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Kato Y, Ushida K, Shimizu M, Momosaki R. Impact of Early Rehabilitation after Endovascular Treatment for Peripheral Arterial Disease. Prog Rehabil Med 2024; 9:20240021. [PMID: 38855421 PMCID: PMC11156502 DOI: 10.2490/prm.20240021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 05/28/2024] [Indexed: 06/11/2024] Open
Abstract
Objectives The prevalence of peripheral arterial disease (PAD) is on the rise, with endovascular treatment being a widely accepted surgical intervention. Patients with PAD often experience reduced activities of daily living (ADL). Therefore, we conducted a retrospective cohort study to investigate the impact of early rehabilitation after endovascular treatment in patients with PAD. Methods Using data from the JMDC hospital database, the study included 529 patients who were hospitalized for PAD and underwent endovascular treatment. Patients were classified into two independent variables: early rehabilitation group (rehabilitation started within 2 days postoperatively) and control group (rehabilitation started within 3-7 days postoperatively). The outcome measures were the occurrence of hospital-associated disability (HAD) and duration of hospitalization. Results Unadjusted data showed that the early rehabilitation group (n=469) had fewer HAD events (8.5% vs. 23.3%, P <0.001) and a shorter mean hospitalization duration (4.4 vs. 18.9 days, P <0.001) than the control group (n=60). The difference remained significant after adjustment by propensity score analysis. Conclusions In patients with PAD, early rehabilitation after endovascular treatment may be beneficial in preventing the development of HAD and reducing the duration of hospitalization.
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Affiliation(s)
- Yuki Kato
- Department of Rehabilitation Medicine, Mie University
Graduate School of Medicine, Tsu, Japan
- Department of Rehabilitation, Mie University Hospital, Tsu,
Japan
| | - Kenta Ushida
- Department of Rehabilitation Medicine, Mie University
Graduate School of Medicine, Tsu, Japan
- Department of Rehabilitation, Mie University Hospital, Tsu,
Japan
| | - Miho Shimizu
- Department of Rehabilitation, Mie University Hospital, Tsu,
Japan
| | - Ryo Momosaki
- Department of Rehabilitation Medicine, Mie University
Graduate School of Medicine, Tsu, Japan
- Department of Rehabilitation, Mie University Hospital, Tsu,
Japan
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Kodama A, Takahara M, Iida O, Soga Y, Terashi H, Kawasaki D, Izumi Y, Mii S, Komori K, Azuma N. Ambulatory Status Over Time after Revascularization in Patients with Chronic Limb-Threatening Ischemia. J Atheroscler Thromb 2021; 29:866-880. [PMID: 34039832 PMCID: PMC9174083 DOI: 10.5551/jat.62892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Aim: Maintaining functional status through revascularization is a major goal in patients with chronic limb-threatening ischemia (CLTI). Nevertheless, there is a lack of clarity on the impact of revascularization on mobility over time. This study examined ambulatory status over time after revascularization and predictors of ambulation loss in CLTI patients.
Methods: We used a clinical database established by the Surgical reconstruction versus Peripheral INtervention in pAtients with critical limb isCHemia study, a prospective, multicentre, observational study including patients with CLTI. The primary endpoint was mobility over time.
Results: Of the 381 patients, the ambulatory proportion at baseline was 71%. The proportion gradually decreased, finally reaching 40% at 36 months. In non-ambulatory patients at revasacularisation, approximately 20-40% of patients achieved ambulation. Multivariate analysis confirmed that age, impaired mobility before CLTI onset and at revascularization, renal failure on dialysis, and WIfI clinical stage 4 were positively associated with ambulation loss at either specific or all time points, whereas male sex and surgical reconstruction were inversely associated with the outcomes at specific time points.
Conclusion: Mobility in the overall population gradually decreased, whereas the number of deceased patients increased. Advanced age, impaired mobility before CLTI onset and at revascularization, renal failure on dialysis, and WIfI stage 4 were associated with ambulation loss at almost all points after revascularization.
