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Siracuse JJ, Farber A, Menard MT, Conte MS, Kaufman JA, Jaff M, Kiang SC, Ochoa Chaar CI, Osborne N, Singh N, Tan TW, Guzman RJ, Strong MB, Hamza TH, Doros G, Rosenfield K. Perioperative complications following open or endovascular revascularization for chronic limb-threatening ischemia in the BEST-CLI Trial. J Vasc Surg 2023; 78:1012-1020.e2. [PMID: 37318428 DOI: 10.1016/j.jvs.2023.05.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/22/2023] [Accepted: 05/22/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Anticipated perioperative morbidity is an important factor for choosing a revascularization method for chronic limb-threatening ischemia (CLTI). Our goal was to assess systemic perioperative complications of patients treated with surgical and endovascular revascularization in the Best Endovascular vs Best Surgical Therapy in Patients with CLTI (BEST-CLI) trial. METHODS BEST-CLI was a prospective randomized trial comparing open (OPEN) and endovascular (ENDO) revascularization strategies for patients with CLTI. Two parallel cohorts were studied: Cohort 1 included patients with adequate single-segment great saphenous vein (SSGSV), whereas Cohort 2 included those without SSGSV. Data were queried for major adverse cardiovascular events (MACE-composite myocardial infarction, stroke, death), non-serious (non-SAEs) and serious adverse events (SAEs) (criteria-death/life-threatening/requiring hospitalization or prolongation of hospitalization/significant disability/incapacitation/affecting subject safety in trial) 30 days after the procedure. Per protocol analysis was used (intervention received without crossover), and risk-adjusted analysis was performed. RESULTS There were 1367 patients (662 OPEN, 705 ENDO) in Cohort 1 and 379 patients (188 OPEN, 191 ENDO) in Cohort 2. Thirty-day mortality in Cohort 1 was 1.5% (OPEN 1.8%; ENDO 1.3%) and in Cohort 2 was 1.3% (2.7% OPEN; 0% ENDO). MACE in Cohort 1 was 4.7% for OPEN vs 3.13% for ENDO (P = .14), and in Cohort 2, was 4.28% for OPEN and 1.05% for ENDO (P = .15). On risk-adjusted analysis, there was no difference in 30-day MACE for OPEN vs ENDO for Cohort 1 (hazard ratio [HR] 1.5; 95% confidence interval [CI], 0.85-2.64; P = .16) or Cohort 2 (HR, 2.17; 95% CI, 0.48-9.88; P = .31). The incidence of acute renal failure was similar across interventions; in Cohort 1 it was 3.6% for OPEN vs 2.1% for ENDO (HR, 1.6; 95% CI, 0.85-3.12; P = .14), and in Cohort 2, it was 4.2% OPEN vs 1.6% ENDO (HR, 2.86; 95% CI, 0.75-10.8; P = .12). The occurrence of venous thromboembolism was low overall and was similar between groups in Cohort 1 (OPEN 0.9%; ENDO 0.4%) and Cohort 2 (OPEN 0.5%; ENDO 0%). Rates of any non-SAEs in Cohort 1 were 23.4% in OPEN and 17.9% in ENDO (P = .013); in Cohort 2, they were 21.8% for OPEN and 19.9% for ENDO (P = .7). Rates for any SAEs in Cohort 1 were 35.3% for OPEN and 31.6% for ENDO (P = .15); in Cohort 2, they were 25.5% for OPEN and 23.6% for ENDO (P = .72). The most common types of non-SAEs and SAEs were infection, procedural complications, and cardiovascular events. CONCLUSIONS In BEST-CLI, patients with CLTI who were deemed suitable candidates for open lower extremity bypass surgery had similar peri-procedural complications following either OPEN or ENDO revascularization: In such patients, concern about risk of peri-procedure complications should not be a deterrent in deciding revascularization strategy. Rather, other factors, including effectiveness in restoring perfusion and patient preference, are more relevant.
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Affiliation(s)
- Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA.
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - John A Kaufman
- Department of Interventional Radiology, Oregon Health & Science University, Portland, OR
| | | | - Sharon C Kiang
- Division of Vascular Surgery, Loma Linda University Medical Center and Veterans Affairs, Loma Linda, CA
| | - Cassius I Ochoa Chaar
- Division of Vascular and Endovascular Surgery, Yale University, School of Medicine, New Haven, CT
| | - Nicholas Osborne
- Division of Vascular and Endovascular Surgery, University of Michigan, Ann Arbor, MI
| | - Niten Singh
- Division of Vascular and Endovascular Surgery, University of Washington, Seattle, WA
| | - Tze-Woei Tan
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California, Los Angeles, CA
| | - Raul J Guzman
- Division of Vascular and Endovascular Surgery, Yale University, School of Medicine, New Haven, CT
| | - Michael B Strong
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Gheorghe Doros
- Department of Biostatics, Boston University, School of Public Health, Boston, MA
| | - Kenneth Rosenfield
- Section of Vascular Medicine and Intervention Massachusetts General Hospital, Harvard Medical School, Boston, MA
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202
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Mantha Y, Asif A, Fath A, Prasad A. Implications of Kidney Disease in Patients with Peripheral Arterial Disease and Vascular Calcification. Interv Cardiol Clin 2023; 12:531-538. [PMID: 37673497 DOI: 10.1016/j.iccl.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Persons with chronic kidney disease (CKD) are at a higher risk of developing peripheral artery disease (PAD) and its adverse health outcomes than individuals with normal renal function. Among patients with CKD, PAD is predominantly characterized by the calcification of the medial layer of arterial vessels in addition to intimal atherosclerosis and calcification. Vascular calcification (VC) is initiated by CKD-associated hyperphosphatemia, hypercalcemia, high concentrations of parathyroid hormone (PTH) as well as inflammation and oxidative stress. VC is widely prevalent in this cohort (>80% dialysis and 50% patients with CKD) and contributes to reduced arterial compliance and symptomatic peripheral arterial disease (PAD). The most severe form of PAD is critical limb ischemia (CLI) which has a substantial risk for increased morbidity and mortality. Percutaneous endovascular interventions with transluminal angioplasty, atherectomy, and intravascular lithotripsy are the current nonsurgical treatments for severe calcific plaque. Unfortunately, there are no randomized controlled trials that address the optimal approach to PAD and CLI revascularization in patients with CKD.
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Affiliation(s)
- Yogamaya Mantha
- Division of Cardiology, Department of Medicine, UT Health San Antonio, MC 7872, 8300 Floyd Curl Drive, San Antonio, TX 78229-3900, USA
| | - Anum Asif
- Division of Cardiology, Department of Medicine, UT Health San Antonio, MC 7872, 8300 Floyd Curl Drive, San Antonio, TX 78229-3900, USA
| | - Ayman Fath
- Division of Cardiology, Department of Medicine, UT Health San Antonio, MC 7872, 8300 Floyd Curl Drive, San Antonio, TX 78229-3900, USA
| | - Anand Prasad
- Division of Cardiology, Department of Medicine, UT Health San Antonio, MC 7872, 8300 Floyd Curl Drive, San Antonio, TX 78229-3900, USA.
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203
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Paraskevas KI, Veith FJ. Expansion of Bypass as a Revascularization Option for Patients With Chronic Limb-Threatening Ischemia. Angiology 2023; 74:809-811. [PMID: 36880697 DOI: 10.1177/00033197231162707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Affiliation(s)
| | - Frank J Veith
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY, USA
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA
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204
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Kumar M, Long GW, Rimar SD, Studzinski DM, Callahan RE, Brown OW. Indications for a "Surgery-First" Approach for the Treatment of Lower Extremity Arterial Disease. Ann Vasc Surg 2023; 96:241-252. [PMID: 37023923 DOI: 10.1016/j.avsg.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/24/2023] [Accepted: 03/24/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND In recent years, there has been a tendency toward an "endovascular-first" approach for the treatment for femoropopliteal arterial disease. The purpose of this study is to determine if there are patients that are better served with an initial femoropopliteal bypass (FPB) rather than an endovascular attempt at revascularization. METHODS A retrospective analysis of all patients undergoing FPB between June 2006 - December 2014 was performed. Our primary endpoint was primary graft patency, defined as patent using ultrasound or angiography without secondary intervention. Patients with <1-year follow-up were excluded. Univariate analysis of factors significant for 5-year patency was performed using χ2 tests for binary variables. A binary logistic regression analysis incorporating all factors identified as significant by univariate analysis was used to identify independent risk factors for 5-year patency. Event-free graft survival was evaluated using Kaplan-Meier models. RESULTS We identified 241 patients undergoing FPB on 272 limbs. FPB indication was disabling claudication in 95 limbs, chronic limb-threatening ischemia (CLTI) in 148, and popliteal aneurysm in 29. In total, 134 FPB were saphenous vein grafts (SVG), 126 were prosthetic grafts, 8 were arm vein grafts, and 4 were cadaveric/xenografts. There were 97 bypasses with primary patency at 5 or more years of follow-up. Grafts patent at 5 years by Kaplan-Meier analysis were more likely to have been performed for claudication or popliteal aneurysm (63% 5-year patency) as compared with CLTI (38%, P < 0.001). Statistically significant predictors (using log rank test) of patency over time were use of SVG (P = 0.015), surgical indication of claudication or popliteal aneurysm (P < 0.001), Caucasian race (P = 0.019) and no history of COPD (P = 0.026). Multivariable regression analysis confirmed these 4 factors as significant independent predictors of 5-year patency. Of note, there was no statistical correlation between FPB configuration (above or below knee anastomosis, in-situ versus reversed saphenous vein) and 5-year patency. There were 40 FPBs in Caucasian patients without a history of COPD receiving SVG for claudication or popliteal aneurysm that had a 92% estimated 5-year patency by Kaplan-Meier survival analysis. CONCLUSIONS Long-term primary patency that was substantial enough to consider open surgery as a first intervention was demonstrated in Caucasian patients without COPD, having good quality saphenous vein, and who underwent FPB for claudication or popliteal artery aneurysm.
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Affiliation(s)
- Mohineesh Kumar
- Department of Surgery, Section of Vascular Surgery, Corewell Health - William Beaumont University Hospital, Royal Oak, MI
| | - Graham W Long
- Department of Surgery, Section of Vascular Surgery, Corewell Health - William Beaumont University Hospital, Royal Oak, MI; Department of Surgery, Oakland University William Beaumont School of Medicine, Rochester, MI.
| | - Steven D Rimar
- Department of Surgery, Section of Vascular Surgery, Corewell Health - William Beaumont University Hospital, Royal Oak, MI
| | - Diane M Studzinski
- Department of Surgery, Section of Vascular Surgery, Corewell Health - William Beaumont University Hospital, Royal Oak, MI
| | - Rose E Callahan
- Department of Surgery, Section of Vascular Surgery, Corewell Health - William Beaumont University Hospital, Royal Oak, MI
| | - O William Brown
- Department of Surgery, Section of Vascular Surgery, Corewell Health - William Beaumont University Hospital, Royal Oak, MI; Department of Surgery, Oakland University William Beaumont School of Medicine, Rochester, MI.
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205
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Palte NK, Adler LSF, Ady JW, Truong H, Rahimi SA, Beckerman WE. Area Deprivation Index is not predictive of worse outcomes after open lower extremity revascularization. J Vasc Surg 2023; 78:1030-1040.e2. [PMID: 37318431 DOI: 10.1016/j.jvs.2023.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Prior research has shown that socioeconomic status (SES) is associated with higher rates of diabetes, peripheral vascular disease, and amputation. We sought to determine whether SES or insurance type increases the risk of mortality, major adverse limb events (MALE), or hospital length of stay (LOS) after open lower extremity revascularization. METHODS We conducted a retrospective analysis of patients who underwent open lower extremity revascularization at a single tertiary care center from January 2011 to March 2017 (n = 542). SES was determined using state Area Deprivation Index (ADI), a validated metric determined by income, education, employment, and housing quality by census block group. Patients undergoing amputation in this same time period (n = 243) were included to compare rates of revascularization to amputation by ADI and insurance status. For patients undergoing revascularization or amputation procedures on both limbs, each limb was treated individually for this analysis. We performed a multivariate analysis of the association between ADI and insurance type with mortality, MALE, and LOS using Cox proportional hazard models, including confounding variables such as age, gender, smoking status, body mass index, hyperlipidemia, hypertension, and diabetes. The cohort with an ADI quintile of 1, meaning least deprived, and the Medicare cohort were used for reference. P values of <.05 were considered statistically significant. RESULTS We included 246 patients undergoing open lower extremity revascularization and 168 patients undergoing amputation. Controlling for age, gender, smoking status, body mass index, hyperlipidemia, hypertension, and diabetes, ADI was not an independent predictor of mortality (P = .838), MALE (P = .094), or hospital LOS (P = .912). Controlling for the same confounders, uninsured status was independently predictive of mortality (P = .033), but not MALE (P = .088) or hospital LOS (P = .125). There was no difference in the distribution of revascularizations or amputations by ADI (P = .628), but there was higher proportion of uninsured patients undergoing amputation compared with revascularization (P < .001). CONCLUSIONS This study suggests that ADI is not associated with an increased risk of mortality or MALE in patients undergoing open lower extremity revascularization, but that uninsured patients are at higher risk of mortality after revascularization. These findings indicate that individuals undergoing open lower extremity revascularization at this single tertiary care teaching hospital received similar care, regardless of their ADI. Further study is warranted to understand the specific barriers that uninsured patients face.
