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Endo T, Takayama T, Miyahara K, Shirasu T, Mochizuki Y, Taniguchi R, Hoshina K. Poor Limb Prognosis of Patients with Chronic Limb-Threatening Ischemia on Hemodialysis: A Retrospective Observational Study Based on the Global Limb Anatomic Staging System. Ann Vasc Surg 2024; 102:42-46. [PMID: 38307233 DOI: 10.1016/j.avsg.2023.11.049] [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: 07/12/2023] [Accepted: 11/25/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND The Global Limb Anatomic Staging System (GLASS) has been widely used to evaluate patients with chronic limb-threatening ischemia (CLTI). As end-stage kidney disease (ESKD) is a well-known CLTI risk factor, we aimed to determine whether patients on hemodialysis (HD) have a worse limb prognosis than those without ESKD, considering the same GLASS background. METHODS The data of 445 patients who underwent surgical and/or endovascular revascularization procedures for lower extremity ischemia were retrospectively collected in our division between 2005 and 2018. The major amputation rate and amputation-free survival (AFS) were compared between HD and non-HD patients. RESULTS Among the 215 (48%) patients receiving HD, 58 limbs required major amputation (27% limb loss rate). Among the non-HD group, the limb loss rate was 13% (P < 0.0001). The overall AFS was significantly worse in patients receiving HD than those not (P < 0.0001). The AFS was significantly worse in HD patients when comparing GLASS-standardized subgroups. CONCLUSIONS Patients with CLTI who were receiving HD had a worse limb prognosis than those not receiving, even when considering the same GLASS classification. Furthermore, there is a need for an ideal guideline focused on ESKD-directed peripheral artery disease.
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Affiliation(s)
- Takashi Endo
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshio Takayama
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Kazuhiro Miyahara
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takuro Shirasu
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuaki Mochizuki
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryosuke Taniguchi
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsuyuki Hoshina
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Kumada Y, Kawai N, Ishida N, Nakamura Y, Takahashi H, Ohshima S, Ito R, Izawa H, Murohara T, Ishii H. Combined Prognostic Value of Preprocedural Protein-Energy Wasting and Inflammation Status for Amputation and/or Mortality after Lower-Extremity Revascularization in Hemodialysis Patients with Peripheral Arterial Disease. J Clin Med 2023; 13:126. [PMID: 38202133 PMCID: PMC10779791 DOI: 10.3390/jcm13010126] [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: 11/16/2023] [Revised: 12/03/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
Protein-energy wasting is associated with inflammation and advanced atherosclerosis in hemodialysis patients. We enrolled 800 patients who had undergone successful lower-extremity revascularization, and we investigated the association among the Geriatric Nutritional Risk Index (GNRI) as a surrogate marker of protein-energy wasting, C-reactive protein (CRP), and their joint roles in predicting amputation and mortality. They were divided into lower, middle, and upper tertiles (T1, T2, and T3) according to GNRI and CRP levels, respectively. Regarding the results, the amputation-free survival rates over 8 years were 47.0%, 56.9%, and 69.5% in T1, T2, and T3 of the GNRI and 65.8%, 58.7%, and 33.2% for T1, T2, and T3 of CRP, respectively (p < 0.0001 for both). A reduced GNRI [adjusted hazard ratio (aHR) 1.78, 95% confidence interval (CI) 1.24-2.59, p = 0.0016 for T1 vs. T3] and elevated CRP (aHR 1.86, 95% CI 1.30-2.70, p = 0.0007 for T3 vs. T1) independently predicted amputation and/or mortality. When the two variables were combined, the risk was 3.77-fold higher (95% CI 1.97-7.69, p < 0.0001) in patients who occupied both T1 of the GNRI and T3 of CRP than in those who occupied both T3 of the GNRI and T1 of CRP. In conclusion, patients with preprocedurally decreased GNRI and elevated CRP levels frequently experienced amputation and mortality, and a combination of these two variables could more accurately stratify the risk.
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Affiliation(s)
- Yoshitaka Kumada
- Department of Cardiovascular Surgery, Matsunami General Hospital, Kasamatsu 501-6062, Japan; (Y.K.); (N.K.); (N.I.); (Y.N.)
| | - Norikazu Kawai
- Department of Cardiovascular Surgery, Matsunami General Hospital, Kasamatsu 501-6062, Japan; (Y.K.); (N.K.); (N.I.); (Y.N.)
| | - Narihiro Ishida
- Department of Cardiovascular Surgery, Matsunami General Hospital, Kasamatsu 501-6062, Japan; (Y.K.); (N.K.); (N.I.); (Y.N.)
| | - Yasuhito Nakamura
- Department of Cardiovascular Surgery, Matsunami General Hospital, Kasamatsu 501-6062, Japan; (Y.K.); (N.K.); (N.I.); (Y.N.)
| | - Hiroshi Takahashi
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake 470-1192, Japan; (H.T.); (H.I.)
| | - Satoru Ohshima
- Department of Cardiology, Nagoya Kyoritsu Hospital, Nagoya 454-0933, Japan; (S.O.); (R.I.)
| | - Ryuta Ito
- Department of Cardiology, Nagoya Kyoritsu Hospital, Nagoya 454-0933, Japan; (S.O.); (R.I.)
| | - Hideo Izawa
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake 470-1192, Japan; (H.T.); (H.I.)
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan;
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Japan
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Vivekanand V, Motukuru V, Kolalu S, Rangaswamy GK, Jain P. Effect of Comorbidities on Outcomes of Infrapopliteal Angioplasty in Patients with Chronic Limb-Threatening Ischemia. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:392-400. [PMID: 36226666 DOI: 10.1177/15569845221123327] [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: 12/24/2022]
Abstract
OBJECTIVE This subgroup analysis aimed to evaluate the effect of comorbidities on infrapopliteal angioplasty outcomes in patients with chronic limb-threatening ischemia (CLTI). METHODS This was an observational study evaluating eligible CLTI patients aged >18 years who underwent infrapopliteal angioplasty between April 2014 and May 2017 at a tertiary care center. Subgroup analyses were based on (1) baseline glycated hemoglobin (HbA1c ≤6.5% vs >6.5%), (2) presence/absence of chronic kidney disease (CKD), and (3) control of lipid parameters. RESULTS A total of 231 patients with 332 infrapopliteal vessels were treated. While diabetes was prevalent in all participants, hypertension, coronary artery disease, and CKD were reported in 76.6%, 46.3%, and 25.5% of patients at baseline, respectively. The overall technical success rate was 84.4%, and the patency rate at 6 months was 82.04%. Patency at 6 months, wound healing, in-line flow, and complete plantar arch formation were numerically higher in patients with HbA1c ≤6.5% versus >6.5%, but all comparisons were nonsignificant. According to multivariable analysis, the odds of wounds not healing was 2.38 times higher (odds ratio [OR] = 2.4, 95% confidence interval [CI]: 1.2 to 4.5) and developing plantar arch was 5.88 times higher (OR = 5.9, 95% CI: 1.3 to 25) among patients with CKD compared with patients without CKD. CONCLUSIONS The 6-month outcomes of infrapopliteal angioplasty may be better in patients with controlled versus uncontrolled glycemic levels. Control of lipid parameters may not have a significant influence on outcomes, especially in patients on statin therapy. The short-term outcomes may be similar in patients with and without CKD.
