialysis (HR, 2.7; 95% CI, 1.6-4.5; P < .01), tissue loss (HR, 2.0; 95% CI, 1.1-3.7; P = .02), prior major contralateral amputation (HR, 2.0; 95% CI, 1.1-3.5; P = .02), non-Caucasian race (HR, 1.7; 95% CI, 1.0-2.9; P = .045), and male gender (HR, 1.6; 95% CI, 1.1-2.6; P = .03), whereas smoking (HR, .60; 95% CI, 0.4-1.0; P = .042) was protective. CONCLUSIONS Survival and major amputation after PVI for CLI are associated with different patient characteristics. Dialysis dependence is a common predictor that portends especially poor outcomes. These data may facilitate efforts to improve patient selection and, after further validation, enable risk-adjusted outcome reporting for CLI patients undergoing PVI.
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Tsuchiya T, Iida O, Shiraki T, Soga Y, Hirano K, Suzuki K, Yamaoka T, Miyashita Y, Kitayama M, Kajinami K. Clinical characteristics of patients with Rutherford category IV, compared with V and VI. SAGE Open Med 2015; 3:2050312115597087. [PMID: 26770796 PMCID: PMC4679321 DOI: 10.1177/2050312115597087] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 06/27/2015] [Indexed: 12/20/2022] Open
Abstract
Objective: Patients categorized Rutherford category IV might have different characteristics compared with Rutherford category V and VI. Our study aims were to estimate the clinical differences between Rutherford category IV and Rutherford category V and VI, for those underwent endovascular therapy for isolated infrapopliteal disease, and also to find risk factors for endovascular therapy in Rutherford category IV. Methods: Based on the Japanese multi-center registry data, 1091 patients with 1332 limbs (Rutherford category IV: 226 patients with 315 limbs, Rutherford category V and VI: 865 patients with 1017 limbs) were analyzed retrospectively. Results: Patients’ backgrounds and lesions’ characteristics had significant differences. Both freedom rate from major adverse limb event with perioperative death and amputation-free survival rate at 1 year were better in Rutherford category IV than Rutherford category V and VI (93.6% vs 78.3%, 87.7% vs 66.7%) and those maintained to 3 years (p < 0.0001). Significant predictors for major adverse limb event/perioperative death were small body mass index (<18.5 kg/m3) and initial endovascular therapy success, and those for amputation-free survival were small body mass index (<18.5 kg/m3), non-ambulatory status, high systematic inflammatory reaction (C-reactive protein > 3.0 mg/dL), chronic obstructive pulmonary disease, and coronary artery disease in Rutherford category IV. Conclusion: From the present results, Rutherford category IV should be recognized to have quite different backgrounds and better outcome from Rutherford category V and VI.
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Affiliation(s)
- Taketsugu Tsuchiya
- Division of Trans-catheter Cardiovascular Therapeutics, Kanazawa Medical University Hospital, Kahoku, Japan
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Tatsuya Shiraki
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Keisuke Hirano
- Division of Cardiology, Saiseikai Yokohama-City Eastern Hospital, Yokohama, Japan
| | - Kenji Suzuki
- Department of Cardiology, Sendai Kousei Hospital, Sendai, Japan
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Yusuke Miyashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Shinshu University, Matsumoto, Japan
| | - Michihiko Kitayama
- Division of Trans-catheter Cardiovascular Therapeutics, Kanazawa Medical University Hospital, Kahoku, Japan
| | - Koji Kajinami
- Division of Cardiology, Kanazawa Medical University Hospital, Kahoku, Japan
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Association of dual-antiplatelet therapy with reduced major adverse cardiovascular events in patients with symptomatic peripheral arterial disease. J Vasc Surg 2015; 62:157-165.e1. [DOI: 10.1016/j.jvs.2015.01.051] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 01/21/2015] [Indexed: 11/18/2022]
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Abstract
Trials hampered by poor definitions
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Affiliation(s)
- M S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, California, 94143-0222, USA
| | - A Farber
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
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Iida O, Takahara M, Soga Y, Yamauchi Y, Hirano K, Tazaki J, Yamaoka T, Suematsu N, Suzuki K, Shintani Y, Miyashita Y, Uematsu M. Impact of angiosome-oriented revascularization on clinical outcomes in critical limb ischemia patients without concurrent wound infection and diabetes. J Endovasc Ther 2015; 21:607-15. [PMID: 25290786 DOI: 10.1583/14-4692r.1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To investigate the impact of angiosome-oriented revascularization on clinical outcomes in critical limb ischemia (CLI) patients excluding those with both diabetes and wound infection. METHODS Using a retrospective multicenter database, a propensity score matching analysis was performed of 539 consecutive CLI patients (375 men; mean age 71±11 years) without concurrent wound infection and diabetes who underwent balloon angioplasty of isolated infrapopliteal lesions. Propensity score matching produced 2 groups of 182 patients each who underwent angiosome-oriented direct revascularization (123 men; mean age 72±11 years) or indirect revascularization (125 men; mean age 72±11 years). The groups were compared for wound healing rate, freedom from major adverse limb events (MALE), and amputation-free survival (AFS). RESULTS In the overall population, indirect revascularization was performed in 36.6% (n=197). In the propensity matching analysis, the complete wound healing rate at 12 months was higher in the direct group than the indirect revascularization patients (75% vs. 64%, p=0.01), while freedom from MALE (p=0.99) and AFS (p=0.17) were not significantly different at up to 24 months. In multivariate analysis, indirect revascularization had an independent negative impact on wound healing (adjusted hazard ratio 0.7, p=0.008). CONCLUSION After propensity matching analysis for CLI patients other than those with both diabetes and wound infection, the wound healing rate was higher after direct revascularization than after indirect revascularization, whereas MALE and AFS were not significantly different.
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Affiliation(s)
- Osamu Iida
- 1 Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
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