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Affiliation(s)
- Nadia K Palte
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ
| | - Lily S F Adler
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ
| | - Justin W Ady
- Department of Surgery, Division of Vascular and Endovascular Therapy, Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Huong Truong
- Department of Surgery, Division of Vascular and Endovascular Therapy, Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Saum A Rahimi
- Department of Surgery, Division of Vascular and Endovascular Therapy, Robert Wood Johnson Medical School, New Brunswick, NJ
| | - William E Beckerman
- Department of Surgery, Division of Vascular and Endovascular Therapy, Robert Wood Johnson Medical School, New Brunswick, NJ.
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206
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Ricco JB, Roiger RJ, Schneider F, Guetarni F, Thaveau F, Illuminati G, Pasqua R, Chaufour X, Porterie J, Hostalrich A. Editor's Choice - Infra-inguinal Endovascular Revascularisation and Bypass Surgery for Chronic Limb Threatening Ischaemia: a Retrospective European Multicentre Cohort Study with Propensity Score Matching. Eur J Vasc Endovasc Surg 2023; 66:531-540. [PMID: 37385368 DOI: 10.1016/j.ejvs.2023.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 05/31/2023] [Accepted: 06/17/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE The aim of this study was to compare the long term efficacy of lower limb bypass with that of endovascular treatment (EVT) in patients with chronic limb threatening ischaemia (CLTI). METHODS This retrospective, multicentre study evaluated the outcomes of patients with CLTI who underwent first time infra-inguinal bypass or EVT. The primary outcome was to compare amputation free survival (AFS) rates between the two propensity score matched groups. The secondary outcome was to compare wound healing within the first six months. Major adverse events were compared according to the type of revascularisation. RESULTS Overall, 793 patients fulfilled the eligibility criteria, from whom 236 propensity score matched pairs were analysed. The mean follow up was 52 months. The 236 bypass procedures included 190 autogenous bypass grafts (80.5%), 151 (64.0%) of which were infrapopliteal. Among the 236 EVT procedures, the target lesion was the femoropopliteal segment in 81 patients (34.3%), the femoropopliteal and infrapopliteal segments in 101 patients (42.8%), and the infrapopliteal segment in 54 patients (22.9%). AFS was significantly better in the bypass group at five years (60.5 ± 3.6%) compared with the EVT group (35.3 ± 3.6%) (p < .001). Major amputation occurred in 61 patients (25.8%) in the bypass group and 85 patients (36.0%) in the EVT group (HR 0.66, 95% CI 0.47 - 0.92; p = .014). The probability of healing was significantly better in the bypass group at six months compared with the EVT group (p = .003). The median length of stay was shorter for the EVT group (4 days) than for the bypass group (8 days) (p = .001). Urgent re-intervention and re-admission rates were high and did not differ significantly between the groups. CONCLUSION This study has shown that lower limb bypass surgery offered a significantly higher probability of AFS and wound healing compared with EVT in patients with CLTI.
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Affiliation(s)
- Jean-Baptiste Ricco
- Department of Clinical Research and Vascular Surgery Service, Poitiers University Hospital, Poitiers, France.
| | - Richard J Roiger
- Department of Computer Information Science, Minnesota State University, Mankato, MN, USA
| | - Fabrice Schneider
- Department of Vascular Surgery and CIC INSERM 1402, Poitiers University Hospital, Poitiers, France
| | - Farid Guetarni
- Department of Clinical Research and Data Management, Poitiers University Hospital, Poitiers, France; and CNAM, Paris, France
| | - Fabien Thaveau
- Department of Vascular Surgery, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Giulio Illuminati
- Department of Vascular Surgery, University of Rome, La Sapienza, Rome, Italy
| | - Rocco Pasqua
- Department of Vascular Surgery, University of Rome, La Sapienza, Rome, Italy
| | - Xavier Chaufour
- Department of Vascular Surgery, Toulouse University Hospital, Toulouse, France
| | - Jean Porterie
- Department of Cardiovascular Surgery, University Hospital Rangueil Toulouse, Toulouse, France
| | - Aurélien Hostalrich
- Department of Vascular Surgery, Toulouse University Hospital, Toulouse, France
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207
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Levin SR, Farber A, Goodney PP, King EG, Eslami MH, Malas MB, Patel VI, Kiang SC, Siracuse JJ. Five Year Survival in Medicare Patients Undergoing Interventions for Peripheral Arterial Disease: a Retrospective Cohort Analysis of Linked Registry Claims Data. Eur J Vasc Endovasc Surg 2023; 66:541-549. [PMID: 37543356 DOI: 10.1016/j.ejvs.2023.07.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 06/19/2023] [Accepted: 07/31/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE To justify the up front risks of offering elective interventions for intermittent claudication (IC), patients should have reasonable life expectancy to derive durable clinical benefits. Open surgery for chronic limb threatening ischaemia (CLTI) is maximally beneficial in patients surviving ≥ 2 years. The aim was to assess long term survival after IC and CLTI interventions. METHODS In a retrospective cohort analysis, the Vascular Quality Initiative (VQI) registry from 1 January 2010 to 31 May 2021 was queried for peripheral vascular intervention (PVI), infra-inguinal bypasses (IIB), and supra-inguinal bypasses (SIB) for IC and CLTI across 286 US centres. VQI linkage to Medicare insurance claims provided five year survival data. Multivariable analysis identified factors associated with five year mortality. RESULTS There were 31 457 PVIs (44.7% IC, 55.3% CLTI), 7 978 IIBs (26.9% IC, 73.1% CLTI), and 2 149 SIBs (50.1% IC, 49.9% CLTI) recorded in the VQI. Among the PVI, IIB, and SIB cohorts, average ages were 75, 73, and 72 years, respectively. Respective five year mortality after PVI for IC and CLTI was 37.2% and 71.1%; after IIB for IC and CLTI it was 37.8% and 60%; and after SIB for IC and CLTI it was 33.8% and 53.8%. On multivariable analysis, across all procedures, end stage renal disease, CLTI, congestive heart failure, anaemia, chronic obstructive pulmonary disease, and prior amputation were independently associated with increased mortality. Pre-admission home living and pre-operative aspirin use were independently associated with decreased mortality. CONCLUSION Long term survival in Medicare patients undergoing interventions in VQI centres for peripheral arterial disease is poor. Two thirds of CLTI patients and over one third of IC patients were not alive at five years. Intervening for IC in patients with high mortality risk should be avoided. For CLTI patients identified with decreased survival likelihood, intervention durability may be less important than invasiveness. Pre-operative medical optimisation should always be undertaken.
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Affiliation(s)
- Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Centre, Boston, MA, USA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Centre, Boston, MA, USA
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Centre, Lebanon, NH, USA
| | - Elizabeth G King
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Centre, Boston, MA, USA
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Virendra I Patel
- Section of Vascular Surgery and Endovascular Interventions, NYP/Columbia University Irving Medical Centre, New York, NY, USA
| | - Sharon C Kiang
- Division of Vascular and Endovascular Surgery, Loma Linda University Medical Centre, Loma Linda, CA, USA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Centre, Boston, MA, USA.
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208
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Neufang A. [Surgical therapy of peripheral arterial occlusive disease]. Dtsch Med Wochenschr 2023; 148:1307-1316. [PMID: 37757891 DOI: 10.1055/a-2017-7829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
The surgical treatment of peripheral arterial occlusive disease focuses not only on the direct restoration of the femoral bifurcation but also on the peripheral bypass, especially in the case of chronic amputation-threatening ischemia. Comprehensive imaging is indispensable for planning surgical therapy. The local reconstruction of the femoral bifurcation offers very good long-term results and can be easily combined with endovascular methods. The peripheral bypass is the central pillar of surgical therapy, especially in CLTI. Autologous vein should always be the first-choice material. It delivers good long-term results in every position. Prosthetic material is only used if there is no vein and should be combined with autologous veins in the crural and pedal area if possible. The technical limit for a bypass system lies in the pedal arteries and their branches. These methods can be combined with upstream and downstream endovascular interventions in the form of a hybrid intervention. Surgical and endovascular interventions are to be considered as complementary.
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209
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Teßarek J, Elger F, Kolvenbach R, Liebetrau D. [Atherectomy with a Novel Device Offering Wider Options]. Zentralbl Chir 2023; 148:429-437. [PMID: 37699429 DOI: 10.1055/a-2156-5891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
Catheter-based atherectomy has been discussed for some years, although the conclusions have been controversial. Recent study data did show the feasibility of multifunctional atherectomy devices for complex lesion morphologies, with moderate material use. This is then thus an alternative to bypass surgery, although a direct comparison is lacking.The results of the ByCross approval study were compared to technical and clinical data from various atherectomy systems in terms of range of indication, limitations as defined by the manufacturer, the success and complication rate and the instructions for use. As in many recent studies, a residual stenosis ≤ 50% after atherectomy and ≤ 30% in the completion imaging was defined as the primary endpoint and proof of technical success.Lesions recruited for the ByCross study were more complex than in other studies, with respect to the lesion length (124.7 mm vs. 34 mm in the EASE study and 67.2 mm in the VISION study) and the degree of stenosis (99.4% vs. 88.5% in the EASE and 78,7% in the VISION study). Calcification was also more severe - as defined by the PACSS (Peripheral Artery Calcification Severity Score). ByCross allowed recanalisation of lesions without wire passage prior to atherectomy (26.82%), which is a must for all other systems. The variable tip diameter of the ByCross can achieve a lumen gain of 4.7 mm without tip or wire exchange or run time limits. The 0% rate of embolic events, which is unique for atherectomy device approval studies, can be explained by the working principle and the high aspiration rate. No vessel injuries occurred, and the 6-month follow-up results showed 0% revascularisation rate.New generation atherectomy systems offer safe and effective enlargement of the endovascular portfolio. The ByCross device is an atherectomy, thrombectomy and crossing device free from investment and has a wider range of indications for the iliac and the femorodistal segments, which supports ByCross atherectomy as an alternative for bypass surgery.
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Affiliation(s)
- Jörg Teßarek
- Gefäßchirurgie, Bonifatius-Hospital, Lingen, Deutschland
| | - Florian Elger
- Gefäßchirurgie, Universitätsklinikum Göttingen, Gottingen, Deutschland
| | - Ralf Kolvenbach
- Gefäßchirurgie, Sana Kliniken Düsseldorf GmbH, Düsseldorf, Deutschland
| | - Dominik Liebetrau
- Gefäßchirurgie, Universitätsklinikum Augsburg, Augsburg, Deutschland
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Bosiers MJ, De Donato G, Torsello G, Silveira PG, Scheinert D, Veroux P, Hendriks J, Maene L, Keirse K, Navarro T, Eckstein HH, Teβarek J, Giaquinta A, van den Eynde W, Verbist J, Callaert J, Deloose K, Bosiers M. ZILVERPASS Study: ZILVER PTX Stent versus Prosthetic Above-the-Knee Bypass Surgery in Femoropopliteal Lesions, 5-year Results. Cardiovasc Intervent Radiol 2023; 46:1348-1358. [PMID: 37670198 PMCID: PMC10547807 DOI: 10.1007/s00270-023-03549-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/24/2023] [Indexed: 09/07/2023]
Abstract
PURPOSE To report the 60-month safety and effectiveness results of a multicenter, prospective, randomized controlled trial comparing the ZILVER PTX paclitaxel-eluting stent to prosthetic above-the-knee bypass for the treatment of symptomatic TransAtlantic Inter-Society Consensus (TASC) C and D femoropopliteal lesions. MATERIALS AND METHODS Patients were enrolled between October 2013 and July 2017. One of the secondary outcomes was primary patency at 60 months, defined as no evidence of binary restenosis or occlusion within the target lesion or bypass graft based on a duplex ultrasound peak systolic velocity ratio < 2.4 and no clinically-driven target lesion revascularization (TLR) in endovascular cases or reintervention to restore flow in the bypass at 60 months. Survival rates after 5 years were also analyzed. RESULTS 220 patients (mean age 68.6 ± 10.5 years; 159 men) were included and randomized to ZILVER PTX (n = 113, 51.40%) or BYPASS group (n = 107, 48.60%). The 60-month primary patency rate was 49.3% for the ZILVER PTX group versus 40.7% for the bypass group (p = 0.6915). Freedom from TLR was 63.8% for the ZILVER PTX group versus 52.8% for the bypass group (p = 0.2637). At 5 years, no significant difference in survival rate could be seen between the ZILVER PTX and the bypass group (69.1% vs. 71% respectively, p = 0.5503). CONCLUSION Even at 5 years, non-inferior safety and effectiveness results of the ZILVER PTX could be seen. These findings confirmed that the use of ZILVER PTX stents can be considered as a valid alternative for bypass surgery when treating long and complex femoropopliteal lesions.
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Affiliation(s)
- Michel J Bosiers
- Department of Vascular Surgery, St. Franziskus-Hospital, Münster, Germany.