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Affiliation(s)
- Vivekanand Vivekanand
- Jain Institute of Vascular Sciences, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
| | - Vishnu Motukuru
- Jain Institute of Vascular Sciences, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
| | - Sumanthraj Kolalu
- Jain Institute of Vascular Sciences, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
| | | | - Piyushkumar Jain
- Jain Institute of Vascular Sciences, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
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Natour AK, Al Adas Z, Nypaver T, Shepard A, Weaver M, Malinzak L, Patel A, Kabbani L. Rate of Ipsilateral Chronic Limb-Threatening Ischemia (CLTI) After Kidney Transplantation: A Retrospective Single-Center Study. Cureus 2022; 14:e25455. [PMID: 35774684 PMCID: PMC9239297 DOI: 10.7759/cureus.25455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2022] [Indexed: 11/23/2022] Open
Abstract
Objective: To analyze whether the rate of lower extremity (LE) ischemia is higher on the ipsilateral side after kidney transplantation. Methods: Our institutional transplant database was retrospectively queried for all patients who received a kidney transplant and underwent subsequent LE revascularization or major limb amputations between January 2004 and July 2020. The one-sample binomial test was used to test whether the LE ipsilateral to the transplanted kidney was at higher risk of peripheral arterial disease (PAD) complications necessitating intervention (major amputation or revascularization). Results: There were 1,964 patients who received a kidney transplant during the study period. Of these, 51 patients (3%) had subsequent LE arterial revascularizations or major amputations. The mean age was 58 ± 10 years, and 37 patients (73%) were male. A total of 33 patients had ipsilateral LE vascular interventions (26 major amputations and seven revascularizations) while 18 patients had contralateral vascular interventions (14 major amputations and four revascularizations) (P = 0.049). The average interval between transplantation and subsequent vascular intervention was 52 months for the ipsilateral intervention group and 41 months for the contralateral intervention group (P = 0.33). Conclusions: In patients who received kidney transplantation and required subsequent LE surgical intervention, we observed an association between the side of transplantation and the risk of future ipsilateral LE arterial insufficiency. Further studies are needed to determine the etiology of this association.
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Dawson DB, Telles-Garcia NA, Atkins JL, Mina GS, Abreo AP, Virk CS, Dominic PS. End-stage renal disease patients undergoing angioplasty and bypass for critical limb ischemia have worse outcomes compared to non-ESRD patients: Systematic review and meta-analysis. Catheter Cardiovasc Interv 2021; 98:297-307. [PMID: 33825331 DOI: 10.1002/ccd.29688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 03/23/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND End-stage renal disease (ESRD) is associated with increased morbidity and mortality following lower extremity amputation for critical limb ischemia (CLI). Angioplasty and bypass are used in ESRD patients with CLI; however, the treatment of choice remains controversial. We compared the long-term outcomes in patients with CLI undergoing angioplasty or bypass to evaluate the differences between patients with ESRD and those without ESRD. METHODS Established databases were searched for observational studies comparing outcomes following bypass or angioplasty for CLI in patients with ESRD to those in non-ESRD patients. End points included survival, limb salvage, amputation-free survival (AFS), and primary and secondary patency at 1-year post-procedure. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random effect model. RESULTS We included 20 studies with a total of 24,851 patients. ESRD patients compared to non-ESRD patients with CLI had significantly lower survival post-angioplasty (OR 0.51, 95% CI 0.36-0.72, p < .001) and post-bypass (OR 0.26, 95% CI 0.15-0.45, p < .001). ESRD patients had lower rates of limb salvage post-bypass (OR 0.33, 95% CI 0.21-0.53, p < .001) and post-angioplasty (OR 0.54, 95% CI 0.41-0.70, p < .001). AFS was significantly lower in ESRD patients compared to non-ESRD patients following angioplasty (OR 0.48, 95% CI 0.32-0.71, p < .001) and bypass (OR 0.28, 95% CI 0.16-0.47, p < .001) despite no significant differences in primary patency. ESRD patients had overall worse secondary patency post-angioplasty and/or bypass (OR 0.54, 95% CI 0.32-0.94, p = .03) compared to non-ESRD patients. A meta-analysis of four studies directly comparing survival in ESRD patients with CLI based on whether they underwent angioplasty or bypass showed no difference (OR 0.93, 95% CI 0.64-1.35, p = .69). CONCLUSION ESRD patients have worse survival, limb salvage, and AFS outcomes following angioplasty and bypass for CLI compared to non-ESRD patients. Large randomized controlled trials comparing these two modalities of treatment in this patient population are needed for further clarity.
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Affiliation(s)
- Desireé B Dawson
- Department of Medicine and Center of Excellence for Cardiovascular Diseases & Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Nelson A Telles-Garcia
- Department of Medicine and Center of Excellence for Cardiovascular Diseases & Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Jessica L Atkins
- Department of Medicine and Center of Excellence for Cardiovascular Diseases & Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - George S Mina
- Department of Medicine and Center of Excellence for Cardiovascular Diseases & Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Adrian P Abreo
- Division of Nephrology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Chiranjiv S Virk
- Division of Endovascular and Vascular Surgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Paari S Dominic
- Department of Medicine and Center of Excellence for Cardiovascular Diseases & Sciences, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
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Farchioni L, Gennai S, Giuliani E, Cuccì A, Lauricella A, Leone N, Silingardi R. A prognostic risk score for major amputation in dialysis patients with chronic limb-threatening ischemia after endovascular revascularization. INT ANGIOL 2021; 40:206-212. [PMID: 33660496 DOI: 10.23736/s0392-9590.21.04523-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Almost 38% of all patients with end-stage chronic kidney disease (CKD) have peripheral arterial disease of the lower limbs that can lead to chronic limb threatening ischemia (CLTI). The aim of this study was to assess the impact of several factors to conduct a stratification of the amputation risk in CKD patients with CLTI receiving endovascular revascularization. METHODS Observational, retrospective, single-center study of patients treated from 2010 to 2016. The primary endpoint was the major amputation. The study included adult CKD dialysis patients affected by CLTI (rest pain and/or trophic lesions) with indication to endovascular revascularization and excluded for open repair. RESULTS A total of 82 patients were considered (58 men [70.7%], 24 women [29.3%] mean age 70.4±15.0 years). The number of major amputations was 28 (34.1%). The arterial lesion severity (TASC II-classification) and the trophic lesions extension (WIfI classification) were significantly associated with major amputation (OR and 95%CI, 1.20 [1.07-1.34], P=0.001; 2.65 [1.49-4.72], P=0.001; respectively). Based on the above-mentioned characteristics, a prognostic score was proposed to predict the major amputation risk. A score ≥23 was associated with a 67.6% probability of amputation in the following 12 months. CONCLUSIONS The CLTI revascularization is associated with poor outcomes in CKD patients. The present clinical score provided a pragmatic tool to calculate the major amputation risk. An elevated score could facilitate the decision-making process in order to perform an endovascular treatment vs. conservative approach.
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Affiliation(s)
- Luca Farchioni
- Department of Vascular Surgery, Civil Hospital of Baggiovara, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy -
| | - Stefano Gennai
- Department of Vascular Surgery, Civil Hospital of Baggiovara, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Enrico Giuliani
- Department of Anesthsiology and Intensive Care, Polyclinic of Modena, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Antonietta Cuccì
- Department of Vascular Surgery, Civil Hospital of Baggiovara, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Antonio Lauricella
- Department of Vascular Surgery, Civil Hospital of Baggiovara, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Leone
- Department of Vascular Surgery, Civil Hospital of Baggiovara, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Civil Hospital of Baggiovara, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
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Abualhin M, Gargiulo M, Bianchini Massoni C, Mauro R, Morselli-Labate AM, Freyrie A, Faggioli G, Stella A. A prognostic score for clinical success after revascularization of critical limb ischemia in hemodialysis patients. J Vasc Surg 2019; 70:901-912. [DOI: 10.1016/j.jvs.2018.11.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 11/07/2018] [Indexed: 01/08/2023]
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Abstract
PURPOSE OF REVIEW This paper provides a concise update on the management of peripheral artery disease (PAD). RECENT FINDINGS PAD continues to denote a population at high risk for mortality but represents a threat for limb loss only when associated with foot ulcers, gangrene, or infections. Performing either angiogram or non-invasive testing for all patients with foot ulcers, gangrene, or foot infections will help increase the detection of PAD, and refined revascularization strategies may help optimize wound healing in this patient group. Structured exercise programs are becoming available to more patients with claudication as methods to improve adherence to community-based exercise programs will improve. Finally, ensuring more patients with PAD receive aspirin therapy and statins may improve long-term survival, while further research will help determine if adding newer antiplatelet or anticoagulant medications may reduce leg amputations in selected patients. Clinicians should have a low threshold to obtain an angiogram and to pursue revascularization in patients with foot ulcers, gangrene, or foot infections. In patients with claudication, clinicians should maximize the benefits derived from exercise therapy and medical management before offering percutaneous or surgical revascularization.
