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Karonen E, Eek F, Butt T, Acosta S. Sex differences in outcomes after revascularization for acute lower limb ischemia: Propensity score adjusted analysis. World J Surg 2024; 48:746-755. [PMID: 38501573 DOI: 10.1002/wjs.12058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/13/2023] [Indexed: 03/20/2024]
Abstract
BACKGROUND Previous reports have suggested higher rates of mortality and amputation for female patients in acute lower limb ischemia (ALI). The aims of the present study were to investigate if there is a difference in mortality, amputation, and fasciotomy between the sexes. METHODS A retrospective cohort study of consecutive patients undergoing index revascularization for ALI between 2001 and 2018 was conducted. A propensity score was created through a logistic regression with female/male sex as an outcome. Cox regression analyses for 90-day and 1-year mortality, combining major amputation/mortality, and logistic regression for major bleeding and fasciotomy, were performed. All analyses were performed with and without adjusting for propensity score. RESULTS A total of 709 patients were included in the study of which 45.9% were women. Mean age was 72.1 years. Females were older and had higher rates of atrial fibrillation, embolic disease, and lower estimated glomerular filtration rate, while men more often had anemia and chronic peripheral arterial disease. Mortality at 1 year was 21.2% for women and 14.7% for men. The adjusted hazard ratio for 1-year mortality was 0.99 (95% CI 0.67-1.46). Fasciotomy was performed in 7.1% of female and 12.8% of male patients; the adjusted odds ratio was 0.52 (95% CI 0.29-0.91). CONCLUSION Sex was not found to be an independent risk factor for mortality or combined major amputation/mortality after revascularization for acute lower limb ischemia, whereas women had lower odds of undergoing fasciotomy. Whether women are underdiagnosed or do not develop acute compartment syndrome in the lower leg as often as men should be evaluated prospectively.
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Affiliation(s)
- Emil Karonen
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Frida Eek
- Department of Health Sciences, Lund University, Lund, Sweden
| | - Talha Butt
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
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Kulezic A, Acosta S. Epidemiology and Prognostic Factors in Acute Lower Limb Ischaemia: A Population Based Study. Eur J Vasc Endovasc Surg 2022; 63:296-303. [PMID: 35027271 DOI: 10.1016/j.ejvs.2021.10.044] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/28/2021] [Accepted: 10/15/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the contemporary population based incidence of acute lower limb ischaemia (ALI) and factors associated with major amputation/death at one year. METHODS In this retrospective observational study, in hospital, operation, radiological, and autopsy registries were scrutinised to capture 161 citizens of Malmö, Sweden, with ALI between 2015 and 2018. Age and sex specific incidence rates were calculated in the population of Malmö between 2015 and 2018, expressed as number of patients per 100 000 person years (PY). Independent risk factors for major amputation/death at one year were identified by multivariable logistic regression analysis and expressed as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS One hundred and sixty-one patients with ALI gave an overall incidence of 12.2/100 000 PY (95% CI 10.3 - 14.1), with no sex related differences. Embolism (42.2%) was the most common cause of ALI. Among 52 patients with atrial fibrillation, 38.5% were on anticoagulant medication. Endovascular or open vascular revascularisation was performed in 54.7% of patients. The total cause specific mortality ratio was 2.63 (95% CI 1.66 - 3.61)/1 000 deaths, without no sex related differences. The combined major amputation/mortality rate at one year for the whole cohort was 46.6%. Rutherford ≥ IIb ALI (OR 4.19, 95% CI 1.94 - 9.02; p < .001), age (OR 1.03/year, 95% CI 1.00 - 1.06; p = .036), female sex (OR 2.37, 95% 1.07 - 5.26; p = .034), and anaemia (OR 2.46, 95% CI 1.08 - 5.62; p = .033) were associated with an increased risk of major amputation/death at one year. The major amputation/mortality rate at one year was 100% (n = 14/14) for patients living in a nursing home on admission. CONCLUSION The incidence of ALI appears to be unchanged, and major amputation and mortality at one year remain high. It is necessary to include the substantial proportion of patients with ALI that do not undergo revascularisation in epidemiological studies. There is room for improvement in anticoagulation therapy in patients with atrial fibrillation to prevent ALI due to embolism. Research on gender inequalities in patients with ALI is warranted.
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Affiliation(s)
- Andrea Kulezic
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden.