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Affiliation(s)
- Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University School of Medicine
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, and Department of Metabolic Medicine, Osaka University Graduate School of Medicine
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | | | - Hiroto Terashi
- Department of Plastic Surgery, Kobe University Graduate School of Medicine
| | | | | | - Shinsuke Mii
- Department of Vascular Surgery, Saiseikai Yahata General Hospital
| | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University School of Medicine
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
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Ambler GK, Kotta PA, Zielinski L, Kalyanasundaram A, Brooks DE, Ali A, Chowdhury MM, Coughlin PA. The Effect of Frailty on Long Term Outcomes in Vascular Surgical Patients. Eur J Vasc Endovasc Surg 2020; 60:264-272. [PMID: 32417030 DOI: 10.1016/j.ejvs.2020.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 03/13/2020] [Accepted: 04/08/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Frailty is a multidimensional vulnerability due to age associated decline. The impact of frailty on long term outcomes was assessed in a cohort of vascular surgical patients. METHODS Patients aged over 65 years with a length of stay greater than two days admitted to a tertiary vascular unit over a single calendar year were included. Demographics, mode of admission, and diagnosis were recorded alongside a variety of frailty specific characteristics. Using the previously developed Addenbrookes Vascular Frailty Score (AVFS - 6 point score: anaemia on admission, lack of independent mobility, polypharmacy, Waterlow score > 13, depression, and emergency admission) the effect of frailty on five year mortality and re-admission rates was assessed using multivariable regression techniques. The AVFS was further refined to assess longer term outcomes. RESULTS In total, 410 patients (median age 77 years) were included and followed up until death or five years from the index admission. One hundred and thirty-four were treated for aortic aneurysm, 75 and 96 for acute and chronic limb ischaemia respectively, 52 for carotid disease, and 53 for other pathologies. The in hospital mortality rate was 3.6%. The one, three, and five year survival rates were 83%, 70% and 59%; and the one, three, and five year re-admission free survival rates were 47%, 29%, and 22% respectively. Independent predictors of five year mortality were age, lack of independent mobility, high Charlson score, polypharmacy, evidence of malnutrition, and emergency admission (p < .010 for all). Patients with AVFS 0 or 1 had restricted mean survival times which were one year longer than those with AVFS 2 or 3 (p < .001), who in turn had restricted mean survival times over one year longer than those with AVFS of 4 or more (p < .001). CONCLUSION Frailty factors are strong predictors of long term outcomes in vascular surgery. Further prospective studies are warranted to investigate its utility in clinical decision making.
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Affiliation(s)
- Graeme K Ambler
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Prasanti A Kotta
- University of Cambridge, School of Clinical Medicine, Cambridge, UK
| | - Lukasz Zielinski
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - David E Brooks
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Amjad Ali
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Mohammed M Chowdhury
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Patrick A Coughlin
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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Schindewolf M, Fuss T, Fink H, Gemperli A, Haine A, Baumgartner I. Efficacy Outcomes of Endovascular Versus Surgical Revascularization in Critical Limb Ischemia: Results From a Prospective Cohort Study. Angiology 2018; 69:677-685. [PMID: 29355026 DOI: 10.1177/0003319717750486] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Data on efficacy outcomes of endovascular versus surgical revascularization in patients with critical limb ischemia (CLI) in contemporary practice are limited. In this prospective cohort study, 353 consecutive patients with CLI were enrolled and allocated to endovascular (PTA [percutaneous transluminal angioplasty]), surgical (SURG), or no revascularization (No REVASC) after interdisciplinary consensus. Outcome measures were sustained primary clinical success (sPCS; survival without major amputation, repeated target extremity revascularization, and freedom from CLI), limb salvage, and amputation-free survival. Propensity-matched Kaplan-Meier analyses and stratified log-rank tests were performed. The PTA, SURG, and No REVASC groups consisted of 264, 62, and 27 patients, respectively. Compared to SURG patients, PTA patients were significantly older, had more risk factors, and more often had ischemic lesions. Propensity score-adjusted analyses showed no significant differences: sPCS was 51.3%/52.2%, limb salvage rate 91.5%/93.7%, and major amputation-free survival 90.5%/87.2% at 12 months for PTA and SURG, respectively. Amputation-free survival for the No REVASC group was 69% at 12 months. In conclusion, endovascular and surgical revascularization in CLI has comparable efficacy outcomes after 12 months. Contemporary overall outcome of patients with CLI is considerably better compared to earlier studies.
