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Scatena A, Apicella M, Mantuano M, Liistro F, Ventoruzzo G, Petruzzi P, Miranda C, Monge L, Ragghianti B, Silverii A, Ferraro I, Uccioli L, Vermigli C, Mannucci E, Scevola G, Stabile E, Gargiulo M, Monami M. Bypass surgery versus endovascular revascularization for occlusive infrainguinal peripheral artery disease: a meta-analysis of randomized controlled trials for the development of the Italian Guidelines for the treatment of diabetic foot syndrome. Acta Diabetol 2024; 61:19-28. [PMID: 37792028 DOI: 10.1007/s00592-023-02185-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/11/2023] [Indexed: 10/05/2023]
Abstract
To report a review and meta-analysis of all randomized controlled trials (RCTs) comparing bypass surgery (BS) and endovascular treatment (ET) in infrainguinal peripheral arterial disease (PAD) for several endpoints, such as major and minor amputation, major adverse limb events (MALEs), ulcer healing, time to healing, and all-cause mortality to support the development of the Italian Guidelines for the Treatment of Diabetic Foot Syndrome (DFS). A MEDLINE and EMBASE search was performed to identify RCTs, published since 1991 up to June 21, 2023, enrolling patients with lower limb ischemia due to atherosclerotic disease (Rutherford I-VI). Any surgical BS or ET was allowed, irrespective of the approach, route, or graft employed, from iliac to below-the-knee district. Primary endpoint was major amputation rate. Secondary endpoints were amputation-free survival major adverse limb events (MALEs), minor amputation rate, all-cause mortality, ulcer healing rate, time to healing, pain, transcutaneous oxygen pressure (TcPO2) or ankle-brachial index (ABI), quality of life, need for a new procedure, periprocedural serious adverse events (SAE; within 30 days from the procedure), hospital lenght of stay, and operative time. Twelve RCTs were included, one enrolled two separate cohorts of patients, and therefore, the studies included in the analyses were 13. Participants treated with ET had a similar rate of major amputations to participants treated with BS (MH-OR 0.85 [0.60, 1.20], p = 0.36); only one trial reported separately data on patients with diabetes (N = 1), showing no significant difference between ET and BS (MH-OR: 0.67 [0.09, 5.13], p = 0.70). For minor amputation, no between-group significant differences were reported: MH-OR for ET vs BS: 0.83 [0.21, 3.30], p = 0.80). No significant difference in amputation-free survival between the two treatment modalities was identified (MH-OR 0.94 [0.59, 1.49], p = 0.80); only one study reported subgroup analyses on diabetes, with a non-statistical trend toward reduction in favor of ET (MH-OR 0.62 [0.37, 1.04], p = 0.07). No significant difference between treatments was found for all-cause mortality (MH-OR for ET vs BS: 0.98 [0.80, 1.21], p = 0.88). A significantly higher rate of MALE was reported in participants treated with ET (MH-OR: 1.44 [1.05, 1.98], p = 0.03); in diabetes subgroup analysis showed no differences between-group for this outcome (MH-OR: 1.34 [0.76, 2.37], p = 0.30). Operative duration and length of hospital stay were significantly shorter for ET (WMD: - 101.53 [- 127.71, - 75.35] min, p < 0.001, and, - 4.15 [- 5.73, - 2.57] days, p < 0.001 =, respectively). ET was associated with a significantly lower risk of any SAE within 30 days in comparison with BS (MH-OR: 0.60 [0.42, 0.86], p = 0.006). ET was associated with a significantly higher risk of reintervention (MH-OR: 1.57 [1.10, 2.24], p = 0.01). No significant between-group differences were reported for ulcer healing (MH-OR: 1.19 [0.53, 2.69], p = 0.67), although time to healing was shorter (- 1.00 [0.18, 1.82] months, p = 0.02) with BS. No differences were found in terms of quality of life and pain. ABI at the end of the study was reported by 7 studies showing a significant superiority of BS in comparison with ET (WMD: 0.09[0.02; 0.15] points, p = 0.01). The results of this meta-analysis showed no clear superiority of either ET or BS for the treatment of infrainguinal PAD also in diabetic patients. Further high-quality studies are needed, focusing on clinical outcomes, including pre-planned subgroup analyses on specific categories of patients, such as those with diabetes and detailing multidisciplinary team approach and structured follow-up.