- Department of Vascular Surgery, University Hospital Bern, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland.
| | | | - Giovanni Torsello
- Department of Vascular Surgery, St. Franziskus-Hospital, Münster, Germany
| | | | - Dierk Scheinert
- Department of Angiology, University Hospital of Leipzig, Leipzig, Germany
| | | | - Jeroen Hendriks
- Department of Vascular Surgery, University Hospital of Antwerp, Edegem, Belgium
| | - Lieven Maene
- Department of Vascular Surgery, OLV Hospital Aalst, Aalst, Belgium
| | - Koen Keirse
- Department of Vascular Surgery, RZ Heilig Hart Tienen, Tienen, Belgium
| | - Tulio Navarro
- Department of Vascular Surgery, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | - Jörg Teβarek
- Department of Vascular Surgery, St. Bonifatius Hospital Lingen, Lingen, Germany
| | - Alessia Giaquinta
- Department of Vascular Surgery, University Hospital of Catania, Catania, Italy
| | | | - Jürgen Verbist
- Department of Vascular Surgery, Imelda Hospital, Bonheiden, Belgium
| | - Joren Callaert
- Department of Vascular Surgery, AZ St. Blasius, Dendermonde, Belgium
| | - Koen Deloose
- Department of Vascular Surgery, AZ St. Blasius, Dendermonde, Belgium
| | - Marc Bosiers
- Department of Vascular Surgery, AZ St. Blasius, Dendermonde, Belgium
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211
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Reijnen MMPJ, van Wijck I, Brodmann M, Micari A, Torsello G, Rha SW, Menk J, Zeller T. Five-Year Outcomes after Paclitaxel Drug-Coated Balloon Treatment of Femoropopliteal Lesions in Diabetic and Chronic Limb-Threatening Ischemia Cohorts: IN.PACT Global Study Post Hoc Analysis. Cardiovasc Intervent Radiol 2023; 46:1329-1345. [PMID: 37526706 PMCID: PMC10547845 DOI: 10.1007/s00270-023-03478-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/24/2023] [Indexed: 08/02/2023]
Abstract
PURPOSE To summarize the 5-year outcomes of drug-coated balloon (DCB) for the treatment of femoropopliteal lesions in patients with diabetes mellitus (DM) or chronic limb-threatening ischemia (CLTI) compared to non-DM and intermittent claudication (IC). METHODS The IN.PACT Global study was a real-world prospective, multicenter, international, single-arm study that enrolled 1535 participants. Post hoc analyses were conducted for participants with DM (n = 560) versus non-DM (n = 842) and CLTI (n = 156) versus IC (n = 1246). Assessments included freedom from clinically driven target lesion revascularization (CD-TLR) through 60 months, a composite safety outcome (freedom from device- and procedure-related death through 30 days, and freedom from major target limb amputation and freedom from CD-target vessel revascularization within 60 months), and major adverse events (MAEs). RESULTS Kaplan-Meier estimates of 60-month freedom from CD-TLR were 67.7% and 70.5% (p = 0.25) in the DM and non-DM cohorts; and 60.7% and 70.5% (p = 0.006) in the CLTI and IC cohorts. The Kaplan-Meier 60-month composite safety outcomes were 65.1% DM versus 68.9% non-DM (p = 0.12); 53.2% CLTI versus 69.1% IC (p < 0.001). Between DM and non-DM, MAE rates were not significantly different through 60 months except for all-cause mortality which was higher in DM (23.8% versus 16.6%; p < 0.001). Participants with CLTI had a higher cumulative incidence of major target limb amputation (6.8% versus 1.1%; p < 0.001) and all-cause mortality (37.4% versus 17.4%; p < 0.001) through 60 months compared to IC. CONCLUSIONS In this real-world study, 5-year reintervention rates following DCB angioplasty were similar between DM and non-DM, but mortality rates were expectedly higher in patients with DM. Reintervention, mortality, and amputation rates were all higher in CLTI patients compared to IC, which is consistent with the known frailty of this patient population. LEVEL OF EVIDENCE Level 3, Non-randomized controlled cohort/follow-up study.
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Affiliation(s)
- Michel M P J Reijnen
- Department of Vascular Surgery, Rijnstate, Arnhem, The Netherlands.
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, The Netherlands.
| | - Iris van Wijck
- Department of Vascular Surgery, Rijnstate, Arnhem, The Netherlands
| | - Marianne Brodmann
- Department of Internal Medicine, Division of Angiology, Medical University, Graz, Austria
| | | | - Giovanni Torsello
- Institute for Vascular Research, St Franziskus-Hospital, Münster, Germany
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | | | - Thomas Zeller
- Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
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212
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Zenunaj G, Acciarri P, Baldazzi G, Cosacco AM, Gasbarro V, Traina L. Endovascular Revascularisation versus Open Surgery with Prosthetic Bypass for Femoro-Popliteal Lesions in Patients with Peripheral Arterial Disease. J Clin Med 2023; 12:5978. [PMID: 37762924 PMCID: PMC10532352 DOI: 10.3390/jcm12185978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
Aim: Complex atherosclerotic femoro-popliteal lesions have traditionally been treated with bypass surgery. A prosthetic graft is used to save the vein graft for more distal revascularisations or when a vein graft is unavailable. The endovascular approach has gained popularity and is offered as a first-line strategy for complex lesions. This study aimed to evaluate whether endovascular procedures can be used as a first-line treatment strategy for complex native femoro-popliteal lesions over open surgery with prosthetic bypass in patients with peripheral arterial disease (PAD). Methods: This single-centre retrospective observational study was conducted between 2013 and 2021; it included patients with symptomatic PAD who required limb revascularisation at the femoro-popliteal segment and who had complex lesions. The primary endpoints analysed were technical success, primary patency, freedom from clinically driven target lesion revascularisation (cdTLR), freedom from major adverse limb and cardiovascular events (MALE and MACE, respectively), freedom from limb loss, and survival. The secondary endpoints were length of in-hospital stay, and duration and costs of the procedure. Results: We identified 185 limbs among 174 suitable candidates for comparison, wherein 105 were treated with an endovascular procedure and 80 with a femoro-popliteal prosthetic bypass. Most patients in both groups presented with chronic limb-threatening ischaemia, and >90% of them had an American Society of Anesthesiologists (ASA) physical status classification of >3. The endovascular group had more octogenarians (p = 0.02) and patients with coronary disease (p = 0.004). The median follow-up was 30 months. The technical failure rate for endovascular procedures was 4.7%, versus 0% in the open group (p = 0.047). Freedom from MACE was similar in both groups. The endovascular group showed superior primary patency (p < 0.0001), cdTLR (p < 0.0001), MALE (p < 0.0001), and freedom from limb loss (p = 0.0018) at 24 and 48 months. Further analysis performed for the open above-the-knee sub-group showed that the aforementioned endpoints were similar between the groups at 12 months and were better in the endovascular group at 24 and 48 months. Procedural time and in-hospital stay were longer in the open group than in the endovascular group (p < 0.0001 and p < 0.001, respectively). The procedural cost in the endovascular group was 10-fold lower than that in the prosthetic bypass group. Conclusions: Endovascular procedures are safe for treating complex femoro-popliteal lesions in patients at a high risk for surgery and show better outcomes at 24 months than prosthetic bypasses do. The latter may be considered as an alternative should endovascular treatment fail.
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Affiliation(s)
- Gladiol Zenunaj
- Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, 44124 Ferrara, Italy; (P.A.); (V.G.); (L.T.)
| | - Pierfilippo Acciarri
- Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, 44124 Ferrara, Italy; (P.A.); (V.G.); (L.T.)
| | - Giulia Baldazzi
- Department of Translational Medicine for Romagna, School of Vascular Surgery, University of Ferrara, 44121 Ferrara, Italy; (G.B.); (A.M.C.)
| | - Alessio Mario Cosacco
- Department of Translational Medicine for Romagna, School of Vascular Surgery, University of Ferrara, 44121 Ferrara, Italy; (G.B.); (A.M.C.)
| | - Vincenzo Gasbarro
- Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, 44124 Ferrara, Italy; (P.A.); (V.G.); (L.T.)
- Department of Translational Medicine for Romagna, School of Vascular Surgery, University of Ferrara, 44121 Ferrara, Italy; (G.B.); (A.M.C.)
| | - Luca Traina
- Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, 44124 Ferrara, Italy; (P.A.); (V.G.); (L.T.)
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213
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot Ulcer. Eur J Vasc Endovasc Surg 2023:S1078-5884(23)00586-5. [PMID: 37724984 DOI: 10.1016/j.ejvs.2023.07.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
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214
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Cleman J, Romain G, Grubman S, Guzman RJ, Smolderen KG, Mena-Hurtado C. Comparison of lower extremity bypass and peripheral vascular intervention for chronic limb-threatening ischemia in the Medicare-linked Vascular Quality Initiative. J Vasc Surg 2023; 78:745-753.e6. [PMID: 37207790 PMCID: PMC10964324 DOI: 10.1016/j.jvs.2023.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/21/2023]
Abstract
OBJECTIVE There is a relative lack of comparative effectiveness research on revascularization for patients with chronic limb-threatening ischemia (CLTI). We examined the association between lower extremity bypass (LEB) vs peripheral vascular intervention (PVI) for CLTI and 30-day and 5-year all-cause mortality and 30-day and 5-year amputation. METHODS Patients undergoing LEB and PVI of the below-the-knee popliteal and infrapopliteal arteries between 2014 and 2019 were queried from the Vascular Quality Initiative, and outcomes data were obtained from the Medicare claims-linked Vascular Implant Surveillance and Interventional Outcomes Network database. Propensity scores were calculated on 15 variables using a logistic regression model to control for imbalances between treatment groups. A 1:1 matching method was used. Kaplan-Meier survival curves and hierarchical Cox proportional hazards regression with a random intercept for site and operator nested in site to account for clustered data compared 30-day and 5-year all-cause mortality between groups. Thirty-day and 5-year amputation were subsequently compared using competing risk analysis to account for the competing risk of death. RESULTS There was a total of 2075 patients in each group. The overall mean age was 71 ± 11 years, 69% were male, and 76% were white, 18% were black, and 6% were of Hispanic ethnicity. Baseline clinical and demographic characteristics in the matched cohort were balanced between groups. There was no association between all-cause mortality over 30 days and LEB vs PVI (cumulative incidence, 2.3% vs 2.3% by Kaplan Meier; log-rank P-value = .906; hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.62-1.44; P-value = .80). All-cause mortality over 5 years was lower for LEB vs PVI (cumulative incidence, 55.9% vs 60.1% by Kaplan Meier; log-rank P-value < .001; HR, 0.77; 95% CI, 0.70-0.86; P-value < .001). Accounting for competing risk of death, amputation over 30 days was also lower in LEB vs PVI (cumulative incidence function, 1.9% vs 3.0%; Fine and Gray P-value = .025; subHR, 0.63; 95% CI, 0.42-0.95; P-value = .025). There was no association between amputation over 5 years and LEB vs PVI (cumulative incidence function, 22.6% vs 23.4%; Fine and Gray P-value = .184; subHR, 0.91; 95% CI, 0.79-1.05; P-value = .184). CONCLUSIONS In the Vascular Quality Initiative-linked Medicare registry, LEB vs PVI for CLTI was associated with a lower risk of 30-day amputation and 5-year all-cause mortality. These results will serve as a foundation to validate recently published randomized controlled trial data, and to broaden the comparative effectiveness evidence base for CLTI.
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Affiliation(s)
- Jacob Cleman
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Scott Grubman
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Raul J Guzman
- Division of Vascular Surgery, Yale School of Medicine, New Haven, CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT
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215
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Jansen S, Teraa M, Chan N, Bosch J, de Borst GJ, Hinchliffe R. Assessing Limb Outcomes in Drug Trials in Peripheral Artery Disease: The Need for a Universal and Pragmatic Definition. Eur J Vasc Endovasc Surg 2023; 66:442-443. [PMID: 37327967 DOI: 10.1016/j.ejvs.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/15/2023] [Accepted: 06/08/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Shirley Jansen
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
| | - Martin Teraa
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Noel Chan
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jackie Bosch
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Robert Hinchliffe
- Bristol Centre for Surgical Research, Bristol NIHR Biomedical Research Centre, University of Bristol, United Kingdom
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216
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Stavroulakis K, Katsogridakis E, Torsello G, Zayed H, van Herzeele I, Coscas R, Nasr B, Gonzalez TM, Troisi N, Saratzis A. Editor's Choice - RANDOMisation Screening for Drug coated or Drug Eluting Device Randomised Trials Among Patients Undergoing Endovascular FemorOPopliteal Procedures (RANDOM-STOP study). Eur J Vasc Endovasc Surg 2023; 66:362-368. [PMID: 37406876 DOI: 10.1016/j.ejvs.2023.06.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/13/2023] [Accepted: 06/28/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE The aim was to assess the proportion of patients undergoing endovascular therapy for femoropopliteal arterial disease (FP) who would be eligible to take part in seven major randomised controlled trials (RCTs) that investigated the efficacy of some of the currently available paclitaxel based (PTX) devices used in this clinical context. Various RCTs have shown a potential clinical benefit from the use of paclitaxel in FP endovascular therapy. Nonetheless, patients enrolled were highly selected and the generalisability of these findings in pragmatic cohorts is unclear. METHODS Between 1 January and 31 December 2021, all consecutive patients who underwent endovascular procedures for symptomatic FP disease in 16 European centres were retrospectively screened and included in this analysis. The primary outcome measure was individual patient eligibility for inclusion into at least one of the seven RCTs. The reasons for exclusion (clinical and or radiological) as well as in hospital death and morbidity were also reported. RESULTS A total of 1 567 consecutive patients (959 male, 61%), corresponding to 1 567 lower limbs, were included. Most patients (1 009 patients, 64.39%) were treated for chronic limb threatening ischaemia (CLTI). A total 1 280 patients (81.68%) were not eligible for inclusion in any of the evaluated RCTs. Of them, 741 (47.28%) were excluded for clinical and 1 125 (71.79%) for radiological reasons. CONCLUSION The analysed RCTs assessing the efficacy or effectiveness of PTX based endovascular therapies do not seem representative of the patient population with FP disease receiving endovascular therapy in routine clinical practice.