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Affiliation(s)
- Marc Schindewolf
- 1 Department of Clinical and Interventional Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Torsten Fuss
- 1 Department of Clinical and Interventional Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hanspeter Fink
- 1 Department of Clinical and Interventional Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Armin Gemperli
- 2 Department of Clinical Research, Clinical Trials Unit Bern, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,3 Swiss Paraplegic Research, Nottwil, Switzerland.,4 Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland
| | - Axel Haine
- 1 Department of Clinical and Interventional Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Iris Baumgartner
- 1 Department of Clinical and Interventional Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Carlisi E, Caspani P, Morlino P, Bardoni MT, Lisi C, Bejor M, Dalla Toffola E. Early rehabilitative treatment after infrainguinal lower limb bypass surgery. ACTA BIO-MEDICA : ATENEI PARMENSIS 2017; 88:167-171. [PMID: 28845831 PMCID: PMC6166142 DOI: 10.23750/abm.v88i2.5035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 01/13/2016] [Indexed: 11/23/2022]
Abstract
Background and aim of the work: Functional activity may remain limited in patients affected by critical limb ischemia, despite successful infrainguinal lower limb bypass surgery (ILLBS). The aim of the work was to evaluate the impact of a rehabilitative intervention on postoperative ambulatory status and pain. Methods: In an observational study, data were collected on 34 patients undergoing ILLBS for critical limb ischemia or end-stage peripheral arterial disease. All patients underwent a postoperative rehabilitation program aimed at recovering gait autonomy. Information was collected on pre-operative comorbidities, ambulatory status (on admission to and discharge from hospital) and pain in the affected lower limb (on the first physiotherapy session and at discharge). Results: Before ILLBS, 61.8% of the patients walked independently without aids or assistance. The rehabilitative program started on average 5.7 (SD: 2.1) days after surgery. At discharge, 50% of the patients walked independently, 41.2% walked with aids and/or assistance and 8.8% were not able to walk. Overall, 76.5% of the sample recovered their pre-operative ambulatory status. Although pain tended to decrease, the difference at the first (1.5; SD: 2.6) and at the last treatment session (0.8; SD= 1.3) was not statistically significant. Conclusion: Our exercise protocol resulted to be easy to perform during hospital stay, with an overall favourable outcome for ambulatory status. Our results are in line with those reported in literature about the rates of postoperative dependence in walking, but appear to be slightly better in regards to the percentage of patients who recovered pre-operative ambulatory status. (www.actabiomedica.it)
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Affiliation(s)
- Ettore Carlisi
- Physical Medicine and Rehabilitation Unit, I.R.C.C.S. Policlinico San Matteo Foundation & University of Pavia, Pavia.
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Komshian SR, Lu K, Pike SL, Siracuse JJ. Infrainguinal open reconstruction: a review of surgical considerations and expected outcomes. Vasc Health Risk Manag 2017; 13:161-168. [PMID: 28507439 PMCID: PMC5428788 DOI: 10.2147/vhrm.s106898] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Infrainguinal arterial occlusive disease can lead to potentially disabling and limb-threatening conditions. Revascularization may be indicated for claudication, rest pain, or tissue loss. Although endovascular interventions are becoming more prevalent, open surgeries such as endarterectomy and bypass are still needed and performed regularly. Open reconstruction has been associated with postoperative morbidity, both at the local and at the systemic levels. Local complications include surgical site infections (SSIs 0-5.3%), graft failure (12-60%), and amputation (5.7-27%), and more systemic issues include cardiac (2.6-18.4%), respiratory (2.5%), renal (4%), neurovascular (1.5%), and thromboembolic (0.2-1%) complications. While such outcomes present an additional challenge to the postoperative management of surgical patients, it may be possible to minimize their occurrence through careful risk stratification and preoperative assessment. Therefore, individualized selection of candidates for open repair requires weighing the need for intervention against the likelihood of adverse outcomes based on preoperative risk factors. This review provides an overview of open reconstruction, focusing on identifying the clinical indications for surgery and perioperative morbidity and mortality.