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Affiliation(s)
- Neal R Barshes
- Division of Vascular Surgery and Endovascular Therapy, Michael E. Debakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard (OCL 112),, Houston, TX, 77030, USA.
| | - Courtney L Grant
- Division of Vascular Surgery and Endovascular Therapy, Michael E. Debakey Department of Surgery, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard (OCL 112),, Houston, TX, 77030, USA
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Meloni M, Izzo V, Giurato L, Del Giudice C, Da Ros V, Cervelli V, Gandini R, Uccioli L. Recurrence of Critical Limb Ischemia After Endovascular Intervention in Patients with Diabetic Foot Ulcers. Adv Wound Care (New Rochelle) 2018; 7:171-176. [PMID: 29892493 DOI: 10.1089/wound.2017.0778] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 12/22/2017] [Indexed: 02/07/2023] Open
Abstract
Objective: To establish the rate of clinical recurrence of critical limb ischemia (CLI) in diabetic patients with ischemic foot ulcers (DFUs) treated by percutaneous transluminal angioplasty (PTA). Approach: The study group was composed of 304 patients with ischemic DFUs treated by PTA. We evaluated the rate of clinical recurrence of CLI requiring a second PTA (repeated PTA [rePTA]), the factors related to CLI relapse, and the outcomes of rePTA patients. The follow-up was 12.5 ± 6.6 months. Results: Seventy-four of 304 patients (24.3%) needed rePTA. The mean time to rePTA was 3.5 ± 0.64 months. rePTA group in comparison with no rePTA group had lower rate of healing (28.5% vs. 71.9% p = 0.0001), higher rate of ulcer recurrence (20% vs. 10.3% p = 0.03), major amputation (24.3% vs. 4.3% p = 0.0005), and death (33.3% vs. 7.9% p = 0.002). Glycated hemoglobin, type A1C (HbA1c; 2.2 [1.9-2.7] p = 0.02) and dialysis (1.5 [1.4-3.6] p = 0.006) were independently associated to clinical recurrence of CLI after PTA. Innovation: To identify the outcomes of patients with clinical recurrence of CLI and the clinical factors involved to reduce the rate of restenosis after endovascular treatment and improve the rate of limb salvage. Conclusions: Clinical recurrence of CLI is associated with a high rate of nonhealing ulcer recurrence, major amputation, and death. Dialysis and impaired glycemic control were independent predictors of CLI relapse after endovascular treatment.
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Affiliation(s)
- Marco Meloni
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Valentina Izzo
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Laura Giurato
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | | | - Valerio Da Ros
- Department of Interventional Radiology, University of Tor Vergata, Rome, Italy
| | - Valerio Cervelli
- Department of Plastic and Reconstructive Surgery, University of Tor Vergata, Rome, Italy
| | - Roberto Gandini
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Luigi Uccioli
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
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Meloni M, Giurato L, Izzo V, Stefanini M, Pampana E, Gandini R, Uccioli L. Long term outcomes of diabetic haemodialysis patients with critical limb ischemia and foot ulcer. Diabetes Res Clin Pract 2016; 116:117-22. [PMID: 27321326 DOI: 10.1016/j.diabres.2016.04.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 03/23/2016] [Accepted: 04/18/2016] [Indexed: 01/28/2023]
Abstract
AIM To evaluate the outcomes of diabetic dialysis patients with critical limb ischemia and foot ulcer. METHODS The study group included 599 diabetic, 99 dialyzed (Ds) (16.5%) and 500 not dialyzed (NDs) (83%) patients with critical limb ischemia and foot ulcers identified as stage C (ischemia) or D (ischemia plus infection) of Texas Wound Classification. All patients were treated by endovascular revascularization. Outcomes were expressed as healing, major amputation, death and non healing after 12months. The mean follow-up was 15±13months. RESULTS The outcomes of the whole population were: 48.9% healing, 11.3% major amputation, 12.7% death, 27.1 non healing. At the multivariate analysis dialysis was a negative predictor of healing and a positive predictor of major amputation. Outcomes for Ds and NDs were respectively: healing (30.3 vs 52.6%), major amputation (14.4 vs 10.8%), death (21.1 vs 11%) and non-healing (34.2 vs 25.6%) (X=0.0004). Amputation occurred earlier in Ds than in NDs. According to the multivariate analysis in Ds ischemic heart disease and lower ΔTcPO2 were negative predictors for healing. Successful revascularization was a negative predictor for major amputation. HDL and carotid artery disease were predictive factors of death among NDs. Among Ds high blood pressure values were the only predictor of amputation while no variable resulted predictive of healing or death. CONCLUSIONS Our study shows that our limb salvage protocol ensures a good rate of limb salvage in Ds even if they have a higher risk of amputation and death compared to NDs.
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Affiliation(s)
- Marco Meloni
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy.
| | - Laura Giurato
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Valentina Izzo
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | | | - Enrico Pampana
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Roberto Gandini
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Luigi Uccioli
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy
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Meyer A, Schinz K, Lang W, Schmid A, Regus S, Rother U. Outcomes and Influence of the Pedal Arch in Below-the-Knee Angioplasty in Patients with End-Stage Renal Disease and Critical Limb Ischemia. Ann Vasc Surg 2016; 35:121-9. [PMID: 27238998 DOI: 10.1016/j.avsg.2016.01.039] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 01/17/2016] [Accepted: 01/18/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Management of dialysis patients with critical limb ischemia (CLI) still represents a challenge to vascular medicine, whereas the effects of the pedal arch quality in these patients with predominant affection of the infrapopliteal vessels have rarely been evaluated. Therefore, our aim was to analyze the outcomes of infrapopliteal angioplasty in the setting of chronic renal failure (end-stage renal disease) and evaluate the influence of the pedal arch involvement on clinical success. METHODS Prospective follow-up of 32 ERSD patients on hemodialysis (mean age, 72 years) with CLI and consecutive infrapopliteal angioplasty over a 5-year period 2010-2014 was performed. Mean follow-up was 10 months (range, 0-51 months). Statistical end points were defined for amputation-free survival, overall survival, and wound healing. Each patient's pedal arch was classified in 4 categories according to patency on completion angiography and the influence of the pedal arch quality on end points was assessed. RESULTS A total of 44 vessels in 32 ischemic legs were treated. Technical success was achieved in 96% of patients, no major complications were observed. A 30-day mortality rate amounted 6% with no procedure-related deaths. The 1-year amputation-free survival rate was 56% and 34% at 2 years. Two major amputations were required. Subsequent revascularization procedures were necessary in 11 patients (10 redo angioplasty, 1 pedal bypass graft). The pedal arch was classified as category I in 1 patient (3%), category IIa in 12 (38%), IIb in 3 (9%), and III in 16 patients (50%). No statistical significant differences in terms of survival or wound-healing rate were observed between those groups, and the pedal arch quality had no impact on predefined end points. CONCLUSIONS End-stage renal disease patients represent a subgroup with poor prognosis of limb salvage in CLI. Amputation-free survival remains poor and based on these data, an endovascular therapy is feasible and safe in these highly multimorbid patients. The quality of the pedal arch was not found to have any impact on wound healing or survival in the present study.
