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Sachs T, Pomposelli F, Hamdan A, Wyers M, Schermerhorn M. Trends in the national outcomes and costs for claudication and limb threatening ischemia: Angioplasty vs bypass graft. J Vasc Surg 2011; 54:1021-1031.e1. [DOI: 10.1016/j.jvs.2011.03.281] [Citation(s) in RCA: 156] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 03/28/2011] [Accepted: 03/28/2011] [Indexed: 11/28/2022]
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352
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A Framework for the Evaluation of “Value” and Cost-Effectiveness in the Management of Critical Limb Ischemia. J Am Coll Surg 2011; 213:552-66.e5. [DOI: 10.1016/j.jamcollsurg.2011.07.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 07/11/2011] [Accepted: 07/14/2011] [Indexed: 11/20/2022]
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353
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Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK, Golzarian J, Gornik HL, Halperin JL, Jaff MR, Moneta GL, Olin JW, Stanley JC, White CJ, White JV, Zierler RE. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery. J Vasc Surg 2011; 54:e32-58. [PMID: 21958560 DOI: 10.1016/j.jvs.2011.09.001] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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354
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Management of peripheral arterial disease: Role of computed tomography angiography and magnetic resonance angiography. Presse Med 2011; 40:e437-52. [DOI: 10.1016/j.lpm.2010.10.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 10/25/2010] [Indexed: 11/22/2022] Open
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355
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Kechagias A, Romsi P, YlÖNen K, Kechagias G, Juvonen T, Biancari F. Institutional Results and Meta-Analysis of Outcome after Infrainguinal Surgical Revascularization in Patients Greater than 80 Years Old. Am Surg 2011. [DOI: 10.1177/000313481107700936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Our aim was to evaluate the outcome after infrainguinal bypass revascularization in patients greater than 80 years old with lower limb ischemia treated at our institution and to perform a metaanalysis of literature data to better estimate current postoperative results. Eighty-four infrainguinal bypass procedures were performed in 76 patients of at least 80 years of age. Major outcome end points included survival, limb salvage, and amputation-free survival. Systematic review and meta-analysis of literature data on immediate and late outcome in patients older than 80 years who underwent infrainguinal surgical revascularization have been performed. At 30 days, seven patients (8.3%) died and seven major amputations (8.3%) occurred. Kaplan-Meier estimates of survival at 1, 3, and 5 -years were 73.8, 59.8, and 43.1 per cent; leg salvage 78.9, 71.4, and 67.8 per cent; and amputation-free survival 58.3, 42.7, and 28.2 per cent, respectively. The mean survival was 4.6 ± 0.4 years. Only Finnvasc score greater than 2 was predictive of poor late amputation-free survival (at 5 years: 4.5 vs 42.3%; relative risk, 2.19; 95% confidence interval, 1.27 to 3.76). Eleven studies were additionally available for analysis. Pooled estimates of survival at 30 days, 1 year, and 5 years were 94.8, 86.0, and 47.6 per cent, respectively, and of leg salvage were 95.5, 84.7, and 84.1 per cent, respectively. Infrainguinal bypass in patients older than 80 years carries a significant operative risk and is associated with suboptimal long-term amputation-free survival, which is particularly poor among patients with a Finnvasc score greater than 2.
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Affiliation(s)
- Aristotelis Kechagias
- Division of Cardio-thoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Pekka Romsi
- Division of Cardio-thoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Kari YlÖNen
- Division of Cardio-thoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Georgios Kechagias
- Division of Cardio-thoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Tatu Juvonen
- Division of Cardio-thoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Fausto Biancari
- Division of Cardio-thoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
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356
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Tendera M, Aboyans V, Bartelink ML, Baumgartner I, Clément D, Collet JP, Cremonesi A, De Carlo M, Erbel R, Fowkes FGR, Heras M, Kownator S, Minar E, Ostergren J, Poldermans D, Riambau V, Roffi M, Röther J, Sievert H, van Sambeek M, Zeller T. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:2851-906. [PMID: 21873417 DOI: 10.1093/eurheartj/ehr211] [Citation(s) in RCA: 1044] [Impact Index Per Article: 80.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
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- 3rd Division of Cardiology, Medical University of Silesia, Ziolowa 47, 40-635 Katowice, Poland.