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Affiliation(s)
- Sevan R Komshian
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston University Boston, MA, USA
| | - Kimberly Lu
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston University Boston, MA, USA
| | - Steven L Pike
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston University Boston, MA, USA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, School of Medicine, Boston University Boston, MA, USA
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Yamazaki H, Hayashi H, Kawamura M, Sasaki A, Kondo E, Ito S, Wakai K. Validation of the Risk Score of the Mortality and Lower Limb Loss Considering Ambulatory Status after Surgical Revascularization in Maintaining Patients with Dialysis. Ann Vasc Dis 2017; 10. [PMID: 29147167 PMCID: PMC5684166 DOI: 10.3400/avd.oa.17-00063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Surgical revascularization is performed to preserve limb and to maintain functional status of patients with critical limb ischemia (CLI). The PREVENT III risk score helps to predict the postoperative course of CLI. However, this score is not available to estimate the risk of amputation or death properly in patients with hemodialysis (HD) and tissue loss (HD: 4 points, Tissue loss: 3 points), because they are classified as a high-risk group. Therefore, we investigated 213 patients with revascularized HD for CLI and proposed prognosis amputation or death for patients with HD risk score (PAD for HD risk score). PAD for HD risk score (non-ambulation: 3 points, ulcer/gangrene: 2 points, GNRI<92: 2 points, CRP>0.3 mg/dl: 1 point, Age≥75: 1 point) is more accurate for the prediction of amputation or death than the PREVENT III risk score (area under the curve [AUC]: 0.79 [95% confidence interval: CI: 0.71-0.87], p<0.01 vs. AUC: 0.63 [95%CI: 0.56-0.71]). The patients were stratified into three groups by total score in ascending order. The rate of 1-year amputation-free survival and independent ambulatory status were significantly different among three groups. PAD for HD risk score is useful for rehabilitation planning in patients with HD and CLI. (This is a translation of J Jpn Coll Angiol 2016; 56: 85-91.).
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Affiliation(s)
- Haruto Yamazaki
- Department of Rehabilitation, Kohno Clinical Medicine Research Institute, Shinagawa Rehabilitation Hospital, Tokyo, Japan
| | - Hisae Hayashi
- The Faculty of Rehabilitation and Care, Seijoh University, Tokai, Aichi, Japan
| | - Morio Kawamura
- Department of Physical, College of Life and Health Sciences, Chubu University, Kasugai, Aichi, Japan
| | - Ayana Sasaki
- Department of Rehabilitation, Municipal Kisogawa Hospital, Ichinomiya, Aichi, Japan
| | - Eriko Kondo
- Department of Rehabilitation, Nagoya Kyoritsu Hospital, Nagoya, Aichi, Japan
| | - Shinya Ito
- Department of Rehabilitation, Karatsu Red Cross Hospital, Karatsu, Saga, Japan
| | - Kenji Wakai
- Department of Preventive Medicine, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Lejay A, Delay C, Georg Y, Schwein A, Gaertner S, Thaveau F, Geny B, Chakfe N. Endovascular Surgery, Open Surgery, and Primary Amputation in Nonagenarians Presenting with Critical Limb Ischemia. Ann Vasc Surg 2016; 32:25-33. [DOI: 10.1016/j.avsg.2015.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 10/22/2022]
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Oresanya L, Zhao S, Gan S, Fries BE, Goodney PP, Covinsky KE, Conte MS, Finlayson E. Functional outcomes after lower extremity revascularization in nursing home residents: a national cohort study. JAMA Intern Med 2015; 175:951-7. [PMID: 25844523 PMCID: PMC5292255 DOI: 10.1001/jamainternmed.2015.0486] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Lower extremity revascularization often seeks to allow patients with peripheral arterial disease to maintain the ability to walk, a key aspect of functional independence. Surgical outcomes in patients with high levels of functional dependence are poorly understood. OBJECTIVE To determine functional status trajectories, changes in ambulatory status, and survival after lower extremity revascularization in nursing home residents. DESIGN Using full Medicare claims data for 2005 to 2009, we identified nursing home residents who underwent lower extremity revascularization. With the Minimum Data Set for Nursing Homes activities of daily living summary score, we examined changes in their ambulatory and functional status after surgery. We identified patient and surgery characteristics associated with a composite measure of clinical and functional failure-death or nonambulatory status 1 year after surgery. SETTING All nursing homes in the United States participating in Medicare or Medicaid. PARTICIPANTS Nursing home residents who underwent lower extremity revascularization. MAIN OUTCOMES AND MEASURES Functional status, ambulatory status, and death. RESULTS During the study period, 10,784 long-term nursing home residents underwent lower extremity revascularization. Prior to surgery, 75% of the residents were not walking; 40% had experienced functional decline. One year after surgery, 51% of patients had died, 28% were nonambulatory, and 32% had sustained functional decline. Among 1672 residents who were ambulatory before surgery, 63% had died or were nonambulatory at 1 year; among 7188 who were nonambulatory, 89% had died or were nonambulatory. After multivariate adjustment, factors independently associated with death or nonambulatory status were 80 years or older (adjusted hazard ratio [AHR], 1.28; 95% CI, 1.16-1.40), cognitive impairment (AHR, 1.23; 95% CI, 1.18-1.29), congestive heart failure (AHR, 1.16; 95% CI, 1.11-1.22), renal failure (AHR, 1.09; 95% CI, 1.04-1.14), emergent surgery (AHR, 1.29; 95% CI, 1.23-1.35), nonambulatory status before surgery (AHR, 1.88; 95% CI, 1.78-1.99), and decline in activities of daily living before surgery (AHR, 1.23; 95% CI, 1.18-1.28). CONCLUSIONS AND RELEVANCE Of nursing home residents in the United States who undergo lower extremity revascularization, few are alive and ambulatory 1 year after surgery. Most who were still alive had gained little, if any, function.