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Affiliation(s)
- Alexander Meyer
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Katharina Schinz
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Werner Lang
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Axel Schmid
- Institute of Radiology, University Hospital Erlangen, Erlangen, Germany
| | - Susanne Regus
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany.
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Kobayashi S. [CKD and Progression of PAD.]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2016; 105:842-849. [PMID: 29182836 DOI: 10.2169/naika.105.842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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13
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Percutaneous Transluminal Angioplasty in Patients With Infrapopliteal Arterial Disease. Circ Cardiovasc Interv 2016; 9:e003468. [DOI: 10.1161/circinterventions.115.003468] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 03/21/2016] [Indexed: 11/16/2022]
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Matsuzaki K, Hayashi R, Okabe K, Aramaki-Hattori N, Kishi K. Prognosis of critical limb ischemia: Major vs. minor amputation comparison. Wound Repair Regen 2015; 23:759-64. [PMID: 26082356 DOI: 10.1111/wrr.12329] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 06/15/2015] [Indexed: 11/28/2022]
Abstract
Healthcare providers treating wounds have difficulties assessing the prognosis of patients with critical limb ischemia who had been discharged after complete healing of major amputation wounds. The word "major" in "major amputation" gives the impression of "being more severe" than "minor amputation." Therefore, even if wounds are healed after major amputation, they imagine that prognosis after major amputation would be poorer than that after minor amputation. We investigated the prognosis of diabetic nephropathy patients 2 years after amputations. Those patients underwent dialysis as well as amputation following percutaneous transluminal angioplasty for their foot wounds. They were ambulatory prior to these surgeries. Among 56 cases of minor amputation, 45 were males and 11 were females, and mortality was 41.1%. The mortality of cases with and without a coronary intervention history was 53.1% and 25.0%, respectively (p = 0.034). Among 10 cases of major amputation, 9 were males and 1 was female, and mortality was 60%. The mortality of cases with and without a coronary intervention history was 75.0% and 0%, respectively. Although we predicted poor prognosis in cases with major amputation, there was no significant difference in mortality 2 years after amputations (p = 0.267). Thus far poor prognosis has been reported for major amputation. It might be due to inclusion of the following patients: patients with wounds proximal to ankle joints, patients with extensive gangrene spreading to the lower legs, patients with septicemia from wound infection and who died around the time of operation, and patients with malnutrition. The results of our present study showed that the outcomes at 2 years postoperatively were similar between patients with major amputations and those with minor amputations, if surgical wounds were able to heal. We should not estimate the prognosis by the level of amputation, rather we should consider the effect of coronary intervention history on prognosis.
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Affiliation(s)
- Kyoichi Matsuzaki
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ruka Hayashi
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Keisuke Okabe
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Noriko Aramaki-Hattori
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazuo Kishi
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
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Kumada Y, Nogaki H, Ishii H, Aoyama T, Kamoi D, Takahashi H, Murohara T. Clinical outcome after infrapopliteal bypass surgery in chronic hemodialysis patients with critical limb ischemia. J Vasc Surg 2015; 61:400-4. [DOI: 10.1016/j.jvs.2014.09.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 09/11/2014] [Indexed: 10/24/2022]
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Baumann F, Ozdoba C, Gröchenig E, Diehm N. The Importance of Patency in Patients with Critical Limb Ischemia Undergoing Endovascular Revascularization for Infrapopliteal Arterial Disease. Front Cardiovasc Med 2015; 1:17. [PMID: 26664867 PMCID: PMC4668862 DOI: 10.3389/fcvm.2014.00017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 12/16/2014] [Indexed: 12/02/2022] Open
Abstract
Critical limb ischemia (CLI) represents the most severe form of peripheral arterial disease (PAD) and frequently occurs in medically frail patients. CLI patients frequently exhibit multi-segmental PAD commonly including the tibial arterial segment. Endovascular therapy has been established as first-line revascularization strategy for most CLI patients. Restenosis was reported to occur in up to more than two-thirds of CLI patients undergoing angioplasty of complex tibial arterial obstructions. Nevertheless, favorable clinical outcomes were observed for infrapopliteal angioplasty when compared with bypass surgery, despite higher patency rates for the latter. Based on these observations, infrapopliteal patency was considered to be only of secondary importance upon clinical outcomes in CLI patients. In contrast to these earlier observations, however, recent findings from two randomized clinical trials indicate that infrapopliteal patency does impact on clinical outcomes in CLI patients. The purpose of the present manuscript is to provide a critical reappraisal of the present literature on the clinical importance of tibial arterial patency in CLI patients undergoing endovascular revascularization and to discuss utility and limitations of currently available anti-restenosis technologies.
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Affiliation(s)
- Frederic Baumann
- Miami Cardiac and Vascular Institute, Baptist Hospital , Miami, FL , USA
| | - Christoph Ozdoba
- Clinical and Interventional Neuroradiology, University Hospital Bern , Bern , Switzerland
| | - Ernst Gröchenig
- Clinical and Interventional Angiology, Kantonsspital Aarau , Aarau , Switzerland
| | - Nicolas Diehm
- Clinical and Interventional Angiology, Kantonsspital Aarau , Aarau , Switzerland ; University of Applied Sciences Furtwangen , Villingen-Schwenningen , Germany
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Kawarada O, Yokoi Y, Higashimori A, Fujihara M, Sakamoto S, Ishihara M, Yasuda S, Ogawa H. Impact of end-stage renal disease in patients with critical limb ischaemia undergoing infrapopliteal intervention. EUROINTERVENTION 2014; 10:753-60. [DOI: 10.4244/eijv10i6a129] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Razavi MK, Mustapha JA, Miller LE. Contemporary Systematic Review and Meta-Analysis of Early Outcomes with Percutaneous Treatment for Infrapopliteal Atherosclerotic Disease. J Vasc Interv Radiol 2014; 25:1489-96, 1496.e1-3. [DOI: 10.1016/j.jvir.2014.06.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 06/23/2014] [Accepted: 06/23/2014] [Indexed: 12/01/2022] Open
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Ghoneim B, Elwan H, Eldaly W, Khairy H, Taha A, Gad A. Management of critical lower limb ischemia in endovascular era: experience from 511 patients. Int J Angiol 2014; 23:197-206. [PMID: 25317033 PMCID: PMC4172447 DOI: 10.1055/s-0034-1382825] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
This study aims at the assessment of the achievability of the endovascular treatment of patients with critical limb ischemia (CLI) and the role of bypass in such patient. This is a prospective study conducted on patients with chronic atherosclerotic critical lower limb ischemia presenting to us over a period of 3 years. Patients presenting with nonsalvageable limbs requiring primary major amputation and nonatherosclerotic causes of CLI were excluded. Endovascular treatment was the first choice modality of treatment in revascularization of all patients. Open surgery was offered selectively for patient whom endovascular failed or complicated and for long TransAtlantic Inter-Society Consensus (TASC) II lesions in fit patients. This study included 511 cases of CLI, and the mean age was 64.5 years. Patients with Rutherford IV, V, and VI were 19.25, 60.5, and 19.25%, respectively. The TASC II aortoiliac lesions were as follows: A, B, C, and D in 33.7, 12,15.7, and 38.6%, respectively, and infrainguinal lesions were A, B, C, and D in 3.7, 19, 35.4, and 68.3%, respectively. A total of 78.3% of patients were treated by endovascular totally, while 16% were treated by surgery from the start, 3.7% of endovascular cases were converted to open surgery after failure of endovascular treatment, and 2% was offered hybrid treatment. Crossing of lesions by subintimal and intraluminal was 12.5 and 87.5%, respectively. Technical success in endovascular was 94%; however, we could successfully revascularize 96.8% of all CLI presented in this study by either surgery or endovascular. On 24 months follow-up, primary patency, secondary patency, and limb salvage by percutaneous transluminal angioplasty are 77.8, 84.7, and 90.7%, respectively. Revascularization by endovascular achieves high technical success and limb salvage in CLI, hence should be considered as preferred choice of treatment. However, both endovascular and surgery should not be counteracting each other and using both can revascularize 96.6% of CLI.