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357
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Nolan BW, De Martino RR, Stone DH, Schanzer A, Goodney PP, Walsh DW, Cronenwett JL. Prior failed ipsilateral percutaneous endovascular intervention in patients with critical limb ischemia predicts poor outcome after lower extremity bypass. J Vasc Surg 2011; 54:730-5; discussion 735-6. [PMID: 21802888 DOI: 10.1016/j.jvs.2011.03.236] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 03/08/2011] [Accepted: 03/08/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Although open surgical bypass remains the standard revascularization strategy for patients with critical limb ischemia (CLI), many centers now perform peripheral endovascular intervention (PVI) as the first-line treatment for these patients. We sought to determine the effect of a prior ipsilateral PVI (iPVI) on the outcome of subsequent lower extremity bypass (LEB) in patients with CLI. METHODS A retrospective cohort analysis of all patients undergoing infrainguinal LEB between 2003 and 2009 within hospitals comprising the Vascular Study Group of New England (VSGNE) was performed. Primary study endpoints were major amputation and graft occlusion at 1 year postoperatively. Secondary outcomes included in-hospital major adverse events (MAE), 1-year mortality, and composite 1-year major adverse limb events (MALE). Event rates were determined using life table analyses and comparisons were performed using the log-rank test. Multivariate predictors were determined using a Cox proportional hazards model with multilevel hierarchical adjustment. RESULTS Of 1880 LEBs performed, 32% (n = 603) had a prior infrainguinal revascularization procedure (iPVI, 7%; ipsilateral bypass, 15%; contralateral PVI, 3%; contralateral bypass, 17%). Patients with prior iPVI, compared with those without a prior iPVI, were more likely to be women (32 vs 41%; P = .04), less likely to have tissue loss (52% vs 63%; P = .02), more likely to require arm vein conduit (16% vs 5%; P = .001), and more likely to be on statin (71% vs 54%; P = .01) and beta blocker therapy (92% vs 81%; P = .01) at the time of their bypass procedure. Other demographic factors were similar between these groups. Prior PVI or bypass did not alter 30-day MAE and 1-year mortality after the index bypass. In contrast, 1-year major amputation and 1-year graft occlusion rates were significantly higher in patients who had prior iPVI than those without (31% vs 20%; P = .046 and 28% vs 18%; P = .009), similar to patients who had a prior ipsilateral bypass (1 year major amputation, 29% vs 20%; P = .022; 1 year graft occlusion, 33% vs 18%; P = .001). Independent multivariate predictors of higher 1-year amputation and graft occlusion rates were prior iPVI, prior ipsilateral bypass, dialysis dependence, prosthetic conduit and distal (tibial and pedal) bypass target. CONCLUSIONS Prior iPVI is highly predictive for poor outcome in patients undergoing LEB for CLI with higher 1-year amputation and graft occlusion rates than those without prior revascularization, similar to prior ipsilateral bypass These findings provide information, which may help with the complex decisions surrounding revascularization options in patients with CLI.
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Affiliation(s)
- Brian W Nolan
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA.
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358
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Vogel TR, Dombrovskiy VY, Carson JL, Graham AM. In-hospital and 30-day outcomes after tibioperoneal interventions in the US Medicare population with critical limb ischemia. J Vasc Surg 2011; 54:109-15. [DOI: 10.1016/j.jvs.2010.12.055] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 12/10/2010] [Accepted: 12/15/2010] [Indexed: 10/18/2022]
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359
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Moxey PW, Hofman D, Hinchliffe RJ, Jones K, Thompson MM, Holt PJE. Trends and outcomes after surgical lower limb revascularization in England. Br J Surg 2011; 98:1373-82. [DOI: 10.1002/bjs.7547] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2011] [Indexed: 11/07/2022]
Abstract
Abstract
Background
The aim was to analyse contemporary data on the number of surgical revascularization procedures performed each year in England, and their outcome.