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Affiliation(s)
| | - Shoujun Zhao
- Department of Surgery, University of California, San Francisco
| | - Siqi Gan
- The Fielding School of Public Health, University of California, Los Angeles
| | - Brant E Fries
- Institute of Gerontology and University of Michigan and VA Ann Arbor Healthcare Systems, Ann Arbor
| | - Philip P Goodney
- Department of Surgery, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire5The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire6The VA Outcomes Group, White River Junction, Vermont
| | - Kenneth E Covinsky
- Division of Geriatrics, University of California, San Francisco8San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco7Division of Geriatrics, University of California, San Francisco9The Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco
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10
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Abstract
The prevalence of peripheral arterial disease (PAD) is increasing worldwide, with recent global estimates exceeding 200 million people. Advanced PAD leads to a decline in ambulatory function and diminished quality of life. In its most severe form, critical limb ischemia, rest pain, and tissue necrosis are associated with high rates of limb loss, morbidity, and mortality. Revascularization of the limb plays a central role in the management of symptomatic PAD. Concomitant with advances in the pathogenesis, genetics, and medical management of PAD during the last 20 years, there has been an ongoing evolution of revascularization options. The increasing application of endovascular techniques has resulted in dramatic changes in practice patterns and has refocused the question of which patients should be offered surgical revascularization. Nonetheless, surgical therapy remains a cornerstone of management for advanced PAD, providing versatile and durable solutions to challenging patterns of disease. Although there is little high-quality comparative effectiveness data to guide patient selection, existing evidence suggests that outcomes are dependent on definable patient factors such as distribution of disease, status of the limb, comorbid conditions, and conduit availability. As it stands, surgical revascularization remains the standard against which emerging percutaneous techniques are compared. This review summarizes the principles of surgical revascularization, patient selection, and expected outcomes, while highlighting areas in need of further research and technological advancement.
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Affiliation(s)
- Shant M. Vartanian
- From the Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco
| | - Michael S. Conte
- From the Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco
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11
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Ambler GK, Brooks DE, Al Zuhir N, Ali A, Gohel MS, Hayes PD, Varty K, Boyle JR, Coughlin PA. Effect of frailty on short- and mid-term outcomes in vascular surgical patients. Br J Surg 2015; 102:638-45. [PMID: 25764503 DOI: 10.1002/bjs.9785] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 09/22/2014] [Accepted: 01/16/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Frailty is a multidimensional vulnerability resulting from age-associated decline. The impact of frailty on outcomes was assessed in a cohort of vascular surgical patients. METHODS The study included patients aged over 65 years with length of hospital stay (LOS) greater than 2 days, who were admitted to a tertiary vascular unit over a single calendar year. Demographics, mode of admission, diagnosis, mortality, LOS and discharge destination were recorded, as well as a variety of frailty-specific characteristics. The impact of frailty on LOS, discharge destination, survival and readmission rate was assessed using multivariable regression techniques. The ability of the models to predict these outcomes was also assessed. RESULTS In total, 413 patients of median age 77 years were followed for a median of 18 (range 12-24) months. The in-hospital, 3- and 12-month mortality rates were 3·6, 8·5 and 13·8 per cent respectively. Receiver operating characteristic (ROC) curve analysis revealed that frailty-based regression models were excellent predictors of 12-month mortality (area under the ROC curve (AUC) = 0·81), prolonged LOS (AUC = 0·79) and discharge to a care institution (AUC = 0·84). A simple additive frailty score using six key features retained strong predictive power for 12-month mortality (AUC = 0·83), discharge to a care institution (AUC = 0·78) and prolonged LOS (AUC = 0·74). This frailty score was also strongly associated with readmission rates (P < 0·001). CONCLUSION Frailty in vascular surgery patients predicts a multiplicity of poorer outcomes. Optimal management should include identification of at-risk patients and treatment of modifiable risk factors.