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Affiliation(s)
- Baker Ghoneim
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Hussein Elwan
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Waleed Eldaly
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Hussein Khairy
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Ahmad Taha
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Amr Gad
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
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Cost-effectiveness of revascularization for limb preservation in patients with end-stage renal disease. J Vasc Surg 2014; 60:369-374.e1. [PMID: 24657067 DOI: 10.1016/j.jvs.2014.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 02/03/2014] [Accepted: 02/03/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND Limb revascularization in patients with end-stage renal disease (ESRD) has been criticized because of the low rates of limb preservation and overall survival that characterize this patient population. We undertook a formal cost-utility analysis to evaluate the role of revascularization in the ESRD population. METHODS A probabilistic Markov model was used to simulate the clinical outcomes and long-term outcomes after six different strategies for the management of nonhealing foot wounds in patients with critical limb ischemia and ESRD. All scenarios considered all-cause mortality and major amputation for failure of limb salvage. Parameter estimates of the costs, clinical events, and functional outcomes used in the model were derived from primary data or published literature. Costs are reported in 2011 U.S. dollars. RESULTS Local wound care alone had the lowest long-term total cost of the management strategies evaluated; primary amputation had the highest. Purely endovascular intervention yielded the highest limb salvage rates. Endovascular intervention had a cost of $15,403 per additional year of ambulation beyond that by local wound care alone. Endovascular intervention had the potential for cost-savings (ie, better health benefits at lower cost) only with very high 1-year wound healing rates. The 5-year survival rates ranged from 17% to 34% in all management strategies. CONCLUSIONS Endovascular intervention may be a cost-effective alternative to local wound care alone for patients with ESRD and ischemic foot wounds, but with small marginal health benefits at considerable cost. Local wound care alone may be preferable to primary amputation.
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Patel VI, Mukhopadhyay S, Guest JM, Conrad MF, Watkins MT, Kwolek CJ, LaMuraglia GM, Cambria RP. Impact of severe chronic kidney disease on outcomes of infrainguinal peripheral arterial intervention. J Vasc Surg 2014; 59:368-75. [DOI: 10.1016/j.jvs.2013.09.006] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 09/04/2013] [Accepted: 09/04/2013] [Indexed: 11/29/2022]
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Bianchini Massoni C, Freyrie A, Muccini N, Gargiulo M, Faggioli G, Stella A. Endovascular Treatment of the Infrapopliteal Arteries in Hemodialysis Patients with Critical Limb Ischemia: Is it Justified? Ann Vasc Surg 2014; 28:152-8. [DOI: 10.1016/j.avsg.2012.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 12/12/2012] [Accepted: 12/19/2012] [Indexed: 12/25/2022]
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23
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Endovascular Management of Critical Limb Ischemia in Renal Transplant Patients. Ann Vasc Surg 2014; 28:159-63. [DOI: 10.1016/j.avsg.2012.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 12/07/2012] [Accepted: 12/11/2012] [Indexed: 11/20/2022]
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24
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Sultan S, Tawfick W, Hynes N. Cool excimer laser-assisted angioplasty (CELA) and tibial balloon angioplasty (TBA) in management of infragenicular arterial occlusion in critical lower limb ischemia (CLI). Vasc Endovascular Surg 2013; 47:179-91. [PMID: 23448976 DOI: 10.1177/1538574413478473] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We aim to compare cool excimer laser-assisted angioplasty (CELA) versus tibial balloon angioplasty (TBA) in patients with critical limb ischemia (CLI) with tibial artery occlusive disease. The primary end point is sustained clinical improvement (SCI) and amputation-free survival (AFS). The secondary end points are binary restenosis, target extremity revascularization (TER), and cost-effectiveness. From June 2005 to October 2010, 1506 patients were referred with peripheral vascular disease and 572 with CLI. A total of 80 patients underwent 89 endovascular revascularizations (EVRs) for tibial occlusions, 47 using TBA and 42 using CELA. All patients were Rutherford category 4 to 6. Three-year SCI was enhanced with CELA (81%) compared to TBA (63.8%; P = .013). Three-year AFS significantly improved with CELA (95.2%) versus TBA (89.4%; P = .0165). Three-year freedom from TER was significantly improved with CELA (92.9%) versus 78.7% TBA (P = .026). Three-year freedom from MACE was comparable in both the groups (P = .455). Patients with CELA had significantly improved quality time without symptoms of disease or toxicity of treatment (Q-TWiST) at 3 years (10.5 months; P = .048) with incremental cost of €2073.19 per quality-adjusted life year gained. Tibial EVR provides exceptional outcome in CLI. The CELA has superior SCI, AFS, and freedom from TER, with improved Q-TWiST and cost-effectiveness.
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Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, University College Hospital Galway, Galway, Ireland.
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25
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Matsuzaki K, Miyamoto A, Hakamata N, Fukuda M, Yamauchi Y, Akita T, Kuhara R, Tezuka S. Diabetic foot wounds in haemodialysis patients: 2-year outcome after percutaneous transluminal angioplasty and minor amputation. Int Wound J 2012; 9:693-700. [PMID: 23095148 PMCID: PMC7950545 DOI: 10.1111/j.1742-481x.2012.01104.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Critical limb ischaemia (CLI) is known to be associated with high mortality. In some patients, surgery cannot be performed due to high risk of perioperative death and complications. In other cases, there is only pain at rest but no wound. Therefore, it is difficult to accurately predict the prognosis of individual patients. We examined the prognosis of CLI cases in which therapeutic footwear was made for ambulation after wounds healed. The subjects were 31 haemodialysis patients with diabetic foot wounds, which were treated with percutaneous transluminal angioplasty and minor amputation. The subjects were 22 men and 9 women. Female patients were significantly older than male patients (P = 0.046). Two-year postoperative outcomes were survival in 19 patients and death in 12 patients. Eight of twelve deceased patients had a history of coronary intervention. There were 8 deaths among 13 patients with such history, indicating a marginally significant increase in the mortality rate (P = 0.060). Re-amputation was performed in 6 of 19 patients who survived. Two years postoperatively, 41.9% of patients overall survived without re-amputation. It is important to increase the number of cases for further study to improve the well-being of CLI patients and to examine medical economics.
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Affiliation(s)
- Kyoichi Matsuzaki
- Department of Plastic and Reconstructive Surgery, Kawasaki Municipal Tama Hospital, Tama-Ku, Kawasaki, Japan.