Methods
Hospital Episode Statistics and Office for National Statistics data were used to quantify numbers and identify factors associated with outcome after all femoropopliteal and femorodistal bypass procedures performed between 2002 and 2006. Outcome measures were repeat bypass, major amputation, death and a composite measure. Single-level multivariable logistic regression modelling was used to quantify the effect of these variables on outcome.
Results
A total of 21 675 femoropopliteal and 3458 femorodistal bypass procedures were performed. Mean in-hospital mortality rates were 6·7 and 8·0 per cent respectively. One-year survival rates were 82·8 and 79·1 per cent; both increased over the study interval. The mean 1-year major amputation rate after femoropopliteal bypass was 10·4 per cent, which decreased significantly over the 5 years (P < 0·001); after distal bypass the rate of 20·8 per cent remained unchanged (P = 0·456). Diabetes mellitus and chronic kidney disease were significant predictors of adverse outcome for both procedures: odds ratio (OR) at 1 year 1·56 (95 per cent confidence interval 1·46 to 1·67; P < 0·001) and 2·15 (1·88 to 2·45; P < 0·001) respectively for femoropopliteal bypass. Previous femoral angioplasty was associated with an increased rate of major amputation 1 year after proximal bypass (OR 1·18, 1·05 to 1·33; P = 0·004).
Conclusion
Although all mortality rates are improving, the major amputation rate remains high after femorodistal bypass. Adverse events occurred after 37·6 per cent of femoropopliteal and 49·7 per cent of femorodistal bypasses; diabetes and chronic renal failure were the main predictors of poor outcome.
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Affiliation(s)
- P W Moxey
- Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - D Hofman
- Department of Outcomes Research, Community Health Sciences, St George's University of London, London, UK
| | - R J Hinchliffe
- Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - K Jones
- Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - M M Thompson
- Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - P J E Holt
- Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
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360
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Barshes NR, Menard MT, Nguyen LL, Bafford R, Ozaki CK, Belkin M. Infrainguinal bypass is associated with lower perioperative mortality than major amputation in high-risk surgical candidates. J Vasc Surg 2011; 53:1251-1259.e1. [DOI: 10.1016/j.jvs.2010.11.099] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Revised: 11/11/2010] [Accepted: 11/12/2010] [Indexed: 11/29/2022]
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361
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Apelqvist J, Elgzyri T, Larsson J, Löndahl M, Nyberg P, Thörne J. Factors related to outcome of neuroischemic/ischemic foot ulcer in diabetic patients. J Vasc Surg 2011; 53:1582-8.e2. [PMID: 21515021 DOI: 10.1016/j.jvs.2011.02.006] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Revised: 02/04/2011] [Accepted: 02/05/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Peripheral vascular disease (PVD) is an important limiting factor for healing in neuroischemic or ischemic diabetic foot ulcer. The purpose of this study was to identify factors related to healing in patients with diabetes with foot ulcers and severe PVD. METHODS Patients with diabetes with a foot ulcer, consecutively presenting at a multidisciplinary foot center with a systolic toe pressure <45 mm Hg or an ankle pressure <80 mm Hg were prospectively included, followed according to a preset program, and with the exception of specified exclusions, subjected to angiography offered vascular intervention when applicable. All patients had continuous follow-up until healing or death irrespective of the type of vascular intervention. RESULTS One thousand one hundred fifty-one patients were included. Eighty-two percent had a toe pressure <45 mm Hg and 49% had an ankle pressure <80 mm Hg. Eight hundred one patients (70%) underwent an angiography. Out of these, 63% had vascular intervention, either percutaneous transluminal angioplasty (PTA; 39%) or reconstructive surgery (24%). Nine percent of the patients had one or more complications after angiography. PTA was multisegmental in 46% and to the crural arteries in 46%. Reconstructive surgery was distal in 51%. Age (P < .001), renal function impairment (P = .005), congestive heart failure (P = .01), number and type of ulcer (P < .001), and severity of PVD (P = .003) affected the outcome of ulcers. PTA and reconstructive vascular surgery increased the probability of healing without amputation (odds ratio [OR], 1.77 and 2.05, respectively). CONCLUSION Probability of ulcer healing is strongly related to comorbidity, extent of tissue involvement, and severity of PVD in patients with diabetes with severe PVD.