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Karonen E, Wrede A, Acosta S. Risk Factors for Fasciotomy After Revascularization for Acute Lower Limb Ischaemia. Front Surg 2021; 8:662744. [PMID: 33855045 PMCID: PMC8039517 DOI: 10.3389/fsurg.2021.662744] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Acute lower limb ischaemia (ALI) is a life and limb threatening vascular emergency. Acute compartment syndrome (ACS) may develop upon revascularization. The risk of fasciotomy was hypothesized to be decreased in women due to their lower calf muscle mass. The main aim was to evaluate risk factors for fasciotomy after revascularization for ALI. Methods: This is a retrospective observational study of patients undergoing revascularization for ALI between 2001 and 2018. Factors associated with outcome at 1 year in univariable analysis (p < 0.1) were chosen for multi-variable analysis and expressed in Odds Ratios (OR) with 95% confidence intervals (CI). Results: The median age for women (n = 394) was 75 years and men (n = 449) was 70 years (p < 0.001). The frequency of fasciotomy was 10.0% (84/843). The median in-hospital stay was 28 vs. 6 days for patients undergoing fasciotomy and not, respectively (p < 0.001). In adjusted analysis, renal insufficiency (OR 1.77, 95% CI 1.04–3.01), motor deficit (OR 4.40, 95% CI 2.45–7.92), popliteal artery aneurysm thromboembolism (OR 2.26, 95% CI 1.06–4.80), and open vascular surgery (OR 3.43, 95% CI 1.97–5.98) were associated with an increased risk of fasciotomy. Female patients (OR 0.49, 95% CI 0.28–0.84) and anemia (OR 0.52, 95% CI 0.28–0.84) had a lower risk. The major amputation/mortality rate at 1-year was 27.7%; fasciotomy (OR 1.94, 95% CI 1.11–3.40), anemia (OR 1.84, 95% CI 1.24–2.73) and female gender (OR 1.44, 95% CI 1.00–2.08) were independently associated with an increased risk. Conclusions: Female patients had lower rates of fasciotomies, but subsequent higher risk of major amputation/mortality, which may be attributed to inferior results of revascularization. Lower muscle mass and underdiagnosis of ACS could also explain the lower frequency of fasciotomy for female patients. Further studies are needed to better understand gender differences in presentation of ALI, revascularization results and diagnosis of ACS.
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Affiliation(s)
- Emil Karonen
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Vascular Center, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Axel Wrede
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Vascular Center, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Vascular Center, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
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Giusti JCG, Tartarotti SP, Rossi FH, Beraldo JPN, Brochado Neto FC. Fístula arteriovenosa como tratamento adjunto na revascularização arterial do membro em risco. J Vasc Bras 2021; 20:e20210042. [PMID: 35515087 PMCID: PMC9045530 DOI: 10.1590/1677-5449.210042] [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] [Received: 04/15/2021] [Accepted: 06/30/2021] [Indexed: 11/22/2022] Open
Abstract
Acute arterial occlusion remains a major challenge for the vascular surgeon. The therapeutic approach depends mostly upon the severity of the tissue injury and the duration of symptoms. Several techniques are available in the current therapeutic arsenal, however, regardless of the technique chosen, postoperative factors frequently observed, such as poor outflow status, or even low graft flow, can contribute negatively to the outcome of revascularization. We describe a case of acute limb ischemia, in the postoperative period of a femoral-tibial bypass, which was occluded due to outflow limitation and high peripheral vascular resistance. The patient underwent a second tibial revascularization combined with construction of an arteriovenous fistula, followed by forefoot amputation and partial skin graft. An energetic approach to the at-risk limb makes it possible to reduce unfavorable outcomes, such as amputation and death, and accelerates recovery of tissues affected by acute ischemia.