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Hirakata H, Nitta K, Inaba M, Shoji T, Fujii H, Kobayashi S, Tabei K, Joki N, Hase H, Nishimura M, Ozaki S, Ikari Y, Kumada Y, Tsuruya K, Fujimoto S, Inoue T, Yokoi H, Hirata S, Shimamoto K, Kugiyama K, Akiba T, Iseki K, Tsubakihara Y, Tomo T, Akizawa T. Japanese Society for Dialysis Therapy Guidelines for Management of Cardiovascular Diseases in Patients on Chronic Hemodialysis. Ther Apher Dial 2012; 16:387-435. [DOI: 10.1111/j.1744-9987.2012.01088.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Venkatachalam S, Shishehbor MH, Gray BH. Basic Data Related to Endovascular Management of Peripheral Arterial Disease in Critical Limb Ischemia. Ann Vasc Surg 2012; 26:1039-51. [DOI: 10.1016/j.avsg.2012.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 04/13/2012] [Indexed: 10/28/2022]
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Lepäntalo M, Fiengo L, Biancari F. Peripheral arterial disease in diabetic patients with renal insufficiency: a review. Diabetes Metab Res Rev 2012; 28 Suppl 1:40-5. [PMID: 22271722 DOI: 10.1002/dmrr.2233] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Peripheral arterial disease is common among diabetic patients with renal insufficiency, and most of the diabetic patients with end-stage renal disease (ESRD) have peripheral arterial disease. Ischaemia is probably overrepresented as an etiological factor for a diabetic foot ulcer in this group of patients compared with other diabetic patients. ESRD is a strong risk factor for both ulceration and amputation in diabetic patients. It increases the risk of nonhealing of ulcers and major amputation with an OR of 2.5-3. Renal disease is a more important predictor of poor outcome after revascularizations than commonly expected. Preoperative vascular imaging is also affected by a number of limitations, mostly related to side effects of contrast agents poorly eliminated because of kidney dysfunction. Patients with renal failure have high perioperative morbidity and mortality. Persistent ischaemia, extensive infection, forefoot and heel gangrene, poor run-off, poor cardiac function, and the length of dialysis-dependent renal failure all affect the outcome adversely. Despite dismal overall outcome, recent data indicate that by proper selection, favourable results can be obtained even in ESRD patients, with the majority of studies reporting 1-year limb salvage rates of 65-75% after revascularization among survivors. High 1-year mortality of 38% reported in a recent review has to be taken into consideration, though. The preferential use of endovascular-first approach is attractive in this vulnerable multimorbid group of patients, but the evidence for endovascular treatment is very scarce. The need for complete revascularization of the foot may be even more important than in other patients with ischaemic ulcerated diabetic foot because there are a number of factors counteracting healing in these patients. Typically, half of the patients are reported to lose their legs despite open bypass. To control tissue damage and improve chances of ulcer healing, one should understand that early referral to vascular consultation is necessary.
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Affiliation(s)
- Mauri Lepäntalo
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland.
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Zubair M, Malik A, Ahmad J. The impact of creatinine clearance on the outcome of diabetic foot ulcers in north Indian tertiary care hospital. Diabetes Metab Syndr 2011; 5:120-125. [PMID: 22813563 DOI: 10.1016/j.dsx.2012.02.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AIM Wound healing has been reported to be poor in diabetic patients with impaired kidney functions that usually accompanies retinopathy and neuropathy. The insensitive foot is vulnerable to repeated trauma and development of ulcer precedes 70-80% of non-traumatic lower extremity amputation. The present study was aimed to study the impact of creatinine clearance (CCre) on the outcome of diabetic foot ulcers (DFU). MATERIALS AND METHODS Data from 162 DFU patients admitted to Rajiv Gandhi Centre for Diabetes and Endocrinology of J.N. Medical College, Aligarh Muslim University, Aligarh, India, between December 2009 and March 2011 were analyzed. Detailed history and patient's profile, grade of DFU, co-morbidities and complications, laboratory data, microbiological profile and final outcome were collected. CCre was calculated according to MDRD formula. RESULTS The study revealed that, DFU healing was worst in patients with decreased CCre than in those who had normal CCre. Other factors associated with poor outcome were, higher grade of ulcer, infection type (subcutaneous and osteomyelitis) and biofilm infection. Amputation rates were also found to be higher in those with poor renal functions. CONCLUSIONS The results suggest that CCre is an important factor affecting wound healing in patients with DFUs. The automatic reporting of eGFR each time a serum creatinine concentration is requested will increase the awareness of significant kidney dysfunction in clinical practice especially in DFU patients and appropriate measures will improve the outcome.
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Affiliation(s)
- Mohammad Zubair
- Department of Microbiology, Faculty of Medicine, J.N. Medical College, Aligarh Muslim University, Aligarh 202002, India
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Willenberg T, Baumann F, Eisenberger U, Baumgartner I, Do DD, Diehm N. Impact of renal insufficiency on clinical outcomes in patients with critical limb ischemia undergoing endovascular revascularization. J Vasc Surg 2011; 53:1589-97. [DOI: 10.1016/j.jvs.2011.01.062] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 12/18/2010] [Accepted: 01/23/2011] [Indexed: 11/29/2022]
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Conrad MF, Crawford RS, Hackney LA, Paruchuri V, Abularrage CJ, Patel VI, Lamuraglia GM, Cambria RP. Endovascular management of patients with critical limb ischemia. J Vasc Surg 2011; 53:1020-5. [PMID: 21211929 DOI: 10.1016/j.jvs.2010.10.088] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 10/15/2010] [Accepted: 10/15/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although percutaneous intervention (PTA) is considered first-line therapy for peripheral vascular disease in many scenarios, its role in critical limb ischemia (CLI), wherein anatomic disease is more extensive, remains unclear. In the present study, late (5-year) clinical and patency data for PTA in CLI are defined. METHODS From January 2002 to December 2007, 409 patients underwent infrainguinal PTA ± stent for CLI (Rutherford IV-VI) of 447 limbs. Primary patency, assisted patency, limb salvage, and survival were assessed using Kaplan-Meier. Predictors of patency, limb salvage, and death were determined using multivariate models. RESULTS Demographics included age (70 ± 12 years old), diabetes (65.8%), and dialysis dependence (13%). The superficial femoral artery was treated in 58% of the patients, 16% were limited to the crural vessels, 38% had multilevel treatment, and stents were placed in 26%. Eighty percent of patients received postprocedure clopidogrel. Mean follow-up was 28 months (0-83). Five-year primary and assisted patency were 31% ± 0.04 and 75% ± 0.04, respectively. Limb salvage at 5 years was 74% ± 0.038. Sixty-three patients had major amputations. Survival at 5 years was 39% ± 0.03. Multivariate analysis identified dialysis dependence (P = .0005; 2.7 [1.6-4.8]), ≤1 vessel runoff (P = .02; 1.5 [1.1-2.0]), and warfarin use (P = .001; 1.7 [1.25-2.3]) as negative predictors of primary patency, but none of these were negative predictors of assisted patency. Dialysis dependence (P = .006; 2.5 [1.3-4.8]), female gender (P = .02; 2.0 [1.1-3.7]), and ≤1 vessel run-off (P = .04; 1.8 [1.0-3.2]) predicted limb loss. Dialysis dependence (P = .0003; 2.3 [1.5-3.5]), diabetes (P = .04; 1.5 [0.5-2.1]), and poor run-off (P = .04; 1.6 [1.2-2.1]) were predictors of mortality. CONCLUSION Although primary patency is low, excellent limb salvage rates can be achieved in patients with CLI through close follow-up and secondary interventions. These data, and the 12% annual death rate, validate PTA as first-line therapy in patients with CLI.
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Affiliation(s)
- Mark F Conrad
- Massachusetts General Hospital, Vascular and Endovascular Surgery, 15 Parkman Street, WAC 440, Boston, MA 02114, USA.
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Rabellino M, Aragón-Sánchez J, González G, Zander T, Baldi S, Garcia-Nielsen L, Armas-Suarez S, Barbero P, Luis-Rodríguez D, Maynar M. Is endovascular revascularisation worthwhile in diabetic patients with critical limb ischemia who also have end-stage renal disease? Diabetes Res Clin Pract 2010; 90:e79-81. [PMID: 21030104 DOI: 10.1016/j.diabres.2010.09.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Revised: 09/06/2010] [Accepted: 09/20/2010] [Indexed: 10/18/2022]
Abstract
To present the outcomes of endovascular treatment of diabetics patients with critical limb ischemia who have end-stage renal disease. Limb-salvage was achieved in 58.6% of the limbs during a mean follow-up period of 12.4 months. No major amputations were required on patients with rest pain or with grade 1 lesions.