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Affiliation(s)
| | - Emmanuel Katsogridakis
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Giovanni Torsello
- Department of Vascular Surgery, St. Franziskus-Hospital, Munster, Germany
| | - Hany Zayed
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Raphael Coscas
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris
| | - Bahaa Nasr
- Department of Vascular Surgery, Cavale Blanche University Hospital of Brest, France
| | | | - Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy
| | - Athanasios Saratzis
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
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217
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Kuroki MT, Parikh UM, Chandra V. How I do it: Pedal access and pedal loop revascularization for patients with chronic limb-threatening ischemia. J Vasc Surg Cases Innov Tech 2023; 9:101236. [PMID: 37496650 PMCID: PMC10366544 DOI: 10.1016/j.jvscit.2023.101236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
An increasing proportion of patients with chronic limb-threatening ischemia are older and have multiple comorbidities, including diabetes and renal failure. For those who are not candidates for a surgical bypass, this set of patients presents a challenge to vascular surgeons and interventionalists owing to the complex below-the-knee and increasingly below-the-ankle disease pattern that can fail traditional approaches for endovascular intervention. Two techniques, the retrograde pedal access and the pedal-plantar loop technique, can be useful in these settings and in skilled hands can be used safely, with a high technical success rate. In patients with chronic limb-threatening ischemia who are not candidates for a single-segment saphenous vein bypass, the retrograde pedal access technique can be used not only in the setting of failed antegrade treatment, but also primarily when faced with a difficult groin or as an adjunct during a planned antegrade-retrograde intervention. The pedal plantar loop technique allows for retrograde access to tibial vessels without retrograde vessel puncture and additionally offers the ability to treat the pedal-plantar arch, which may have added benefit in wound healing. We describe the tips and tricks for these two techniques used in our limb salvage practice.
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Affiliation(s)
| | | | - Venita Chandra
- Correspondence: Venita Chandra, MD, Clinical Professor of Surgery, Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, 780 Welch Rd, Ste CJ350H, Palo Alto, CA 94304
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218
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Panthofer AM, Yi JA, Chiou AC, Matsumura JS. Acute ischemia secondary to popliteal artery stent fracture and embolization. J Vasc Surg Cases Innov Tech 2023; 9:101143. [PMID: 37799850 PMCID: PMC10547732 DOI: 10.1016/j.jvscit.2023.101143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/14/2023] [Indexed: 10/07/2023] Open
Abstract
Femoropopliteal disease comprises more than one half of lesions in peripheral vascular disease. The treatment modalities for stenosis or occlusion of this anatomic region include femoropopliteal bypass and percutaneous transluminal angioplasty with or without stenting. Our patient developed acute leg ischemia 3 years after stenting, secondary to stent fracture, with distal embolization of stent fragments. Using mechanical thromboembolectomy and superficial femoral artery to below-the-knee popliteal in situ saphenous vein bypass, we were able to restore perfusion to the limb and retrieve fragments of the fractured stent.
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Affiliation(s)
- Annalise M. Panthofer
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jeniann A. Yi
- Division of Vascular Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Jon S. Matsumura
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
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219
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Alonso AG, Kobzeva-Herzog A, Siracuse JJ. Alternative access for peripheral vascular interventions. J Vasc Surg Cases Innov Tech 2023; 9:101232. [PMID: 37408940 PMCID: PMC10319322 DOI: 10.1016/j.jvscit.2023.101232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/11/2023] [Indexed: 07/07/2023] Open
Abstract
Percutaneous endovascular interventions for advanced lower extremity peripheral arterial disease are becoming increasingly used, often as first-line treatment of chronic limb threatening ischemia. Advancements in endovascular techniques have provided safe and effective alternative revascularization options, especially for high-risk surgical patients. Although the classic transfemoral approach results in high technical success and patency rates, an estimated 20% of lesions remain challenging to access via an antegrade approach. As such, alternative access sites are important in the endovascular armamentarium for the management of chronic limb threatening ischemia. The goal of this review is to discuss alternative access sites, specifically the transradial, transpopliteal, and transpedal approaches, in addition to transbrachial and transaxillary access, and their outcomes in peripheral arterial disease and limb salvage.
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Affiliation(s)
| | | | - Jeffrey J. Siracuse
- Correspondence: Jeffrey J. Siracuse, MD, MBA, Department of Surgery, Boston University Chobanian and Avedisian School of Medicine, 85 E Concord St, Boston, MA 02118
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220
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Okazaki R, Hamburg NM. PCSK9-Inhibition to Quench Vascular Injury in Chronic Limb Threatening Ischemia. JACC Basic Transl Sci 2023; 8:1078-1080. [PMID: 37791306 PMCID: PMC10544103 DOI: 10.1016/j.jacbts.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Affiliation(s)
- Ross Okazaki
- Whitaker Cardiovascular Institute and Section of Vascular Biology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Naomi M. Hamburg
- Whitaker Cardiovascular Institute and Section of Vascular Biology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
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221
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Lou V, Dossabhoy SS, Tran K, Yawary F, Ross EG, Stern JR, Dalman RL, Chandra V. Validity of the Global Vascular Guidelines in Predicting Outcomes Based on First-Time Revascularization Strategy. Ann Vasc Surg 2023; 95:142-153. [PMID: 36828135 DOI: 10.1016/j.avsg.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND The Global Vascular Guidelines (GVG) recommend selecting an endovascular versus open-surgical approach to revascularization for chronic limb-threatening ischemia (CLTI), based on the Global Limb Anatomic Staging System (GLASS) and wound, ischemia, and foot infection (WIfI) classification systems. We assessed the utility of GVG-recommended strategies in predicting clinical outcomes. METHODS We conducted a single-center, retrospective review of first-time lower-extremity revascularizations within a comprehensive limb-preservation program from 2010 to 2018. Procedures were stratified by (1) treatment concordance with GVG-recommended strategy (concordant versus nonconcordant groups), (2) GLASS stages I-III, and (3) endovascular versus open strategies. The primary outcome was 5-year freedom from major adverse limb events (FF-MALE), defined as freedom from reintervention or major amputation, and secondary outcomes included 5-year overall survival, freedom from major amputation, freedom from reintervention, and immediate technical failure (ITF) during initial revascularization. Kaplan-Meier (KM) survival analysis and multivariate analysis with Cox proportional hazard models were performed on the primary and secondary outcomes. RESULTS Of 281 first-time revascularizations for CLTI, 251 (89.3%) were endovascular and 186 (66.2%) were in the concordant group, with a mean clinical follow-up of 3.02 ± 2.40 years. Within the concordant group alone, 167 (89.8%) of revascularizations were endovascular. The concordant group had a higher rate of chronic kidney disease (60.8% vs. 45.3%, P = 0.02), WIfI foot infection grade (0.81 ± 1.1 vs. 0.56 ± 0.80, P = 0.03), and WIfI stage (3.1 ± 0.79 vs. 2.8 ± 1.2, P < 0.01) compared to the non-concordant group. After both KM and multivariate analyses, there were no significant differences in 5-year FF-MALE or overall survival between concordant and non-concordant groups. There was higher freedom from major amputation in the non-concordant group on KM analysis (83.9% vs. 74.2%, P = 0.025), though this difference was non-significant on multivariate analysis (hazard ratio [HR]: 0.49, 95% confidence interval [CI]: 0.21-1.15, P = 0.10). The open group had lower MALE compared to the endovascular group (HR: 0.39, 95% CI: 0.17-0.91, P = 0.029) attributed to a lower reintervention rate in the open group (HR: 0.31, 95% CI: 0.11-0.87, P = 0.026). GLASS stage was not associated with significant differences in outcomes, but the severity of GLASS stage was associated with ITF (2.1% in stage 1, 6.4% in stage 2, and 11.7% in stage 3, P = 0.01). CONCLUSIONS In this study, CLTI treatment outcomes did not differ significantly based on whether treatment was received in concordance with GVG-recommended strategy. There was no difference in overall survival between the endovascular and open groups, though there was a higher reintervention rate in the endovascular group. The GVG guidelines are an important resource to help guide the management of CLTI patients. However, in this study, both concordance with GVG guidelines and GLASS staging were found to be indeterminate in differentiating outcomes between complex CLTI patients treated primarily with an endovascular-first approach. The revascularization approach for a CLTI patient is a nuanced decision that must take into account patient anatomy and clinical status, as well as physician skill and experience and institutional resources.
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Affiliation(s)
- Vivian Lou
- Stanford University School of Medicine, Stanford, CA
| | - Shernaz S Dossabhoy
- Stanford Health Care, Division of Vascular & Endovascular Surgery, Stanford, CA
| | - Kenneth Tran
- Stanford Health Care, Division of Vascular & Endovascular Surgery, Stanford, CA
| | - Farishta Yawary
- Stanford Health Care, Division of Vascular & Endovascular Surgery, Stanford, CA
| | - Elsie G Ross
- Stanford Health Care, Division of Vascular & Endovascular Surgery, Stanford, CA
| | - Jordan R Stern
- Stanford Health Care, Division of Vascular & Endovascular Surgery, Stanford, CA
| | - Ronald L Dalman
- Stanford Health Care, Division of Vascular & Endovascular Surgery, Stanford, CA
| | - Venita Chandra
- Stanford Health Care, Division of Vascular & Endovascular Surgery, Stanford, CA.
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222
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Farazdaghi A, Sen I, Anderson PB, Shuja F, Rasmussen TE. The Human Acellular Vessel (HAV) as a vascular conduit for infrainguinal arterial bypass. J Vasc Surg Cases Innov Tech 2023; 9:101123. [PMID: 37674588 PMCID: PMC10477679 DOI: 10.1016/j.jvscit.2023.101123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/24/2023] [Indexed: 09/08/2023] Open
Abstract
Autologous vein is the optimal conduit for peripheral arterial bypass surgery, a standard recently highlighted by findings from the BEST-CLI trial. The Human Acellular Vessel is a novel biologic conduit produced using regenerative medicine technologies with structural and mechanical properties like a human blood vessel. Not yet approved by the United States Food and Drug Administration, the Human Acellular Vessel is being studied as an alternative bypass conduit in patients with peripheral arterial disease, vascular injury, and those in need of arteriovenous access for hemodialysis. This report describes and illustrates the technical aspects of intraoperative handling specific to the use of this new and innovative technology.
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Affiliation(s)
- Armin Farazdaghi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Indrani Sen
- Vascular and Endovascular Surgery, Mayo Clinic Health Systems, EauClaire, WI
| | - Peter B. Anderson
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Todd E. Rasmussen
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
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223
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Campbell DB, Sobol CG, Sarac TP, Stacy MR, Atway S, Go MR. The natural history of chronic limb-threatening ischemia after technical failure of endovascular intervention. J Vasc Surg 2023; 78:737-744. [PMID: 37141950 PMCID: PMC10524400 DOI: 10.1016/j.jvs.2023.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVES The treatment for chronic limb-threatening ischemia (CLTI) has changed dramatically in the last few decades with a shift toward an endovascular-first approach and aggressive revascularization to achieve limb salvage. As the size of the CLTI population and intervention rates increase, patients will continue to experience technical failure (TF). Here, we describe the natural history of patients after TF of endovascular intervention for CLTI. METHODS We conducted a retrospective cohort study of patients with CLTI who attempted endovascular intervention or bypass at our multidisciplinary limb salvage center from 2013 to 2019. Patient characteristics were collected according to the Society for Vascular Surgery's reporting standards. Primary outcomes included survival, limb salvage, wound healing, and revascularization patency. Product-limit Kaplan-Meier estimated survival functions for these outcomes, and between-group comparisons were made using Mantel-Cox log-rank nonparametric tests. RESULTS We identified 242 limbs from 220 unique patients who underwent primary bypass (n = 30) or attempted endovascular intervention (n = 212) at our limb salvage center. Endovascular intervention was a TF in 31 (14.6%) limbs. After TF, 13 limbs underwent secondary bypass and 18 limbs were managed medically. Patients who experienced TF tended to be older (P < .001), male (P = .003), current tobacco users (P = .014), have longer lesions (P = .001), and have chronic total occlusions of target arteries (P < .001) as compared with those who experienced technical success. Furthermore, the TF group had worse limb salvage (P = .047) and slower wound healing (P = .028), but their survival was not different. Survival, limb salvage, and wound healing were not different in patients who received secondary bypass or medical management after TF. The secondary bypass group was older (P = .012) and had a lower prevalence of tibial disease (P = .049) than the primary bypass group and trended toward decreased survival, limb salvage, and wound healing (P = .059, P = .083, and P = .051, respectively). CONCLUSIONS Increased age, male sex, current tobacco use, longer arterial lesions, and occluded target arteries are associated with TF of endovascular intervention. Limb salvage and wound healing are relatively poor after TF of endovascular intervention, but survival appears comparable with patients who experience technical success. Secondary bypass may not always rescue patients after TF, though our sample size limits statistical power. Interestingly, patients who received a secondary bypass after TF trended toward decreased survival, limb salvage, and wound healing compared with primary bypass.