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Affiliation(s)
- Jan Apelqvist
- Department of Endocrinology, Skåne University Hospital, Lund University, Malmö, Sweden.
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362
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Abularrage CJ, Conrad MF, Haurani MJ, Crawford RS, Hackney LA, Lee H, LaMuraglia GM, Cambria RP. Long-term outcomes of patients undergoing endovascular infrainguinal interventions with single-vessel peroneal artery runoff. J Vasc Surg 2011; 53:1007-13. [DOI: 10.1016/j.jvs.2010.10.057] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Revised: 09/29/2010] [Accepted: 10/06/2010] [Indexed: 10/18/2022]
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363
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Femoropopliteal Balloon Angioplasty vs. Bypass Surgery for CLI: A Propensity Score Analysis. Eur J Vasc Endovasc Surg 2011; 41:378-84. [DOI: 10.1016/j.ejvs.2010.11.025] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 11/25/2010] [Indexed: 02/06/2023]
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364
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Abstract
Rest pain, tissue loss, and gangrene are manifestations of critical limb ischemia caused by peripheral arterial disease and define a patient subgroup at highest risk for major limb amputation. Patients with nonhealing lower extremity wounds should be screened for the risk factors for peripheral arterial disease and offered noninvasive vascular testing. The diagnosis of critical limb ischemia mandates prompt institution of medical and surgical management to achieve the best chance of limb salvage. Surgical intervention has evolved from primary amputation to open bypass to the present era of endovascular therapy. The goals of surgical bypass and endovascular therapy are to improve perfusion sufficiently to permit healing. Despite poorer patency rates and the more frequent need for reintervention, endovascular therapy has been shown in multiple retrospective studies to achieve limb salvage similar to open bypass. Only one large, prospective, randomized controlled trial exists comparing open bypass with endovascular therapy: The Bypass versus Angioplasty in Severe Limb Ischemia of the Leg (BASIL) trial. Close clinical surveillance and serial monitoring of limb perfusion by means of noninvasive arterial studies are needed to determine the need for further vascular intervention. Limb salvage patients suffer from multiple comorbidities and benefit from a multidisciplinary, team approach to care.
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365
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Ihnat DM, Mills JL. Current assessment of endovascular therapy for infrainguinal arterial occlusive disease in patients with diabetes. J Am Podiatr Med Assoc 2011; 100:424-8. [PMID: 20847357 DOI: 10.7547/1000424] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Endovascular therapy has increasingly become the initial clinical option for the treatment of lower-extremity peripheral arterial occlusive disease not only for patients with claudication but also for those with critical limb ischemia. Despite this major clinical practice paradigm shift, the outcomes of endovascular therapy for peripheral arterial disease are difficult to evaluate and compare with established surgical benchmarks because of the lack of prospective randomized trials, incomplete characterization of indications for intervention, mixing of arterial segments and extent of disease treated, the multiplicity of endovascular therapy techniques used, the exclusion of early treatment failures, crossover to open bypass during follow-up, and the frequent lack of intermediate and long-term patency and limb salvage rates in life-table format. These data limitations are especially problematic when one tries to assess the outcomes of endovascular therapy in patients with diabetes. The purpose of the present article is to succinctly review and objectively analyze available data regarding the results of endovascular therapy in patients with diabetes.
