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Setia O, Lee SR, Dardik A. Modalities to Deliver Cell Therapy for Treatment of Chronic Limb Threatening Ischemia. Adv Wound Care (New Rochelle) 2024; 13:253-279. [PMID: 37002893 PMCID: PMC11305013 DOI: 10.1089/wound.2022.0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 03/29/2023] [Indexed: 04/04/2023] Open
Abstract
Significance: Chronic limb threatening ischemia (CLTI) is a severe form of peripheral arterial disease (PAD) that is associated with high rates of morbidity and mortality, and especially limb loss. In patients with no options for revascularization, stem cell therapy is a promising treatment option. Recent Advances: Cell therapy directly delivered to the affected ischemic limb has been shown to be a safe, effective, and feasible therapeutic alternative for patients with severe PAD. Multiple methods for cell delivery, including local, regional, and combination approaches, have been examined in both pre-clinical studies and clinical trials. This review focuses on delivery modalities used in clinical trials that deliver cell therapy to patients with severe PAD. Critical Issues: Patients with CLTI are at high risk for complications of the disease, such as amputations, leading to a poor quality of life. Many of these patients do not have viable options for revascularization using traditional interventional or surgical methods. Clinical trials have shown therapeutic benefit for cell therapy in these patients, but methods of cell treatment are not standardized, including the method of cell delivery to the ischemic limb. Future Directions: The ideal delivery approach for stem cell therapy in PAD patients remains unclear. Further studies are needed to determine the best modality of cell delivery to maximize clinical benefits.
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Affiliation(s)
- Ocean Setia
- Vascular Biology and Therapeutics Program, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Shin-Rong Lee
- Vascular Biology and Therapeutics Program, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Alan Dardik
- Vascular Biology and Therapeutics Program, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
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2
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Vossen RJ, Ras D, Vahl AC, Leijdekkers VJ, Montauban van Swijndregt AD, Wisselink W, Balm R. Correlation of patient-reported outcome measures and the ankle–brachial index in patients who underwent revascularization for peripheral artery disease. Vasc Med 2022:1358863X221138879. [DOI: 10.1177/1358863x221138879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Rianne J Vossen
- Department of Vascular Surgery, OLVG Amsterdam, Amsterdam, The Netherlands
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dianne Ras
- Department of Health Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anco C Vahl
- Department of Vascular Surgery, OLVG Amsterdam, Amsterdam, The Netherlands
| | | | | | - Willem Wisselink
- Department of Vascular Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Pedersen BL, Helledie G, Eiken FL, Lawaetz J, Eiberg JP, Quistorff B. Effect of revascularisation on lower extremity muscle function in combined type 2 diabetes and critical limb threatening ischemia. INT ANGIOL 2021; 40:323-334. [PMID: 34008931 DOI: 10.23736/s0392-9590.21.04661-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Critical limb-threatening ischemia (CLTI) and type 2 diabetes (T2D) frequently co-exist and often with less favourable outcome after revascularisation. The objective was to evaluate the effects of revascularisation on muscle function, perfusion and mitochondrial respiration in patients with combined CLTI and T2D. METHODS A prospective translational observational study. Two groups of patients facing unilateral peripheral revascularisation was included: Patients suffering from combined disease with CLTI+T2D (n= 14) and patients suffering from CLTI (n= 15). During pedal exercise testing, calf muscle perfusion was monitored with near-infrared spectroscopy (NIRS) and leg arterial volume flow in the common femoral artery with duplex ultrasound. Calf muscle biopsy and subsequent assessment of mitochondrial respiratory capacity on isolated muscle fibres was performed. Tests was performed before and six weeks after revascularisation. RESULTS After revascularisation, patients CLTI+T2D improved in muscle force from 8.48 kg (CI: 7.49-9.46) to 13.11 kg (CI: 11.58-14.63), (P<.001). Conversely, muscle force in patients suffering from nondiabetic CLTI decreased from 10.03 kg (CI: 9.1-10.96) to 9.73 kg (CI: 8.77- 10.69), (P=0.042). Muscle oxygenation during exercise improved more in the CLTI+T2D group 6.36 AUC (Area Under Curve), ((μM/kg)s) (CI: 5.71-7.01) compared to 2.11 ((μM/kg)s) (CI:1.38-2.83) in the CLTI group (P=.002). No improvement or difference between groups regarding mitochondrial function was detected. CONCLUSIONS Patients with combined CLTI+T2D, had an unsuspected better effect of revascularisation compared to patients with non-diabetic CLTI, in terms of increased muscle force (MVC) and improved muscle perfusion. Further studies are needed to elucidate the apparent interaction of the CLTI and T2D syndromes.