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Affiliation(s)
- Drayson B Campbell
- The Ohio State of Medicine, Columbus, OH; Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Carly G Sobol
- The Ohio State of Medicine, Columbus, OH; Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH; Division of Vascular Surgery, Department of Surgery, University of Wisconsin, Madison, WI
| | - Timur P Sarac
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mitchel R Stacy
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH; Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH; Interdisciplinary Biophysics Graduate Program, The Ohio State University, Columbus, OH
| | - Said Atway
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH
| | - Michael R Go
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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Harnanan D, Parbhu S, Pran L, Baboolal I, Harnarayan P, Naraynsingh V, Seecheran N. Endovascular Revascularization and Outcomes of Critical Limb-Threatening Ischemia in Trinidad and Tobago: The EVENT Pilot Study-Challenges in a Limited-Resource, Caribbean Setting. Cardiol Ther 2023; 12:511-524. [PMID: 37329412 PMCID: PMC10423177 DOI: 10.1007/s40119-023-00322-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/31/2023] [Indexed: 06/19/2023] Open
Abstract
INTRODUCTION This retrospective study investigated major adverse limb events (MALE) and mortality outcomes in critical limb-threatening ischemia (CLTI) patients with tissue loss after an endovascular revascularization-first (EVR-1st) strategy. METHODS MALE and mortality were assessed in 157 consecutive patients with CLTI and tissue loss from June 2019 to June 2022 at the Eric Williams Medical Sciences Complex, Trinidad and Tobago. RESULTS 157 patients underwent the EVR-1st strategy, of whom 20 were pivoted to immediate surgical revascularization (SR). Of the remaining 137 patients, successful EVR was achieved in 112, giving a procedural success of 82% and an all-comer overall success of 71%. The mortality and MALE rates were 2.7% and 8.9% at 2 years, respectively. Males and patients with previous major amputations were at significantly higher risk for MALE (p values of 0.016 and 0.018, respectively). There was a statistically significant difference in successful EVR for both Rutherford-Baker (RB) 5 (minor) and RB 6 (major) classifications: 63 (56%) vs. 5 (20%) and 49 (44%) vs. 20 (80%), both with a p value of 0.01. There were no differences in successful EVR amongst Wound, Ischemia, Foot Infection (WIfI) clinical stages. There were no differences in successful EVR amongst the Trans-Atlantic Inter-Society Consensus (TASC II) classifications. CONCLUSIONS This study may prove clinically informative and applicable for an EVR-1st management strategy for high-risk patients with CLTI in a limited-resource, Caribbean setting. TRIAL REGISTRATION NUMBER NCT05547022 (retrospectively registered).
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Affiliation(s)
- Dave Harnanan
- Department of Clinical Surgical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Sangeeta Parbhu
- Department of Clinical Surgical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Lemuel Pran
- Department of Surgery, North Central Regional Health Authority, Mount Hope, Trinidad and Tobago
| | - Ilecia Baboolal
- Department of Surgery, North Central Regional Health Authority, Mount Hope, Trinidad and Tobago
| | - Patrick Harnarayan
- Department of Clinical Surgical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Naveen Seecheran
- Department of Clinical Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago.
- Faculty of Medical Sciences, The University of the West Indies, 2nd Floor, Building #67, Eric Williams Medical Sciences Complex, Mt. Hope, Trinidad and Tobago.
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225
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O'Banion LA. Does an old dog need new tricks? Advancement of limb salvage in treating chronic limb threatening ischemia. J Vasc Surg Cases Innov Tech 2023; 9:101267. [PMID: 37635742 PMCID: PMC10448157 DOI: 10.1016/j.jvscit.2023.101267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Affiliation(s)
- Leigh Ann O'Banion
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA
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Abstract
As the number of patients affected by peripheral arterial disease continues to increase, new technical approaches and devices have been developed to provide effective and durable treatment options that will lead to improved outcomes. While the mainstay of endovascular intervention remains mostly balloon-based, several innovative techniques and technologies are in development that may provide new solutions. This review highlights recent endovascular advancements in the management of chronic limb-threatening ischemia and additional adjunctive devices that are needed to improve lesion patency, reduce the need for reintervention, and lead to better patient-centered functional outcomes.
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Affiliation(s)
- Arash Fereydooni
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Venita Chandra
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University, Stanford, CA, USA; Stanford School of Medicine, 780 Welch Road, Palo Alto, CA 94304, USA.
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227
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Learned A, Robinson SA, Nguyen TT. Comprehensive Care of Lower-Extremity Wounds. Surg Clin North Am 2023; 103:745-765. [PMID: 37455035 DOI: 10.1016/j.suc.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
There are 5 common types of chronic nonhealing lower-extremity wounds: arterial, venous, diabetic foot ulcer, pressure, and mixed or atypical. Each chronic wound type has distinct features, and understanding the underlying cause will dictate the wound treatment plan. Here, the authors review the distinguishing wound properties for these 5 common chronic nonhealing lower-extremity wounds and outline a comprehensive treatment plan that addresses wound perfusion, debridement, infection control, moisture balance, and use of complementary advanced wound care products.
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Affiliation(s)
- Allison Learned
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA
| | - Sudie-Ann Robinson
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA
| | - Tammy T Nguyen
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA; University of Massachusetts Diabetes Center of Excellence.
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228
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Conte MS, O'Banion LA. Apples and oranges? A comparison of BEST-CLI to BASIL-2. J Vasc Surg 2023; 78:265-268. [PMID: 37481274 DOI: 10.1016/j.jvs.2023.05.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 05/23/2023] [Indexed: 07/24/2023]
Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA.
| | - Leigh Ann O'Banion
- Division of Vascular and Endovascular Surgery, University of California San Francisco - Fresno Branch Campus, Fresno, CA
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229
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Akingba AG, Chow WB, Rowe VL. Lower Extremity Bypass. Surg Clin North Am 2023; 103:767-778. [PMID: 37455036 DOI: 10.1016/j.suc.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
The original description of the lower extremity bypass (LEB) provided surgeons with a reliable method of limb revascularization. The tenets of the operation have formed the foundation for the advances of surgical care. A careful evaluation of the chronic limb-threatening ischemia patient due to the numerous comorbid conditions is paramount to obtain the best possible outcomes. Use of all adjuncts including judicious target vessels control, completion imaging, and vein harvesting techniques to ensure optimal outcomes because a functioning LEB remains a key to successful limb salvage.
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Affiliation(s)
- Ajibola George Akingba
- DC VAMC, Uniformed Services University of Health Sciences, 50 Irving Street, Washington, DC 20422, USA
| | - Warren Bryan Chow
- Division of Vascular Surgery and Endovascular Therapy, David Geffen School of Medicine at UCLA, 200 Peter Morton Medical Building, Suite 526, Los Angeles, CA 90095, USA
| | - Vincent Lopez Rowe
- Division of Vascular Surgery and Endovascular Therapy, David Geffen School of Medicine at UCLA, 200 Peter Morton Medical Building, Suite 526, Los Angeles, CA 90095, USA.
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230
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Lee S, Yun S, Lee J, Kim SH, Ihn MH, Yoo D, Yun SK, Hwang MO. Comparison between radiofrequency ablation and CHIVA procedure in patients with varicose veins. Phlebology 2023; 38:427-435. [PMID: 37277941 DOI: 10.1177/02683555231181857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire, the French acronym for CHIVA, is a strategy aimed to convert a venous reflux into a physiological drainage. We compared CHIVA with radiofrequency ablation and determined its possible advantages. METHODS We retrospectively analyzed the clinical recurrence, ultrasound recurrence, quality of life scores, and complications. They were compared after propensity score matching. RESULTS 212 limbs of 166 patients were included: 42 limbs underwent radiofrequency ablation and 170 limbs underwent CHIVA. The hospital stay was shorter in the CHIVA group. There was no difference in clinical, ultrasound recurrence, quality of life scores and complications between the two groups. The preoperative saphenous vein diameter was larger in the recurrence cases. CONCLUSIONS CHIVA showed comparable results to radiofrequency ablation. There was more ultrasound recurrence with larger vein diameters. The CHIVA appears to be a simple and more efficient treatment method when performed on select patients.
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Affiliation(s)
- Seungjoon Lee
- Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Sangchul Yun
- Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Jihyoun Lee
- Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Sang Hyun Kim
- Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Myung Hoon Ihn
- Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Daegwang Yoo
- Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - So Kyung Yun
- Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Mi-Ok Hwang
- Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
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231
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Shatnawi NJ, Al-Zoubi NA, Al-Bakkar LA, Abu-Baker AM, Khader YS, Al-Omari M, El-Heis MA. Chronic Limb-Threatening Ischemia in Patients with Type 2 Diabetes: Revascularization Index as a Predictor for Primary Endovascular Intervention Outcome. Vasc Health Risk Manag 2023; 19:495-504. [PMID: 37547281 PMCID: PMC10402884 DOI: 10.2147/vhrm.s394521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 06/21/2023] [Indexed: 08/08/2023] Open
Abstract
Purpose Chronic limb-threatening ischemia in patients with diabetes is associated with a high risk of adverse outcomes. The associated co-morbidities, the heterogeneity of foot presentation and the distribution of atherosclerotic lesions led to the emergence of multiple revascularization strategies and scoring systems to improve management outcomes. This study aimed to introduce a new index, the revascularization index (RI), and to assess its predictive value for the outcomes of primary endovascular intervention in patients with type 2 diabetes presenting with chronic limb-threatening ischemia. Patients and Methods A retrospective electronic medical records review was conducted for patients with type 2 diabetes presenting with chronic limb-threatening ischemia managed at King Abdullah University Hospital by primary endovascular interventions between January 2014 and August 2019. The RI was analyzed for its predictive value for the treatment outcomes. Results A total of 187 patients were included in this study, with a major lower limb amputation rate of 19.3%. The performance of the RI was excellent in predicting secondary revascularization (AUC = 0.80, 95% CI: 0.73-0.86, p-value < 0.001), good to predict major amputation (AUC = 0.76, 95% CI: 0.67-0.85, p-value = 0.047), and poor in predicting death (AUC = 0.46, 95% CI: 0.40-0.55, p-value = 0.398). RI of <1.21 was significantly associated with a higher risk of major lower limb amputation (HR = 5.8, 95% CI: 1.25-26.97, p-value < 0.025), and RI of < 1.3 was associated with a higher risk for secondary revascularization. Conclusion The RI can be used to predict major adverse lower limb events (MALE). It might be used as a guide for the extent of endovascular interventions for diabetic chronic limb-threatening ischemia with multi-level outflow atherosclerotic disease.
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Affiliation(s)
- Nawaf J Shatnawi
- Department of Surgery, Jordan University of Science and Technology, Irbid, Jordan
| | - Nabil A Al-Zoubi
- Department of Surgery, Jordan University of Science and Technology, Irbid, Jordan
| | - Lujain A Al-Bakkar
- Department of Surgery, Jordan University of Science and Technology, Irbid, Jordan
| | - Ammar M Abu-Baker
- Department of Surgery, Jordan University of Science and Technology, Irbid, Jordan
| | - Yousef S Khader
- Department of Community Medicine, Public Health and Family Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mamoon Al-Omari
- Department of Radiology, Jordan University of Science and Technology, Irbid, Jordan
| | - Mowafeq A El-Heis
- Department of Radiology, Jordan University of Science and Technology, Irbid, Jordan
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232
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Salamaga S, Stępak H, Żołyński M, Kaczmarek J, Błaszyk M, Stanišić MG, Krasiński Z. Three-Year Real-World Outcomes of Interwoven Nitinol Supera Stent Implantation in Long and Complex Femoropopliteal Lesions. J Clin Med 2023; 12:4869. [PMID: 37510984 PMCID: PMC10381725 DOI: 10.3390/jcm12144869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Peripheral artery disease (PAD) remains a major issue in modern societies and affects more than 200 million people around the world. Endovascular methods have been evaluated to be safe and effective in limb salvage. The Supera is able to withstand increased compression, biomechanical stress and to have higher radial force. The objective of this study is to evaluate performance, durability and 3-year patency of Supera stent implantation in severe femoropopliteal disease. METHODS A retrospective real-world analysis was performed with consideration of 77 patients that had a Supera stent implanted with femoropopliteal atherosclerotic disease at a single center. Among the 77 individuals, 92 Supera stents were implanted. Analysis of patients' demographics, lesions characteristics, reintervention rates and patency rates was performed. RESULTS The median follow-up was 33 months and ranged from 0 to 84 months. Chronic limb-threatening ischemia was observed among 43 patients. Mean lesion length was 152.8 ± 94.6 mm. Chronic total occlusions were observed in a majority of lesions. Overall, primary patency rates at 6, 12, 24 and 36 months were 85.0%, 73.6%, 59.2% and 53.2%, respectively. CONCLUSIONS The Supera stent is effective in the management of long and complex lesions. The results of patency rates were evaluated to be worse among lesions extending to the popliteal artery.