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Affiliation(s)
- Daniel M Ihnat
- Department of Vascular and Endovascular Surgery, University of Arizona Health Sciences Center, Tucson, AZ 85724, USA
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366
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Lara-Hernández R, Lozano-Vilardell P. Isquemia crítica de miembros inferiores: una enfermedad cada vez más prevalente. Med Clin (Barc) 2011; 136:106-8. [DOI: 10.1016/j.medcli.2010.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2010] [Accepted: 09/07/2010] [Indexed: 10/18/2022]
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367
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Conte MS. Challenges of distal bypass surgery in patients with diabetes: patient selection, techniques, and outcomes. J Am Podiatr Med Assoc 2011; 100:429-38. [PMID: 20847358 DOI: 10.7547/1000429] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Surgical revascularization of the lower extremity using bypass grafts to distal target arteries is an established, effective therapy for advanced ischemia. Recent multicenter data confirm the primacy of autogenous vein bypass grafting, yet there remains significant heterogeneity in the utilization, techniques, and outcomes associated with these procedures in current practice. Experienced clinical judgment, creativity, technical precision, and fastidious postoperative care are required to optimize long-term results. The diabetic patient with a critically ischemic limb offers some specific challenges; however, numerous studies demonstrate that the outcomes of vein bypass surgery in this population are excellent and define the standard of care. Technical factors, such as conduit and inflow/outflow artery selection, play a dominant role in determining clinical success. An adequate-caliber, good-quality great saphenous vein is the optimal graft for distal bypass in the leg. Alternative veins perform acceptably in the absence of the great saphenous vein, whereas prosthetic and other nonautogenous conduits have markedly inferior outcomes. Graft configuration (reversed, nonreversed, or in situ) seems to have little effect on outcome. Shorter grafts have improved patency. Inflow can be improved by surgical or endovascular means if necessary, and distal-origin grafts (eg, those arising from the superficial femoral or popliteal arteries) can perform as well as those originating from the common femoral artery. The selected outflow vessel should supply unimpeded runoff to the foot, conserve conduit length, and allow for adequate soft-tissue coverage of the graft and simplified surgical exposure. This review summarizes the available data linking patient selection and technical factors to outcomes and highlights the importance of surgical judgment and operative planning in the current practice of infrainguinal bypass surgery.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, 400 Parnassus Ave, Ste A-581, San Francisco, CA 94143, USA.
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368
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Chirurgische und interventionelle Behandlung der chronisch-kritischen Beinischämie. GEFASSCHIRURGIE 2011. [DOI: 10.1007/s00772-010-0863-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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369
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Discussion. Open surgical revascularization for wound healing: past performance and future directions; and Critical evaluation of endovascular surgery for limb salvage. Plast Reconstr Surg 2011; 127 Suppl 1:174S-176S. [PMID: 21200288 DOI: 10.1097/prs.0b013e318203a684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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370
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Hong MS, Beck AW, Nelson PR. Emerging National Trends in the Management and Outcomes of Lower Extremity Peripheral Arterial Disease. Ann Vasc Surg 2011; 25:44-54. [DOI: 10.1016/j.avsg.2010.08.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 08/16/2010] [Accepted: 08/22/2010] [Indexed: 10/18/2022]
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371
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Abstract
Critical limb ischemia (CLI), the most advanced form of peripheral arterial disease, is associated with a high rate of limb loss and substantial mortality. Revascularization remains the cornerstone of limb salvage in the CLI patient, and surgical bypass is the established standard. Endovascular therapies, such as angioplasty, atherectomy, and stenting offer a less-invasive option, but evidence of efficacy is lacking, and no devices are currently approved specifically for CLI. Design and execution of clinical trials in the CLI population are challenging, in part because of the lack of consensus on cohort definitions and relevant endpoints. Recently, the Society for Vascular Surgery undertook an initiative to define therapeutic benchmarks, objective performance goals (OPGs), for CLI. Using surgical bypass with autogenous vein as the standard for comparison, OPGs were developed for nine safety and efficacy measures that could be utilized in the premarket assessment of new devices in CLI. Data from three large randomized controlled trials of surgical bypass for CLI were analyzed. We defined a major adverse limb event (MALE) as a key endpoint for revascularization therapies in CLI--inclusive of amputation (transtibial or above) or any major vascular reintervention (thrombectomy, thrombolysis, or major surgical procedure [new bypass graft, jump/interposition graft revision]) in the index limb. Freedom from perioperative (30-day) death or any MALE (MALE + POD) was suggested as the primary efficacy endpoint for a single-arm trial design in CLI, with an observed rate of 76.9% for the surgical bypass controls at 1 year. Specific high-risk subgroups were also defined from the surgical dataset--based on clinical (age older than 80 years and tissue loss), arterial anatomy (infrapopliteal disease), and conduit quality (inadequate saphenous vein) characteristics. Risk-adjusted OPG were developed for these subgroups of interest. These OPGs define a new set of benchmarks for assessing the performance of revascularization therapies in CLI, and should facilitate clinical trial design and device development in this arena.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, 400 Parnassus Avenue, Suite A-581, San Francisco, CA 94143, USA.