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Affiliation(s)
- Alessia Scatena
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy.
| | - Matteo Apicella
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy
| | - Michele Mantuano
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy
| | - Francesco Liistro
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy
| | - Giorgio Ventoruzzo
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy
| | - Pasquale Petruzzi
- San Donato Hospital, Arezzo, Health Authorities South East Tuscany, Italy, Via Pietro Nenni, 20, 52100, Arezzo, Italy
| | | | - Luca Monge
- AMD - Italian Association of Clinical Diabetologists, Rome, Italy
| | - Benedetta Ragghianti
- Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | - Antonio Silverii
- Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | | | - Luigi Uccioli
- Diabetes Section CTO Hospital and Dept of Biomedicine and Prevention Tor Vergata, University of Rome, Rome, Italy
| | | | - Edoardo Mannucci
- Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | | | | | - Mauro Gargiulo
- Vascular Surgery, University of Bologna - DIMEC, Bologna, Italy
- Vascular Surgery Unit, IRCCS, University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Matteo Monami
- Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
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Park YS, Ryu GW, Choi M. Multiple metabolic comorbidities and their consequences among patients with peripheral arterial disease. PLoS One 2022; 17:e0268201. [PMID: 35536826 PMCID: PMC9089858 DOI: 10.1371/journal.pone.0268201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/22/2022] [Indexed: 11/28/2022] Open
Abstract
Older adults with peripheral arterial disease (PAD) have increased risks of major cardiovascular events and hospitalization. Metabolic comorbidities, such as hypertension, diabetes mellitus, and dyslipidemia, are common risk factors for these unfavorable health events. This study aimed to determine how multiple metabolic comorbidities affect the risk of adverse health outcomes in older adults with PAD. A retrospective cohort study was adopted using administrative claim data from the Health Insurance Review and Assessment Service Agency. The study sample included 3,122 older adults (≥ 65 years old) with at least one PAD diagnosis in an inpatient setting from 2011 to 2013 and who had at least one follow-up visit after hospitalization by 2018. The three metabolic comorbidities were defined as having at least two diagnostic claims or one prescription per year of anti-hypertensive, anti-diabetic, or anti-dyslipidemic medications for the corresponding diagnosis. The outcome variables included major adverse cardiovascular events (MACEs) and major adverse limb events (MALE). Kaplan-Meier survival curves demonstrated that PAD patients with more metabolic comorbidities had shorter MACE-free and MALE-free periods. Adjusted Cox proportional hazards analyses suggested significant additive effects of multiple metabolic comorbidities on increased risks of MACE and MALE among older adults with PAD. Lower socioeconomic status and non-metabolic comorbidities also increased the risk of MACE. Male sex, being young-old (65–74 years), and a higher proportion of inpatient claims increased the risk of MALE. The findings of this study suggest the need for a comprehensive care program for older adults with PAD and metabolic comorbidities. In addition, the healthcare utilization pattern should be considered when designing preventive care for older patients with comorbidities to manage PAD at an earlier stage.
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Affiliation(s)
- Young Shin Park
- Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, Seoul, Republic of Korea
| | - Gi Wook Ryu
- Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, Seoul, Republic of Korea
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University College of Nursing, Seoul, Republic of Korea
- Department of Nursing, Hansei University, Gyeonggi-do, Republic of Korea
| | - Mona Choi
- Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, Seoul, Republic of Korea
- * E-mail:
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Seo A, Yamamoto K, Akai A, Akagi D, Takayama T, Hoshina K. The relationship between medical expenses and the severity of peripheral arterial disease in Japan. Heart Vessels 2018; 33:853-858. [PMID: 29396768 DOI: 10.1007/s00380-018-1127-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 01/24/2018] [Indexed: 11/26/2022]
Abstract
The main objective is to examine whether the severity of peripheral arterial disease (PAD) affects the expenses and hospital stay of the patients who undergo bypass surgery below the inguinal ligament for PAD. Eighty consecutive patients who underwent infrainguinal bypass surgery for PAD between January 2012 and December 2014 were included in the study. Patients were divided into groups according to their critical limb ischemia (CLI) symptoms and the Wound, Ischemia, and Foot Infection (WIfI) classification. As endpoints, we assessed the duration of postoperative hospital stay and expenses during hospitalization. CLI was a significant factor for longer hospital stay and increased medical expenses (p = 0.009 and p = 0.001). In the patients with CLI, significant factors for longer hospital stay and increased medical expenses were (1) history of distal bypass (p = 0.33 and p = 0.003, respectively) and stage 4 local lower limb status in WIfI classification (p = 0.0007 and p = 0.053). PAD severity was associated with prolonged postoperative hospital stay and increased medical expenses. The presence or absence of CLI and its severity according to the WIfI classification correlated with medical expenses and hospital stay duration between the milder and severe groups.
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Affiliation(s)
- Akihiko Seo
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kota Yamamoto
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Atsushi Akai
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Daisuke Akagi
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Toshio Takayama
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Katsuyuki Hoshina
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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