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Affiliation(s)
- Szymon Salamaga
- Department of Vascular and Endovascular Surgery, Angiology and Phlebology, Poznan University of Medical Sciences, Długa Street, 61-848 Poznan, Poland
| | - Hubert Stępak
- Department of Vascular and Endovascular Surgery, Angiology and Phlebology, Poznan University of Medical Sciences, Długa Street, 61-848 Poznan, Poland
| | - Mikołaj Żołyński
- Department of Cardiology-Intensive Therapy, Poznan University of Medical Sciences, Ul. Przybyszewskiego 49, 60-355 Poznan, Poland
| | - Jagoda Kaczmarek
- Faculty of Medicine, Poznan University of Medical Sciences, 1/2 Długa Street, 61-848 Poznan, Poland
| | - Maciej Błaszyk
- Department of Radiology, Poznan University of Medical Sciences, 1/2 Długa Street, 61-848 Poznan, Poland
| | - Michał-Goran Stanišić
- Department of Vascular and Endovascular Surgery, Angiology and Phlebology, Poznan University of Medical Sciences, Długa Street, 61-848 Poznan, Poland
| | - Zbigniew Krasiński
- Department of Vascular and Endovascular Surgery, Angiology and Phlebology, Poznan University of Medical Sciences, Długa Street, 61-848 Poznan, Poland
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233
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Nugteren MJ, Hazenberg CEVB, Akkersdijk GP, Bakker OJ, Dinkelman MK, Fioole B, van den Heuvel DAF, Heyligers JMM, Hinnen JW, Pierie M, Schouten O, Schreve MA, Verhoeven BAN, de Borst GJ, Ünlü Ç. The Dutch chronic lower limb-threatening ischemia registry (THRILLER): A study protocol for popliteal and infrapopliteal endovascular interventions. PLoS One 2023; 18:e0288912. [PMID: 37471351 PMCID: PMC10358906 DOI: 10.1371/journal.pone.0288912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 07/04/2023] [Indexed: 07/22/2023] Open
Abstract
INTRODUCTION Chronic limb-threatening ischemia (CLTI) is the end stage of peripheral arterial disease (PAD) and is associated with high amputation rates, mortality and disease-related health care costs. In infrapopliteal arterial disease (IPAD), endovascular revascularization should be considered for the majority of anatomical and clinical subgroups of CLTI. However, a gap of high-quality evidence exists in this field. The aim of the Dutch Chronic Lower Limb-Threatening Ischemia Registry (THRILLER) is to collect real world data on popliteal and infrapopliteal endovascular interventions. METHODS THRILLER is a clinician-driven, prospective, multicenter, observational registry including all consecutive patients that undergo a popliteal or infrapopliteal endovascular intervention in seven Dutch hospitals. We estimate that THRILLER will include 400-500 interventions annually. Standardized follow-up visits with wound monitoring, toe pressure measurement and duplex ultrasonography will be scheduled at 6-8 weeks and 12 months after the intervention. The independent primary endpoints are primary patency, limb salvage and amputation free survival. Patients must give informed consent before participation and will be included according to predefined reporting standards. A data log of patients who meet the inclusion criteria but are not included in the registry will be maintained. We intend to conduct the first interim analysis two years after the start of inclusion. The results will be published in a scientific journal. DISCUSSION Despite innovations in medical therapy and revascularization techniques, patients with CLTI undergoing endovascular revascularization still have a moderate prognosis. Previous prospective cohort studies were hampered by small sample sizes or heterogeneous reporting. Randomized controlled trials (RCTs) have high costs, potential conflicts of interest and give a limited reflection of daily practice. THRILLER aims to provide the largest prospective well phenotyped up-to-date dataset on treatment outcomes in CLTI patients to answer multiple underexplored research questions regarding diagnostics, medication, patient selection, treatment strategies and post intervention follow-up.
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Affiliation(s)
- Michael J Nugteren
- Department of Vascular Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - George P Akkersdijk
- Department of Vascular Surgery, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | - Olaf J Bakker
- Department of Vascular Surgery, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Maarten K Dinkelman
- Department of Vascular Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | | | - Jan M M Heyligers
- Department of Vascular Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Jan-Willem Hinnen
- Department of Vascular Surgery, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, The Netherlands
| | - Maurice Pierie
- Department of Vascular Surgery, Isala Ziekenhuis, Zwolle, The Netherlands
| | - Olaf Schouten
- Department of Vascular Surgery, Isala Ziekenhuis, Zwolle, The Netherlands
| | - Michiel A Schreve
- Department of Vascular Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Bart A N Verhoeven
- Department of Vascular Surgery, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Çağdaş Ünlü
- Department of Vascular Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
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Rodway AD, Harris J, Hanna L, Allan C, Casal FP, Giltinan C, Dehghan-Nayeri A, Santos A, Whyte MB, Ntagiantas N, Walton I, Brown R, Skene SS, Pankhania A, Field BCT, Maytham GD, Heiss C. Understanding the Impact of COVID-19 on Angioplasty Service and Outcome of Patients Treated for Chronic Limb-Threatening Ischaemia: A Single-Centre Retrospective Cohort Study. Biomedicines 2023; 11:2034. [PMID: 37509673 PMCID: PMC10377405 DOI: 10.3390/biomedicines11072034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/09/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
We evaluated the impact of COVID-19 restriction on the angioplasty service and outcome of chronic limb-threatening ischaemia (CLTI) patients undergoing lower-limb angioplasty in a UK secondary care setting. Consecutive patients were analysed retrospectively. Pre-COVID-19 (08/2018-02/2020), 106 CLTI patients (91% Fontaine 4; 60% diabetes mellitus) and during COVID-19 (03/2020-07/2021) 94 patients were treated (86% Fontaine 4; 66% diabetes mellitus). While the average monthly number of patients treated did not change, the proportion of day cases significantly increased (53% to 80%), and hospitalised patients decreased. Patients treated in ≤14/5 days after referral significantly increased to 64/63%. Kaplan-Meier survival analysis (30-day/1-year) showed that neither wound healing nor mortality were significantly changed during COVID-19. In day cases, 1-year but not 30-day major amputations significantly increased, and clinically driven target-lesion revascularisation decreased during COVID-19. One-year mortality was significantly worse in hospitalised compared to day cases (14% vs. 43%) at similar wound healing rates (83% vs. 84%). The most frequent known cause of death was infectious disease (64%), while cardiovascular (21%) was less frequent. Despite COVID-19 restrictions, a safe and effective angioplasty service was maintained while shortening waiting times. Very high mortality rates in hospitalised patients may indicate that CLTI patients need to be referred and treated more aggressively earlier.
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Affiliation(s)
- Alexander D Rodway
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Vascular Surgery, University Hospital Sussex NHS Trust, Brighton BN2 5BE, UK
| | - Jenny Harris
- Department of Adult Nursing, School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Lydia Hanna
- Department of Vascular Surgery, Imperial College Healthcare NHS Trust, London SW7 2BX, UK
| | - Charlotte Allan
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
| | - Felipe Pazos Casal
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
| | - Ciara Giltinan
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Ali Dehghan-Nayeri
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Andre Santos
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Martin B Whyte
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Nikolaos Ntagiantas
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- St. George's Vascular Institute, St. George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Ivan Walton
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- St. George's Vascular Institute, St. George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Richard Brown
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
| | - Simon S Skene
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Ajay Pankhania
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
| | - Benjamin C T Field
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Gary D Maytham
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- St. George's Vascular Institute, St. George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Christian Heiss
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
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Lin JHX, Papanas N, Zayed H, Vas PRJ. Revascularisation Options for Chronic Limb Threatening Ischaemia in Diabetes: Implications From Two Recent Trials. INT J LOW EXTR WOUND 2023:15347346231188874. [PMID: 37464779 DOI: 10.1177/15347346231188874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Chronic limb-threatening ischaemia (CLTI) is a severe form of peripheral arterial disease (PAD) and is associated with an increased risk of amputation, mortality, and significantly impaired quality of life. International guidelines recommend considering timely revascularisation and optimal medical therapy to improve limb perfusion in individuals with CLTI. The 2 primary revascularization approaches for CLTI are open bypass surgery (BS) and endovascular therapy (EV), however, there is currently no consensus on the best initial treatment strategy for CLTI, leading to uncertainty among clinicians. To shed light on this issue, 2 recent trials, namely best endovascular versus best surgical therapy in patients with CLI (BEST-CLI) and bypass versus angioplasty for severe ischaemia of the leg (BASIL-2), have tried to provide valuable insights. While a definitive conclusion on the optimal revascularisation approach is still pending, these trials offer immediate and clinically relevant information to the diabetic foot multidisciplinary team. The trials encompassed a distinct range of patient cohorts and included participants with varying degrees of medical and physical frailty. Taken together, their findings, highlight the need for an individualised revascularisation strategy which accounts for underlying comorbidities, risk factors, disease severity, availability of suitable bypass conduits, surgical risks, and timely access to procedures. Regardless of the chosen strategy, early referral of patients with diabetes and CLTI to a specialist team within a multidisciplinary environment is crucial. Comprehensive care should encompass essential elements such as adequate debridement, infection control, offloading, glycaemic control, smoking cessation, and patient education. By addressing these aspects, healthcare providers can optimise the management and outcomes for individuals with CLTI and diabetes.
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Affiliation(s)
- Jaime H X Lin
- Diabetes and Diabetic Foot, King's College NHS Foundation Trust, London, UK
- Department of Medicine, Woodlands Health, Singapore
| | - Nikolaos Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Hany Zayed
- Vascular Surgical Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Prashanth R J Vas
- Diabetes and Diabetic Foot, King's College NHS Foundation Trust, London, UK
- King's College London, UK
- King's Health Partners' Institute of Diabetes, Endocrinology and Obesity, London, UK
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Abstract
Importance Approximately 18.6 million people worldwide are affected by a diabetic foot ulcer each year, including 1.6 million people in the United States. These ulcers precede 80% of lower extremity amputations among people diagnosed with diabetes and are associated with an increased risk of death. Observations Neurological, vascular, and biomechanical factors contribute to diabetic foot ulceration. Approximately 50% to 60% of ulcers become infected, and about 20% of moderate to severe infections lead to lower extremity amputations. The 5-year mortality rate for individuals with a diabetic foot ulcer is approximately 30%, exceeding 70% for those with a major amputation. The mortality rate for people with diabetic foot ulcers is 231 deaths per 1000 person-years, compared with 182 deaths per 1000 person-years in people with diabetes without foot ulcers. People who are Black, Hispanic, or Native American and people with low socioeconomic status have higher rates of diabetic foot ulcer and subsequent amputation compared with White people. Classifying ulcers based on the degree of tissue loss, ischemia, and infection can help identify risk of limb-threatening disease. Several interventions reduce risk of ulcers compared with usual care, such as pressure-relieving footwear (13.3% vs 25.4%; relative risk, 0.49; 95% CI, 0.28-0.84), foot skin measurements with off-loading when hot spots (ie, greater than 2 °C difference between the affected foot and the unaffected foot) are found (18.7% vs 30.8%; relative risk, 0.51; 95% CI, 0.31-0.84), and treatment of preulcer signs. Surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection are first-line therapies for diabetic foot ulcers. Randomized clinical trials support treatments to accelerate wound healing and culture-directed oral antibiotics for localized osteomyelitis. Multidisciplinary care, typically consisting of podiatrists, infectious disease specialists, and vascular surgeons, in close collaboration with primary care clinicians, is associated with lower major amputation rates relative to usual care (3.2% vs 4.4%; odds ratio, 0.40; 95% CI, 0.32-0.51). Approximately 30% to 40% of diabetic foot ulcers heal at 12 weeks, and recurrence after healing is estimated to be 42% at 1 year and 65% at 5 years. Conclusions and Relevance Diabetic foot ulcers affect approximately 18.6 million people worldwide each year and are associated with increased rates of amputation and death. Surgical debridement, reducing pressure from weight bearing, treating lower extremity ischemia and foot infection, and early referral for multidisciplinary care are first-line therapies for diabetic foot ulcers.
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Affiliation(s)
- David G Armstrong
- Department of Surgery, Keck School of Medicine at the University of Southern California, Los Angeles
| | - Tze-Woei Tan
- Department of Surgery, Keck School of Medicine at the University of Southern California, Los Angeles
| | - Andrew J M Boulton
- Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, England
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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Butala NM, Chandra V, Beckman JA, Parikh SA, Lookstein R, Misra S, Secemsky EA. Contextualizing the BEST-CLI Trial Results in Clinical Practice. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101036. [PMID: 37575528 PMCID: PMC10417884 DOI: 10.1016/j.jscai.2023.101036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Background Chronic limb-threatening ischemia (CLTI) is associated with poor long-term outcomes. Although prompt revascularization is recommended, the optimal revascularization strategy remains uncertain. The BEST-CLI trial compared endovascular and open surgical revascularization for CLTI, but the generalizability of this study to the clinical population with CLTI has not been evaluated. Methods We included Medicare beneficiaries aged 65-85 years with CLTI who underwent revascularization and would be eligible for enrollment in BEST-CLI between 2016 and 2019. The primary exposure was type of revascularization (endovascular vs autologous graft [cohort 1] vs nonautologous graft [cohort 2]), and the primary outcome was a composite of major adverse limb events (MALE) and death. MALE included above-ankle amputation and major intervention, which was defined as new bypass of index limb, thrombectomy, or thrombolysis. Results A total of 66,153 patients were included in this study (10,125 autologous grafts; 7867 nonautologous grafts; 48,161 endovascular). Compared with those enrolled in BEST-CLI cohort 1, patients in this study were older (mean age, 73.5 ± 5.7 vs 69.9 ± 9.9 years), more likely to be female (38.3% [22,340/58,286] vs 28.5% [408/1434]), and presented with more comorbidities. Endovascular operators for the study population vs BEST-CLI cohort 1 were less likely to be surgeons (55.9% [26,924/48,148] vs 73.0% [520/708]) and more likely to be cardiologists (25.5% [5900/48,148] vs 14.5% [103/78]). When assessing long-term outcomes, the crude risk of death or MALE in this cohort was higher with surgery (56.6% autologous grafts vs 42.6% BEST-CLI cohort 1 at a median of follow-up 2.7 years; 51.6% nonautologous grafts vs 42.8% BEST-CLI cohort 2 at a median follow-up of 1.6 years) but similar with the endovascular cohort (58.7% Medicare vs 57.4% cohort 1 at 2.7 years; 47.0% Medicare vs 47.7% cohort 2 at 1.6 years). Of those who received endovascular treatment, the risk of incident major intervention was less than half in this cohort compared with the trial cohort (10.0% Medicare vs 23.5% cohort 1 at 2.7 years; 8.6% Medicare vs 25.6% cohort 2 at 1.6 years), although technical endovascular failures were not captured. Conclusions These results suggest that the findings of the BEST-CLI trial may not be applicable to the entirety of the Medicare population of patients with CLTI undergoing revascularization.