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372
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Conte MS. Challenges of distal bypass surgery in patients with diabetes: Patient selection, techniques, and outcomes. J Vasc Surg 2010; 52:96S-103S. [DOI: 10.1016/j.jvs.2010.06.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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373
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Ihnat DM, Mills JL. Current assessment of endovascular therapy for infrainguinal arterial occlusive disease in patients with diabetes. J Vasc Surg 2010; 52:92S-95S. [DOI: 10.1016/j.jvs.2010.06.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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374
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375
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Forbes JF, Adam DJ, Bell J, Fowkes FGR, Gillespie I, Raab GM, Ruckley CV, Bradbury AW. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: Health-related quality of life outcomes, resource utilization, and cost-effectiveness analysis. J Vasc Surg 2010; 51:43S-51S. [DOI: 10.1016/j.jvs.2010.01.076] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 10/27/2009] [Accepted: 01/24/2010] [Indexed: 11/26/2022]
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376
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Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FGR, Gillespie I, Ruckley CV, Raab GM. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: Analysis of amputation free and overall survival by treatment received. J Vasc Surg 2010; 51:18S-31S. [DOI: 10.1016/j.jvs.2010.01.074] [Citation(s) in RCA: 253] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Revised: 06/08/2009] [Accepted: 01/24/2010] [Indexed: 11/17/2022]
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377
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Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FGR, Gillespie I, Ruckley CV, Raab GM. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: A description of the severity and extent of disease using the Bollinger angiogram scoring method and the TransAtlantic Inter-Society Consensus II classification. J Vasc Surg 2010; 51:32S-42S. [DOI: 10.1016/j.jvs.2010.01.075] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Revised: 08/10/2009] [Accepted: 01/24/2010] [Indexed: 12/01/2022]
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Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) and the (hoped for) dawn of evidence-based treatment for advanced limb ischemia. J Vasc Surg 2010; 51:69S-75S. [DOI: 10.1016/j.jvs.2010.02.001] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 02/01/2010] [Accepted: 02/02/2010] [Indexed: 11/21/2022]
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379
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Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FGR, Gillespie I, Ruckley CV, Raab GM. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: A survival prediction model to facilitate clinical decision making. J Vasc Surg 2010; 51:52S-68S. [DOI: 10.1016/j.jvs.2010.01.077] [Citation(s) in RCA: 174] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2009] [Revised: 06/01/2009] [Accepted: 01/24/2010] [Indexed: 11/17/2022]
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Abstract
Critical limb ischemia (CLI), defined as chronic ischemic rest pain, ulcers, or gangrene attributable to objectively proven arterial occlusive disease, is the most advanced form of peripheral arterial disease. Traditionally, open surgical bypass was the only effective treatment strategy for limb revascularization in this patient population. However, during the past decade, the introduction and evolution of endovascular procedures have significantly increased treatment options. In a certain subset of patients for whom either surgical or endovascular revascularization may not be appropriate, primary amputation remains a third treatment option. Definitive high-level evidence on which to base treatment decisions, with an emphasis on clinical and cost effectiveness, is still lacking. Treatment decisions in CLI are individualized, based on life expectancy, functional status, anatomy of the arterial occlusive disease, and surgical risk. For patients with aortoiliac disease, endovascular therapy has become first-line therapy for all but the most severe patterns of occlusion, and aortofemoral bypass surgery is a highly effective and durable treatment for the latter group. For infrainguinal disease, the available data suggest that surgical bypass with vein is the preferred therapy for CLI patients likely to survive 2 years or more, and for those with long segment occlusions or severe infrapopliteal disease who have an acceptable surgical risk. Endovascular therapy may be preferred in patients with reduced life expectancy, those who lack usable vein for bypass or who are at elevated risk for operation, and those with less severe arterial occlusions. Patients with unreconstructable disease, extensive necrosis involving weight-bearing areas, nonambulatory status, or other severe comorbidities may be considered for primary amputation or palliative measures.
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