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Affiliation(s)
- Martín Rabellino
- Interventional Radiology Department, Hospiten Group, Santa Cruz de Tenerife, Spain.
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Akinci B, Yesil S, Bayraktar F, Kucukyavas Y, Yener S, Comlekci A, Eraslan S. The effect of creatinine clearance on the short-term outcome of neuropathic diabetic foot ulcers. Prim Care Diabetes 2010; 4:181-185. [PMID: 20471934 DOI: 10.1016/j.pcd.2010.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Revised: 02/18/2010] [Accepted: 04/09/2010] [Indexed: 11/17/2022]
Abstract
Reduced creatinine clearance is related to an increased risk for diabetic foot ulcer development. Wound healing has been reported to be worse in diabetic patients with impaired kidney functions than general diabetic population. This study aimed to investigate the effect of creatinine clearance on the short-term outcome of neuropathic diabetic foot ulcers. Data from 147 neuropathic diabetic foot ulcer episodes were included in this observational study. Patients were admitted to Dokuz Eylul University Hospital between January 2003 and June 2008. Patients were excluded if they had limb ischemia. Diabetic nephropathy was investigated by 24h urinary albumin excretion and serum creatinine levels. Creatinine clearance was calculated according to Cockcroft-Gault formula. Foot ulcers were followed up for 6 months to determine the outcome. Our short-term follow-up revealed that neuropathic diabetic ulcers healed worse in patients with decreased creatinine clearance than in those who had normal creatinine clearance. Amputation rates were also found to be higher. Our results suggest that creatinine clearance is an important factor affecting wound healing in patients with neuropathic diabetic foot ulcers.
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Affiliation(s)
- Baris Akinci
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Dokuz Eylul University, Turkey.
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Gray BH, Grant AA, Kalbaugh CA, Blackhurst DW, Langan EM, Taylor SA, Cull DL. The Impact of Isolated Tibial Disease on Outcomes in the Critical Limb Ischemic Population. Ann Vasc Surg 2010; 24:349-59. [DOI: 10.1016/j.avsg.2009.07.034] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Accepted: 07/18/2009] [Indexed: 10/20/2022]
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Kalish J, Hamdan A. Management of diabetic foot problems. J Vasc Surg 2010; 51:476-86. [DOI: 10.1016/j.jvs.2009.08.043] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 08/11/2009] [Accepted: 08/12/2009] [Indexed: 01/20/2023]
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36
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Angioplasty or Primary Stenting for Infrapopliteal Lesions: Results of a Prospective Randomized Trial. Cardiovasc Intervent Radiol 2009; 33:260-9. [DOI: 10.1007/s00270-009-9765-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Accepted: 11/06/2009] [Indexed: 10/20/2022]
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Conrad MF, Kang J, Cambria RP, Brewster DC, Watkins MT, Kwolek CJ, LaMuraglia GM. Infrapopliteal balloon angioplasty for the treatment of chronic occlusive disease. J Vasc Surg 2009; 50:799-805.e4. [DOI: 10.1016/j.jvs.2009.05.026] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2009] [Revised: 05/13/2009] [Accepted: 05/14/2009] [Indexed: 11/25/2022]
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Werneck CC, Lindsay TF. Tibial Angioplasty for Limb Salvage in High-Risk Patients and Cost Analysis. Ann Vasc Surg 2009; 23:554-9. [DOI: 10.1016/j.avsg.2009.05.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2008] [Revised: 03/31/2009] [Accepted: 05/21/2009] [Indexed: 11/28/2022]
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Casserly IP. Interventional management of critical limb ischemia in renal patients. Adv Chronic Kidney Dis 2008; 15:384-95. [PMID: 18805385 DOI: 10.1053/j.ackd.2008.07.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Critical limb ischemia (CLI) represents the most severe clinical manifestation of peripheral arterial disease (PAD), defined as the presence of chronic ischemic rest pain, ulcers, or gangrene attributable to objectively proven arterial occlusive disease. The occurrence of CLI in patients with kidney insufficiency portends a strikingly high rate of subsequent morbidity and mortality. Generally, the primary therapy for CLI is revascularization of the affected limb. However, patients with CLI and kidney insufficiency represent a unique and challenging patient subset, and data from surgical series suggest reduced rates of limb salvage and higher medium and long-term mortality rates for patients with kidney insufficiency compared with those with normal kidney function. In contemporary practice, endovascular techniques are fast replacing surgical bypass as the first-line revascularization strategy for CLI, based on high technical success rates and low rates of procedure-related morbidity and mortality. However, a large series on endovascular outcomes for the treatment of CLI in patients with kidney insufficiency is lacking. Based on the severely reduced long-term survival rates of patients with CLI and kidney insufficiency, future efforts should focus on early detection of PAD in patients with kidney insufficiency and institution of aggressive medical therapy to prevent progression in the global burden of atherosclerosis in this patient population.
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Gargiulo M, Maioli F, Ceccacci T, Morselli-Labate AM, Faggioli G, Freyrie A, Giovanetti F, Testi G, Muccini N, Stella A. What's Next After Optimal Infrapopliteal Angioplasty? Clinical and Ultrasonographic Results of a Prospective Single-Center Study. J Endovasc Ther 2008; 15:363-9. [DOI: 10.1583/08-2423.1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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41
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Romiti M, Albers M, Brochado-Neto FC, Durazzo AES, Pereira CAB, De Luccia N. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg 2008; 47:975-981. [DOI: 10.1016/j.jvs.2008.01.005] [Citation(s) in RCA: 401] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Revised: 12/20/2007] [Accepted: 01/03/2008] [Indexed: 12/20/2022]
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42
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Lantis J, Jensen M, Benvenisty A, Mendes D, Gendics C, Todd G. Outcomes of Combined Superficial Femoral Endovascular Revascularization and Popliteal to Distal Bypass for Patients with Tissue Loss. Ann Vasc Surg 2008; 22:366-71. [DOI: 10.1016/j.avsg.2007.09.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2007] [Revised: 09/17/2007] [Accepted: 09/19/2007] [Indexed: 11/29/2022]
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Leon LR, Psalms SB, Walters J. Diabetic foot infections in the elderly: primary amputation versus 'foot-sparing surgery'. A case report. Int Wound J 2007; 4:315-21. [PMID: 18154625 DOI: 10.1111/j.1742-481x.2007.00348.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Renal failure diabetic patients who present with lower extremity gangrene represent one of the most difficult problems encountered in a typical vascular practice. We report the hospital course and management of a 74-year-old male patient with such comorbidities, affected by a non healing ulcer that progressed into a large plantar abscess. Our case unfortunately mirrors a common method of evaluation and therapy of patients with such comorbidities and sets up the stage for a very controversial subject.