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Affiliation(s)
- Neel M. Butala
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Venita Chandra
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Joshua A. Beckman
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sahil A. Parikh
- Division of Cardiology, Department of Medicine, Columbia University School of Medicine, New York, New York
| | - Robert Lookstein
- Department of Radiology, Mt. Sinai School of Medicine, New York, New York
| | - Sanjay Misra
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Eric A. Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Peters F, Behrendt CA. Limb Related Outcomes of Endovascular vs. Open Surgical Revascularisation in Patients with Peripheral Arterial Occlusive Disease: A Report from the Prospective GermanVasc Cohort Study. Eur J Vasc Endovasc Surg 2023; 66:85-93. [PMID: 36972814 DOI: 10.1016/j.ejvs.2023.03.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 03/01/2023] [Accepted: 03/23/2023] [Indexed: 03/28/2023]
Abstract
OBJECTIVE The goal of this study was to compare clinical outcomes in patients with peripheral arterial occlusive disease undergoing revascularisation by peripheral endovascular intervention (EVI), bypass surgery, endarterectomy (EA), and hybrid surgery in an unselected real world setting. METHODS This was a German, prospective, multicentre, comparative cohort study, enrolling patients at hospital admission for revascularisation at 35 vascular centres with 12 months of follow up. Primary composite endpoints were major amputation or death, major adverse limb events, and any minor or major amputation. Twelve month incidences and hazard ratios (HRs) for the four subgroups and 95% confidence intervals (CIs) were estimated using Kaplan-Meier functions and Cox proportional hazard models. Sociodemographic and clinical characteristics, pharmacological treatment, and comorbidities were used to adjust for patient differentials (unique identifier ClinicalTrials.gov: NCT03098290). RESULTS In total, 4 475 patients were analysed (mean age 69 years, 69.4% males, and 31.5% suffering from chronic limb threatening ischaemia). After 12 months of follow up, 5.3% (95% CI 3.6 - 6.9%) of the patients experienced either death or major amputation, 7.2% (95% CI 4.8 - 9.6%) major adverse limb event, and 6.6% (95% CI 5.0 - 8.2%) any minor or major amputation. Compared with EVI, bypass surgery was associated with an increased risk of amputation or death (HR 2.59, 95% CI 1.75 - 3.85), major adverse limb event (HR 1.93, 95% CI 1.11 - 3.36), and any minor or major amputation (HR 2.12, 95% CI 1.42 - 3.16), and hybrid surgery with an increased risk of amputation or death (HR 2.29, 95% CI 1.27 - 4.13) and major adverse limb event (HR 1.62, 95% CI 1.03 - 2.54). After adjusting for patient differentials, no significant differences among study groups remained. CONCLUSION More favourable outcomes after EVI were completely attributed to differentials in patient characteristics and not procedure type. The current study emphasised that all competing approaches performed similarly in a real world setting.
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Affiliation(s)
- Frederik Peters
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christian-Alexander Behrendt
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany; Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany; Brandenburg Medical School Theodor Fontane, Neuruppin, Germany.
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239
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Morisaki K, Guntani A, Kinoshita G, Kawanami S, Yamashita S, Matsubara Y, Furuyama T, Mii S, Komori K, Yoshizumi T. Impact of ambulatory status change on survival in patients with chronic limb-threatening ischemia undergoing infrainguinal surgical or endovascular revascularization. J Vasc Surg 2023; 78:193-200.e2. [PMID: 36933751 DOI: 10.1016/j.jvs.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/05/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023]
Abstract
OBJECTIVE This study aimed to evaluate the influence of change in ambulatory status on the prognosis of patients with chronic limb-threatening ischemia (CLTI) undergoing infrainguinal bypass surgery or endovascular therapy (EVT). METHODS We retrospectively analyzed data from two vascular centers for patients who underwent revascularization for CLTI between 2015 and 2020. The primary endpoint was overall survival (OS), and the secondary endpoints were changes in ambulatory status and postoperative complications. RESULTS Throughout the study, 377 patients and 508 limbs were analyzed. In the preoperative nonambulation cohort, the average body mass index (BMI) was lower in the postoperative nonambulatory group than in the postoperative ambulatory group (P < .01). The percentage of cerebrovascular disease (CVD) was higher in the postoperative nonambulatory group than in the postoperative ambulatory group (P = .01). In the preoperative ambulation cohort, the average controlling nutritional status (CONUT) score was higher in the postoperative nonambulatory group than in the postoperative ambulatory group (P < .01). There was no difference in the bypass percentage and the EVT in the preoperative nonambulation (P = .32) and ambulation (P = .70) cohorts. According to the change in ambulatory status before and after revascularization, the 1-year OS rates were 86.8% in the ambulatory → ambulatory group, 81.1% in the nonambulatory → ambulatory group, 54.7% in the nonambulatory → nonambulatory group, and 23.9% in the ambulatory → nonambulatory group (P < .01). On multivariate analysis, increased age (P = .04), higher Wound, Ischemia, and foot Infection stage (P = .02), and increased CONUT score (P < .01) were independent risk factors for the decline in ambulatory status in patients with preoperative ambulation. In patients with preoperative nonambulation, increased BMI (P < .01) and absence of CVD (P = .04) were independent factors related to the improved ambulatory status. The percentages of postoperative complications were 31.0% and 17.0% in the preoperative nonambulation and the preoperative ambulation in the overall cohort (P < .01). Preoperative nonambulatory status (P < .01), CONUT score (P < .01), and bypass surgery (P < .01) were risk factors for postoperative complications. CONCLUSIONS Improved ambulatory status is associated with better OS in patients with preoperative nonambulatory status after infrainguinal revascularization for CLTI. Although patients with preoperative nonambulatory status have a risk of postoperative complication, some may benefit from revascularization if they have no factors such as low BMI and CVD, improving their ambulatory status.
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Affiliation(s)
- Koichi Morisaki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Atsushi Guntani
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan
| | - Go Kinoshita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shogo Kawanami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Sho Yamashita
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan
| | - Yutaka Matsubara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tadashi Furuyama
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinsuke Mii
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan
| | - Kimihiro Komori
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Lyons OT, Behrendt CA, Björck M. Beyond Wires and Knives: What Can We Learn From BEST-CLI and BASIL-2? Eur J Vasc Endovasc Surg 2023; 66:1-3. [PMID: 37217073 DOI: 10.1016/j.ejvs.2023.05.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023]
Affiliation(s)
- Oliver T Lyons
- Vascular Endovascular & Transplant Surgery, Christchurch Hospital, New Zealand; Department of Surgery, University of Otago Christchurch, New Zealand.
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany. https://twitter.com/VASCevidence
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Institute of Clinical Medicine, Tartu University, Tartu, Estonia. https://twitter.com/mabjo425
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O'Dell BL, Rothenberg GM, Schmidt BM. Letter to the Editor Regarding "Evaluation of Proposed Protocol Changing Statistical Significance From 0.05 to 0.005 in Foot and Ankle Randomized Controlled Trials". J Foot Ankle Surg 2023; 62:752. [PMID: 37407146 DOI: 10.1053/j.jfas.2022.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 12/10/2022] [Indexed: 07/07/2023]
Affiliation(s)
- Brennen L O'Dell
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan Medical School, Ann Arbor, MI.
| | - Gary M Rothenberg
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan Medical School, Ann Arbor, MI
| | - Brian M Schmidt
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan Medical School, Ann Arbor, MI
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Myers R, Mushtaq B, Taylor N, Rashid H, Pineda DM. Limb salvage in octogenarians with critical limb ischemia after lower extremity bypass surgery. J Vasc Surg 2023; 78:217-222. [PMID: 36914077 DOI: 10.1016/j.jvs.2023.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/18/2023] [Accepted: 02/26/2023] [Indexed: 03/13/2023]
Abstract
OBJECTIVES Peripheral artery disease is a worldwide epidemic that affects millions of patients, especially the elderly. It has a prevalence of 20% in individuals >80 years old. Although peripheral artery disease affects >20% of octogenarians, information about limb salvage rates in this patient population is limited. Therefore, this study aims to understand the impact of bypass surgery on limb salvage in patients aged >80 years with critical limb ischemia. METHODS We conducted a retrospective analysis by querying the electronic medical records at a single institution from 2016 through 2022 to identify the population of interest and analyzed their outcomes after lower extremity bypass. The primary outcomes were limb salvage and primary patency, with hospital length of stay and 1-year mortality as secondary outcomes. RESULTS We identified 137 patients who met the inclusion criteria. The lower extremity bypass population was divided into two cohorts: <80 years old (n = 111) with a mean age of 66 or ≥80 years old (n = 26) with a mean age of 84 years. The gender distribution was similar (P = .163). No significant difference was found in the two cohorts when it came to coronary artery disease, chronic kidney disease, or diabetes mellitus. However, when current and former smokers were grouped together, they were significantly more common in the younger cohort when compared with nonsmokers (P = .028). The primary end point of limb salvage was not significantly different between the two cohorts. Hospital length of stay was not significantly different between the two cohorts with 4.13 days vs 4.17 days in the younger vs octogenarian cohorts, respectively (P = .95). The 30-day all-cause readmissions were also not found to be significantly different between the two groups. The primary patency at 1 year was 75% and 77% (P = .16) for the <80-year-old and ≥80-year-old cohorts, respectively. Mortality was low in both cohorts, with two and three for the younger and octogenarian populations, respectively; thus, no analysis was performed. CONCLUSIONS Our study shows that octogenarians who undergo the same preoperative risk assessment as younger populations have similar outcomes when it comes to primary patency, hospital length of stay, and limb salvage when comorbidities were considered. Further studies need to be done to determine the statistical impact on mortality in this population with a larger cohort.
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Affiliation(s)
- Robert Myers
- Department of Vascular Surgery, Jefferson Abington Health, Abington, PA
| | - Bakhtawar Mushtaq
- Department of Vascular Surgery, Jefferson Abington Health, Abington, PA
| | - Nicholas Taylor
- Department of Vascular Surgery, Jefferson Abington Health, Abington, PA
| | - Hajar Rashid
- Department of Vascular Surgery, Jefferson Abington Health, Abington, PA
| | - Danielle M Pineda
- Department of Vascular Surgery, Jefferson Abington Health, Abington, PA.
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Nardella E, Biscetti F, Rando MM, Cecchini AL, Nicolazzi MA, Rossini E, Angelini F, Iezzi R, Eraso LH, Dimuzio PJ, Pitocco D, Massetti M, Gasbarrini A, Flex A. Development of a biomarker panel for assessing cardiovascular risk in diabetic patients with chronic limb-threatening ischemia (CLTI): a prospective study. Cardiovasc Diabetol 2023; 22:136. [PMID: 37308885 DOI: 10.1186/s12933-023-01872-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/30/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Lower-extremity endovascular revascularization (LER) is often required for diabetic patients with chronic limb threatening ischemia (CLTI). During the post-revascularization period patients may unpredictably experience major adverse cardiac events (MACE) and major adverse limb events (MALE). Several families of cytokines are involved in the inflammatory process that underlies the progression of atherosclerosis. According to current evidence, we have identified a panel of possible biomarkers related with the risk of developing MACE and MALE after LER. The aim was to study the relationship between a panel of biomarkers - Interleukin-1 (IL-1) and 6 (IL-6), C-Reactive Protein (CRP), Tumor Necrosis Factor-α (TNF-α), High-Mobility Group Box-1 (HMGB-1), Osteoprotegerin (OPG), Sortilin and Omentin-1- at baseline, with cardiovascular outcomes (MACE and MALE) after LER in diabetic patients with CLTI. METHODS In this prospective non-randomized study, 264 diabetic patients with CLTI undergoing endovascular revascularization were enrolled. Serum levels of each biomarker were collected before revascularization and outcomes' incidence was evaluated after 1, 3, 6 and 12 months. RESULTS During the follow-up period, 42 cases of MACE and 81 cases of MALE occurred. There was a linear association for each biomarker at baseline and incident MACE and MALE, except Omentin-1 levels that were inversely related to the presence of MACE or MALE. After adjusting for traditional cardiovascular risk factors, the association between each biomarker baseline level and outcomes remained significant in multivariable analysis. Receiver operating characteristics (ROC) models were constructed using traditional clinical and laboratory risk factors and the inclusion of biomarkers significantly improved the prediction of incident events. CONCLUSIONS Elevated IL-1, IL-6, CRP, TNF-α, HMGB-1, OPG and Sortilin levels and low Omentin-1 levels at baseline correlate with worse vascular outcomes in diabetic patients with CLTI undergoing LER. Assessment of the inflammatory state with this panel of biomarkers may support physicians to identify a subset of patients more susceptible to the procedure failure and to develop cardiovascular adverse events after LER.