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Affiliation(s)
- G K Ambler
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
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12
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Chang Y, Li F, Wang W, Song L, Li L, Li Z, Su D, Fu Z. Integrated treatment for lower-limb stage II thromboangiitis obliterans by interventional therapy and oral administration of Chinese medicine: a randomized controlled clinical trial. J TRADIT CHIN MED 2015; 35:41-6. [DOI: 10.1016/s0254-6272(15)30007-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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13
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Ambler GK, Dapaah A, Al Zuhir N, Hayes PD, Gohel MS, Boyle JR, Varty K, Coughlin PA. Independence and mobility after infrainguinal lower limb bypass surgery for critical limb ischemia. J Vasc Surg 2014; 59:983-987.e2. [DOI: 10.1016/j.jvs.2013.10.077] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 10/15/2013] [Accepted: 10/16/2013] [Indexed: 11/30/2022]
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Vogel TR, Petroski GF, Kruse RL. Functional status of elderly adults before and after interventions for critical limb ischemia. J Vasc Surg 2013; 59:350-8. [PMID: 24139567 DOI: 10.1016/j.jvs.2013.08.087] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 08/27/2013] [Accepted: 08/27/2013] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The impact of interventions for critical limb ischemia (CLI) on functional status in the elderly remains unclear. Open and endovascular procedures were evaluated. METHODS Medicare inpatient claims were linked with nursing home assessment data to identify elective admissions for lower extremity procedures for CLI. A functional impairment score (0-28; higher scores indicating greater impairment) based on residents' need for assistance with self-care activities, walking, and locomotion was calculated before and after interventions. Hierarchical modeling determined the effect of the surgery on residents' function, controlling for comorbidity, cognition, and prehospital function. RESULTS Three hundred fifty-two and 350 patients underwent open and endovascular procedures, respectively (rest pain, 84; ulceration, 351; gangrene, 267). Hospitalization was associated with a significant worsening in function following both procedures. Disease severity was associated with the amount of initial decline but not with the rate of recovery (P > .35). Residents who received open surgery improved more quickly following hospital discharge (P = .011). CONCLUSIONS In the frail elderly, open and endovascular procedures for CLI were associated with similar initial declines in functional status, suggesting that compared with open procedures, less invasive endovascular procedures were not associated with maintaining baseline function. In this select population, endovascular procedures for CLI were not associated with improved functional status over time compared with open. Six months posthospital, patients who received traditional open bypass had significantly better functional status than those who received endovascular procedures for all CLI diagnoses. Further analysis is required to assist stakeholders in performing procedures most likely to preserve functional status in the frail elderly and nursing home population.
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Affiliation(s)
- Todd R Vogel
- Department of Surgery, Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Mo.
| | - Gregory F Petroski
- Department of Health Management and Informatics, University of Missouri, School of Medicine, Columbia, Mo
| | - Robin L Kruse
- Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, Mo
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15
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Lepäntalo MJ, Houbballah R, Raux M, LaMuraglia G. Lower extremity bypass vs endovascular therapy for young patients with symptomatic peripheral arterial disease. J Vasc Surg 2012; 56:545-54. [DOI: 10.1016/j.jvs.2012.06.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Houbballah R, Raux M, LaMuraglia G. Part Two: Against the Motion. Endovascular Therapy is the Preferred Treatment for Patients <65 Years Old with Symptomatic Infrainguinal Arterial Disease. Eur J Vasc Endovasc Surg 2012; 44:116-9. [DOI: 10.1016/j.ejvs.2012.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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