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Björck M, Earnshaw JJ, Acosta S, Bastos Gonçalves F, Cochennec F, Debus ES, Hinchliffe R, Jongkind V, Koelemay MJW, Menyhei G, Svetlikov AV, Tshomba Y, Van Den Berg JC, Esvs Guidelines Committee, de Borst GJ, Chakfé N, Kakkos SK, Koncar I, Lindholt JS, Tulamo R, Vega de Ceniga M, Vermassen F, Document Reviewers, Boyle JR, Mani K, Azuma N, Choke ETC, Cohnert TU, Fitridge RA, Forbes TL, Hamady MS, Munoz A, Müller-Hülsbeck S, Rai K. Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg 2019; 59:173-218. [PMID: 31899099 DOI: 10.1016/j.ejvs.2019.09.006] [Citation(s) in RCA: 223] [Impact Index Per Article: 44.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Shimada T, Urasawa K, Haraguchi T, Kitani S, Tan M, Koshida R, Igarashi Y, Sato K. Thrombectomy Using Myocardial Biopsy Forceps in Acute Limb Ischemia Patients. J Vasc Interv Radiol 2018; 29:1174-1179. [PMID: 29887182 DOI: 10.1016/j.jvir.2018.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 02/10/2018] [Accepted: 02/19/2018] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To evaluate the efficacy and safety of thrombectomy using myocardial biopsy forceps for the treatment of acute limb ischemia (ALI). MATERIALS AND METHODS A retrospective review of 11 ALI patients (12 affected limbs, 18 affected vessels) who underwent thrombectomy using biopsy forceps between November 2011 and April 2016 was performed. Of the 12 affected limbs, 2 limbs had stent thrombosis, 1 limb had thrombotic occlusion at a de novo stenosis site, and 9 limbs had embolic ALI. Biopsy forceps were used for angiographically limited arterial flow that persisted after the use of an aspiration catheter and conventional balloon angioplasty. The general technique for use of the biopsy forceps included advancement in parallel to a guidewire to the thrombus site, grasping of the thrombus with the forceps, and confirmation of grasping the thrombus with injection of a contrast medium prior to thrombus extraction. RESULTS Partial or total retrieval of the thrombus was angiographically confirmed in 12 of the 18 affected vessels, with restoration of normal blood flow in 11 vessels. Unsuccessful results in the remaining 6 affected vessels appeared to be due to friction at the aortoiliac bifurcation caused by the contralateral approach, small vessel size, or curvature of the anterior tibial artery. None of the 18 treated vessels had any complications such as dissection or perforation of the target vessel wall and distal emboli. None of the surviving patients required major or minor amputation. CONCLUSIONS Thrombectomy using biopsy forceps is a feasible technique for removal of an arterial thrombus in patients with ALI.
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Affiliation(s)
- Takenobu Shimada
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan; Department of Cardiology, Kurashiki Central Hospital, Okayama, Japan.
| | - Kazushi Urasawa
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan
| | - Takuya Haraguchi
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan
| | - Shunsuke Kitani
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan
| | - Michinao Tan
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan
| | - Ryoji Koshida
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan
| | - Yasumi Igarashi
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan
| | - Katsuhiko Sato
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan
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Golledge J, Moxon JV, Rowbotham S, Pinchbeck J, Yip L, Velu R, Quigley F, Jenkins J, Morris DR. Risk of major amputation in patients with intermittent claudication undergoing early revascularization. Br J Surg 2018; 105:699-708. [PMID: 29566427 DOI: 10.1002/bjs.10765] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 09/29/2017] [Accepted: 10/22/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Revascularization is being used increasingly for the treatment of intermittent claudication and yet few studies have reported the long-term outcomes of this strategy. The aim of this study was to compare the long-term outcome of patients with intermittent claudication who underwent revascularization compared with a group initially treated without revascularization. METHODS Patients with symptoms of intermittent claudication and a diagnosis of peripheral arterial disease were recruited from outpatient clinics at three hospitals in Queensland, Australia. Based on variation in the practices of different vascular specialists, patients were either treated by early revascularization or received initial conservative treatment. Patients were followed in outpatient clinics using linked hospital admission record data. The primary outcome was the requirement for major amputation. Kaplan-Meier curves, Cox regression and competing risks analyses were used to compare major amputation rates. RESULTS Some 456 patients were recruited; 178 (39·0 per cent) underwent early revascularization and 278 (61·0 per cent) had initial conservative treatment. Patients were followed for a mean(s.d.) of 5·00(3·37) years. The estimated 5-year major amputation rate was 6·2 and 0·7 per cent in patients undergoing early revascularization and initial conservative treatment respectively (P = 0·003). Early revascularization was associated with an increased requirement for major amputation in models adjusted for other risk factors (relative risk 5·40 to 4·22 in different models). CONCLUSION Patients presenting with intermittent claudication who underwent early revascularization appeared to be at higher risk of amputation than those who had initial conservative treatment.
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Affiliation(s)
- J Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia.,Department of Vascular and Endovascular Surgery, Townsville Hospital, Townsville, Queensland, Australia.,Department of Vascular and Endovascular Surgery, Mater Hospital, Townsville, Queensland, Australia
| | - J V Moxon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
| | - S Rowbotham
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Vascular and Endovascular Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - J Pinchbeck
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - L Yip
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - R Velu
- Department of Vascular and Endovascular Surgery, Townsville Hospital, Townsville, Queensland, Australia.,Department of Vascular and Endovascular Surgery, Mater Hospital, Townsville, Queensland, Australia
| | - F Quigley
- Department of Vascular and Endovascular Surgery, Mater Hospital, Townsville, Queensland, Australia
| | - J Jenkins
- Department of Vascular and Endovascular Surgery, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - D R Morris
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,Nuffield Department of Population Health, University of Oxford, Oxford, UK
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