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Affiliation(s)
- Luis R Leon
- Vascular Surgery Section, Southern Arizona Veteran Affairs Health Care System (SAVAHCS), Tucson, AZ 85723, USA
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Siablis D, Karnabatidis D, Katsanos K, Kagadis GC, Kraniotis P, Diamantopoulos A, Tsolakis J. Sirolimus-eluting versus bare stents after suboptimal infrapopliteal angioplasty for critical limb ischemia: enduring 1-year angiographic and clinical benefit. J Endovasc Ther 2007; 14:241-50. [PMID: 17484536 DOI: 10.1177/152660280701400217] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE To report the 1-year angiographic and clinical outcome from a prospective single-center study investigating the infrapopliteal application of sirolimus-eluting versus bare metal stents in patients with critical limb ischemia (CLI) who underwent below-the-knee endovascular revascularization. METHODS Stenting was performed as a bailout procedure for suboptimal angioplasty results (flow-limiting dissection, elastic recoil, or postangioplasty residual stenosis >30%). In the first 29 patients, infrapopliteal stenting was performed with bare metal stents (group B) and with sirolimus-eluting stents in the other 29 patients (group S). RESULTS Below-the-knee angioplasty and stenting involved 65 lesions in 40 infrapopliteal arteries of 29 limbs in group B and 66 lesions in 41 infrapopliteal arteries of 29 limbs in group S. Baseline comorbidities (hyperlipidemia and symptomatic cardiac and carotid disease) were more pronounced in group S (p<0.05). At 6 months, sirolimus-eluting stents demonstrated significantly higher primary patency (OR 5.625, 95% CI 1.711 to 18.493, p = 0.004) and decreased in-stent binary restenosis (OR 0.067, 95% CI 0.021 to 0.017, p<0.001) and in-segment binary restenosis (OR 0.229, 95% CI 0.099 to 0.533, p = 0.001). After 1 year, sirolimus-eluting stents were steadily associated with increased primary patency (OR 10.401, 95% CI 3.425 to 31.589, p<0.001) and significantly less in-stent (OR 0.156, 95% CI 0.060 to 0.407, p<0.001) and in-segment (OR 0.089, 95% CI 0.023 to 0.349, p = 0.001) binary restenosis. In addition, sirolimus-eluting stents were associated with significantly fewer cumulative target lesion reinterventions at 6 months (OR 0.057, 95% CI 0.008 to 0.426, p = 0.005) and 1 year (OR 0.238, 95% CI 0.067 to 0.841, p = 0.026). No significant differences between groups B and S were noted at 1 year with respect to mortality (10.3% versus 13.8%, respectively), minor amputation (17.2% versus 10.3%), or limb salvage (100% versus 96%). CONCLUSION The application of sirolimus-eluting stents reduces the restenosis rate in the infrapopliteal arteries and the rate of repeat endovascular procedures the first year after treatment.
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Affiliation(s)
- Dimitris Siablis
- Department of Radiology (Angiography Suite), University Hospital of Patras, Rion, Greece.
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45
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Siablis D, Karnabatidis D, Katsanos K, Kagadis GC, Kraniotis P, Diamantopoulos A, Tsolakis J. Sirolimus-eluting Versus Bare Stents After Suboptimal Infrapopliteal Angioplasty for Critical Limb Ischemia: Enduring 1-year Angiographic and Clinical Benefit. J Endovasc Ther 2007. [DOI: 10.1583/1545-1550(2007)14[241:svbsas]2.0.co;2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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46
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Albers M, Romiti M, De Luccia N, Brochado-Neto FC, Nishimoto I, Pereira CAB. An updated meta-analysis of infrainguinal arterial reconstruction in patients with end-stage renal disease. J Vasc Surg 2007; 45:536-42. [PMID: 17257801 DOI: 10.1016/j.jvs.2006.11.036] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2006] [Accepted: 11/13/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND A previous meta-analysis reported on the mid-term outcomes of infrainguinal bypass grafts in patients with critical limb ischemia and end-stage renal disease. Given the competing interest in endovascular procedures, the results of bypass surgery must be assessed as precisely as possible for future comparison. In this study, the original meta-analysis was refined and updated by increasing the number of studies reviewed, estimating primary graft patency, extending follow-up time, and investigating the problem of early amputation despite a patent graft. METHODS Studies published from 1987 through 2005 were identified from two electronic databases. Two investigators independently extracted the survival data from life tables, survival curves, and texts. Pooled survival curves were then constructed for graft patency, limb salvage, and patient survival according to a random-effects protocol for meta-analysis. RESULTS Of 28 articles included, 18 reported amputation despite a patent graft in 84 (10%) out of 844 limbs, and 25 described a perioperative mortality of 88 (8.8%) out of 996 patients. The 5-year pooled estimate (SE) was 50.4% (15.4%) for primary patency, 50.8% (19.0%) for secondary patency, 66.6% (11.2%) for limb salvage, and 23.0% (11.7%) for patient survival. No publication bias was detected. CONCLUSIONS Limb salvage can be achieved in most end-stage renal disease patients who undergo bypass surgery for critical ischemia, but survival is poor. To avoid early amputation despite a patent graft, bypass grafting should not be offered to patients with a great amount of tissue loss or extensive infection.
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Affiliation(s)
- Maximiano Albers
- Vascular Surgery Section, Department of Surgery, Health and Medical Sciences Sector, Lusiada Foundation (UNILUS), Santos, SP, Brazil.
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47
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Taylor SM, Kalbaugh CA, Blackhurst DW, Kellicut DC, Langan EM, Youkey JR. A comparison of percutaneous transluminal angioplasty versus amputation for critical limb ischemia in patients unsuitable for open surgery. J Vasc Surg 2007; 45:304-10; discussion 310-1. [PMID: 17264008 DOI: 10.1016/j.jvs.2006.09.038] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2006] [Accepted: 09/06/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND Percutaneous transluminal angioplasty (PTA), although not the traditional therapy, seems to be a safe alternative for patients with critical limb ischemia who are believed to be unsuitable candidates for open surgery. However, the efficacy of PTA in this setting has not been analyzed. The purpose of this study was to compare the outcomes of PTA for limb salvage with outcomes of major limb amputation in physiologically impaired patients believed to be unsuitable for open surgery. METHODS From a prospective vascular registry, 314 patients (183 underwent amputation, and 131 underwent complex PTA for limb salvage) were identified as physiologically impaired or unsuitable for open surgery. This was defined as having at least one of the following: functional impairment (homebound ambulatory or transfer only), mental impairment (dementia), or medical impairment (two of the following: end-stage renal disease, coronary artery disease, and chronic obstructive pulmonary disease). Patients undergoing PTA were compared with patients undergoing amputation by examining the outcome parameters of survival, maintenance of ambulation, and maintenance of independent living status. Parameters were assessed by using Kaplan-Meier life-table curves (log-rank test and 95% confidence intervals [CIs]) and hazard ratios (HRs) from the Cox model. RESULTS PTA resulted in a 12-month limb salvage rate of 63%. Thirty-day mortality was 4.4% for the amputation group and 3.8% for the PTA group. After adjustment for age, race, diabetes, prior vascular procedure, dementia, and baseline functional status, PTA patients had significantly lower rates of ambulation failure (HR, 0.44; P = .0002) and loss of independence (HR, 0.53; P = .025) but had significantly higher mortality (HR, 1.62; P = .006) than amputees. However, when life tables were examined, the maintenance of ambulation advantage lasted only 12 months (PTA, 68.6%; 95% CI, 59.6%-77.7%; amputation, 48%; 95% CI, 40.4%-55.5%) and was not statistically significant at 2 years (62.2% [95% CI, 48.8%-71.5%] and 44% [95% CI, 35.8%-52.2%], respectively). Maintenance of independent living status advantage lasted only 3 months, with no statistically significant difference at 2 years (PTA, 60.5%; 95% CI, 45.4%-75.6%; amputation, 52.6%; 95% CI, 40.4%-64.9%). Although mortality was high in both cohorts, patients who underwent amputation had a survival advantage for all time intervals examined (at 2 years: PTA, 29%; 95% CI, 19.9%-38.1%; amputation, 48.1%; 95% CI, 39.2%-56.9%). CONCLUSIONS Patients who present with critical limb ischemia and physiologic impairments that preclude open surgery seem to have comorbidities that blunt any functional advantage achieved after PTA for limb salvage. PTA in this setting affords very little benefit compared with amputation alone.
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Affiliation(s)
- Spence M Taylor
- Academic Department of Surgery, Greenville Hospital System University Medical Center, Greenville, SC 29605, USA.
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