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Affiliation(s)
- Elisabetta Nardella
- Cardiovascular Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, Roma, 00168, Italy
| | - Federico Biscetti
- Cardiovascular Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, Roma, 00168, Italy.
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, Roma, 00168, Italy.
| | - Maria Margherita Rando
- Cardiovascular Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, Roma, 00168, Italy
| | | | - Maria Anna Nicolazzi
- Cardiovascular Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, Roma, 00168, Italy
| | - Enrica Rossini
- Cardiovascular Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, Roma, 00168, Italy
| | - Flavia Angelini
- Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Roma, 00168, Italy
| | - Roberto Iezzi
- Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Roma, 00168, Italy
- Radiology Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Luis H Eraso
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Paul J Dimuzio
- Division of Vascular and Endovascular Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dario Pitocco
- Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Roma, 00168, Italy
- Diabetology Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Roma, Italy
| | - Massimo Massetti
- Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Roma, 00168, Italy
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, Roma, 00168, Italy
| | - Antonio Gasbarrini
- Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Roma, 00168, Italy
- Department of Medical and Surgical sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, Roma, 00168, Italy
| | - Andrea Flex
- Cardiovascular Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, Roma, 00168, Italy
- Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Roma, 00168, Italy
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El Khoury R, Tzvetanov I, Estrada EA, McCarroll E, Goor JB, Guy LG, Laflamme M, Schwartz LB. Drug-eluting, balloon-expandable, bioresorbable vascular scaffolds reduce neointimal thickness and stenosis in an animal model of percutaneous peripheral intervention. JVS Vasc Sci 2023; 4:100114. [PMID: 37546529 PMCID: PMC10403740 DOI: 10.1016/j.jvssci.2023.100114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/31/2023] [Indexed: 08/08/2023] Open
Abstract
Objective Recanalization with balloon angioplasty and/or self-expanding stents (SES) has become the endovascular treatment of choice for symptomatic femoropopliteal occlusive disease. These strategies generate suboptimal clinical results, however, because they fail to expand the artery fully and ineffectively prevent recoil, neointimal hyperplasia, and restenosis. Balloon-expandable stents, given their greater radial force and rigid structure, represent a more effective treatment strategy, but only short lengths can be implanted safely in arteries that deform and bend with skeletal motion. The purpose of this preclinical experiment was to test the hypothesis that simultaneous implantation of a series of short, resorbable, balloon-expandable, paclitaxel-eluting scaffolds would prevent neointimal hyperplasia and stenosis compared with SES in an animal model of percutaneous femoropopliteal intervention. Methods We extruded 6 × 60 mm Efemoral Vascular Scaffold Systems (EVSS) from copolymers of poly-L-lactic acid, coated with paclitaxel 3 μg/mm2, crimped onto a single delivery balloon, and implanted percutaneously into the iliofemoral arteries of eight Yucatan mini-swine. We implanted 7- to 8-mm × 60 mm SES into the contralateral experimental arteries. The animals were serially imaged with contrast angiography and optical coherence tomography after 30, 90, 180, 365, and 730 days. The primary end point of this study was neointimal morphometry over time. Secondary end points included acute deformation and angiographic and optical coherence tomography-derived measurements of chronic vascular response. Results Over the 2-year study period, one SES was found to be completely occluded at 90 days; all EVSS were widely patent at all time points. Arteries treated with SES exhibited profound neointimal hyperplasia with in-stent stenosis. In contrast, arteries treated with EVSS exhibited only modest vascular responses and minimal stenosis. After 2 years, the mean neointimal thickness (0.45 ± 0.12 vs 1.31 ± 0.91 mm; P < .05) and area (8.41 ± 3.35 vs 21.86 ± 7.37 mm2; P < .05) were significantly decreased after EVSS implantation. By 2 years, all scaffolds in all EVSS-treated arteries had resorbed fully. Conclusions In this preclinical animal model of peripheral endovascular intervention, the EVSS decreased neointimal hyperplasia and stenosis significantly compared with SES, then dissolved completely between the first and second years after implantation.
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Affiliation(s)
| | | | | | | | | | | | | | - Lewis B. Schwartz
- Efemoral Medical, Inc., Los Altos, CA
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
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245
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Kasirajan K. Retrograde superficial femoral artery recanalization through a deep femoral collateral: A transradial approach. J Vasc Surg Cases Innov Tech 2023; 9:101127. [PMID: 37181475 PMCID: PMC10173004 DOI: 10.1016/j.jvscit.2023.101127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/30/2023] [Indexed: 05/16/2023] Open
Abstract
A novel endovascular approach using retrograde access to an occluded superficial femoral artery via collaterals of the deep femoral artery is described. Owing to a prior aortobifemoral bypass, transradial access was used.
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Affiliation(s)
- Karthikeshwar Kasirajan
- Correspondence: Karthikeshwar Kasirajan, MD, Clinical Professor of Surgery, Stanford Health Care TriValley, 5565 W. Las Positas Blvd, #150, Pleasanton, CA 94588
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246
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Karelis A, Ferrara D, Sonesson B, Dias N. Percutaneous access of an intraoperatively recanalized mid-superficial femoral artery for distal lower limb revascularization. J Vasc Surg Cases Innov Tech 2023; 9:101170. [PMID: 37152910 PMCID: PMC10160776 DOI: 10.1016/j.jvscit.2023.101170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/09/2023] [Indexed: 05/09/2023] Open
Abstract
A 61-year-old male patient presented with rest pain and ulceration in his left leg 1 week after a hybrid procedure with bilateral external iliac stenting, common femoral artery thromboendarterectomy, and left-sided femoral popliteal bypass with an in situ saphenous vein. The bypass had been stented intraoperatively but had again become occluded directly after surgery. In the present report, we demonstrate the usefulness of direct percutaneous access to the mid-superficial femoral artery that had been intraoperatively recanalized via brachial artery access during the same procedure. This innovative combination of approaches allows for proximal and distal lower limb revascularization with stenting when avoidance of femoral artery access is considered appropriate.
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Affiliation(s)
- Angelos Karelis
- Vascular Center, Department of Thoracic and Vascular Diseases, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Correspondence: Angelos Karelis, MD, Vascular Center, Department of Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Ruth Lundskogs Gata 10/1, Malmö 205 02, Sweden
| | - Doriana Ferrara
- Vascular Center, Department of Thoracic and Vascular Diseases, Skåne University Hospital, Malmö, Sweden
- ASST Fatebenefratelli Sacco, AOU Federico II, Milan, Italy
| | - Björn Sonesson
- Vascular Center, Department of Thoracic and Vascular Diseases, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Nuno Dias
- Vascular Center, Department of Thoracic and Vascular Diseases, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
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247
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Troisi N, Bertagna G, Juszczak M, Canovaro F, Torri L, Adami D, Berchiolli R. Emergent management of diabetic foot problems in the modern era: Improving outcomes. Semin Vasc Surg 2023; 36:224-233. [PMID: 37330236 DOI: 10.1053/j.semvascsurg.2023.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 06/19/2023]
Abstract
Limb amputation is a consequence, and the leading complication, of diabetic foot ulcers. Prevention depends on prompt diagnosis and management. Patients should be managed by multidisciplinary teams and efforts should be focused on limb salvage ("time is tissue"). The diabetic foot service should be organized in a way to meet the patient's clinical needs, with the diabetic foot centers at the highest level of this structure. Surgical management should be multimodal and include not only revascularization, but also surgical and biological debridement, minor amputations, and advanced wound therapy. Medical treatment, including an adequate antimicrobial therapy, has a key role in the eradication of infection and should be guided by microbiologists and infection disease physicians with special interest in bone infection. Input from diabetologists, radiologists, orthopedic teams (foot and ankle), orthotists, podiatrists, physiotherapists, and prosthetics, as well as psychological counseling, is required to make the service comprehensive. After the acute phase, a well-structured, pragmatic follow-up program is necessary to adequately manage the patients with the aim to detect earlier potential failures of the revascularization or antimicrobial therapy. Considering the cost and societal impact of diabetic foot problems, health care providers should provide resources to manage the burden of diabetic foot problems in the modern era.
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Affiliation(s)
- Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy.
| | - Giulia Bertagna
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Maciej Juszczak
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Francesco Canovaro
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Lorenzo Torri
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Daniele Adami
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Raffaella Berchiolli
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
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Benfor B, Sinha K, Lumsden AB, Roy TL. Scoping review of atherectomy and intravascular lithotripsy with or without balloon angioplasty in below-the-knee lesions. J Vasc Surg Cases Innov Tech 2023; 9:101185. [PMID: 37274435 PMCID: PMC10238458 DOI: 10.1016/j.jvscit.2023.101185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/28/2023] [Indexed: 06/06/2023] Open
Abstract
Objective We evaluated how contemporary data on infrapopliteal vessel preparation have been reported to identify knowledge gaps and opportunities for future research. Methods A literature search was performed on Web of Science, PubMed, and Google Scholar to identify clinical research studies reporting on the outcomes of vessel preparation in below-the-knee lesions between 2006 and 2021. Studies were excluded if they were case reports or case series with a sample size of <10. Results A total of 15 studies comprising 5450 patients were included in this review, with vessel preparation performed in 2179 cases (40%). Of the 15 studies, 2 were randomized controlled trials, 6 were prospective cohort studies, and 7 were retrospective studies. Only 2 of the 15 studies evaluated intravascular lithotripsy devices, and 6 were noncomparative studies. The mean diameter stenosis treated was 86.7% ± 12.6%, and the lesion length was 71.7 ± 55.3 mm. Large heterogeneity was found in the choice and definitions of end points and lesion characterization. Procedural success ranged between 84% and 90%, and bailout stenting was performed in 0.8% to 15% of cases. Of the five studies comparing procedural success of atherectomy with or without balloon angioplasty to balloon angioplasty alone, only one was in favor of the former (99% vs 90%; P < .001). The remaining studies did not show any statistically significant differences. Similarly, atherectomy had a significantly superior limb salvage rate in only one of seven studies (91% vs 73%; P = .036). In contrast, the seven studies evaluating target lesion revascularization reported conflicting outcomes, with two in favor of atherectomy, two against atherectomy, and three reporting similar outcomes between atherectomy and balloon angioplasty alone. None of the studies evaluating intravascular lithotripsy was comparative. Conclusions The current body of evidence on vessel preparation in tibial arteries is largely based on observational studies with a large amount of heterogeneity and a number of inconsistencies. Further clinical and experimental studies with more robust study designs are warranted to investigate the comparative efficacy and safety of vessel preparation in calcified tibial arteries.
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Affiliation(s)
- Bright Benfor
- Correspondence: Bright Benfor, MD, Department of Vascular Surgery, Houston Methodist DeBakey Heart and Vascular Center, 6565 Fannin St, Ste B5-022, Houston, TX 77030
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Brito-Queiroz A, Mota RDS, Barros BR, Moraes TMD, Mulatti GC, Araújo Filho JSD. Lateral exposure of the proximal and distal peroneal artery without bone resection. J Vasc Surg Cases Innov Tech 2023; 9:101144. [PMID: 37235173 PMCID: PMC10205758 DOI: 10.1016/j.jvscit.2023.101144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/14/2023] [Indexed: 05/28/2023] Open
Abstract
Surgical revascularization with distal bypass surgery is associated with good outcomes for chronic limb-threatening ischemia. The peroneal artery, the most-often preserved outflow vessel, is commonly reached through a lateral approach involving resection of the fibula. We present two different techniques for a lateral approach to the peroneal artery: the first by proximal exposure and the second by exposing the distal segment of the peroneal artery. Both techniques are performed without bone resection.
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250
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Gomez-Sanchez CM, Conte MS. Case planning and execution of inframalleolar bypass for chronic limb-threatening ischemia. J Vasc Surg Cases Innov Tech 2023; 9:101116. [PMID: 37152915 PMCID: PMC10160785 DOI: 10.1016/j.jvscit.2023.101116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 01/18/2023] [Indexed: 05/09/2023] Open
Abstract
Chronic limb-threatening ischemia is challenging to treat because of the complex patient population, heterogeneity of limb presentations, and complicated arterial pathology. To meet this challenge, vascular surgeons need a broad range of skills to appropriately tailor interventions to each patient's specific needs. One tool in the armamentarium for patients with extensive arterial occlusive disease below the knee is an inframalleolar bypass. However, these procedures require a systematic approach to surgical planning and a high degree of technical competence. We describe our approach to inframalleolar bypass for limb preservation in suitable patients with advanced tibial artery disease.
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Affiliation(s)
- Clara M. Gomez-Sanchez
- Correspondence: Clara M. Gomez-Sanchez, MD, Division of Vascular and Endovascular Surgery, University of California San Francisco, 400 Parnassus Ave, A-581, San Francisco, CA 94143
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