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Affiliation(s)
- Brian L Pedersen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark -
| | - Gladis Helledie
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Frederik L Eiken
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Jonathan Lawaetz
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark.,Copenhagen Academy for Medical Education and Simulation (CAMES), The Capital Region of Denmark, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonas P Eiberg
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark.,Copenhagen Academy for Medical Education and Simulation (CAMES), The Capital Region of Denmark, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bjørn Quistorff
- Department of Biomedical Sciences, Nuclear Magnetic Resonance Centre, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Albaghdadi MS, Young MN, Chowdhury MM, Assmann S, Hamza T, Siami S, Villarreal M, Strong M, Menard M, Farber A, Rosenfield K. Clinical practice patterns and ascertainment bias for cardiovascular events in a randomized trial: A survey of investigators in the BEST-CLI trial. Vasc Med 2021; 26:180-186. [PMID: 33825577 DOI: 10.1177/1358863x21995897] [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: 11/16/2022]
Abstract
Ascertainment bias is a well-recognized source of bias in research, but few studies have systematically analyzed sources of ascertainment bias in randomized trials in which blinding is not possible and endpoint assessment is not protocolized. In the current study, we sought to evaluate differences in the clinical practice patterns of trial investigators with respect to bias in the ascertainment of pre-revascularization patient risk and the incidence of secondary endpoints post-revascularization. We conducted a cross-sectional survey of active investigators (n = 936) from the Best Endovascular Versus Best Surgical Therapy for Patients with Critical Limb Ischemia (BEST-CLI) trial. The total survey response rate was 19.6% (183/936). Vascular surgeons were more likely than nonsurgical interventionalists to order tests for cardiac complications after both surgical bypass (p < 0.001) and endovascular revascularization (p = 0.038). Post-procedure, investigators were more likely to order additional testing for cardiac complications in open surgery versus endovascular cases (7% vs 16% never, 41% vs 65% rarely, 43% vs 17% sometimes, 9% vs 2% always, respectively; p < 0.0001). Significant variation in practice patterns exist in the pre- and post-procedure assessment of cardiac risk and events for patients with CLI undergoing revascularization. Variation in the ascertainment of risk and outcomes according to the type of revascularization procedure and physician specialty should be considered when interpreting the results of clinical studies, such as the BEST-CLI trial. ClinicalTrials.gov Identifier: NCT02060630.
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Affiliation(s)
- Mazen S Albaghdadi
- Division of Cardiology and Section of Vascular Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Medicine, Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
| | - Michael N Young
- Cardiology Division, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Mohammed M Chowdhury
- Department of Vascular and Endovascular Surgery, Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Susan Assmann
- HealthCore-New England Research Institutes, Inc., Watertown, MA, USA
| | - Taye Hamza
- HealthCore-New England Research Institutes, Inc., Watertown, MA, USA
| | - Sandra Siami
- HealthCore-New England Research Institutes, Inc., Watertown, MA, USA
| | - Maria Villarreal
- Department of Vascular Surgery, Boston Medical Center, Boston University, Boston, MA, USA
| | - Michael Strong
- Department of Vascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew Menard
- Department of Vascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alik Farber
- Department of Vascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kenneth Rosenfield
- Division of Cardiology and Section of Vascular Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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5
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Harfouch T, Tarus A, Agafitei ET, Chistol RO, Tinica G. Combined Superficial and Deep Venous Arterialization in No-Option Critical Limb Ischemia: Case Report. Vasc Endovascular Surg 2021; 55:501-504. [PMID: 33511922 DOI: 10.1177/1538574421989861] [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: 11/15/2022]
Abstract
The management of peripheral artery disease with no revascularization options can be challenging due to the very limited treatment options available and the high rate of major amputation which is linked to increased mortality and poor quality of life. Using a distal venous bed as an alternative bypass runoff seems to be a viable option when arterial reconstruction is not feasible. We report our experience with distal venous arterialization for limb salvage in non-reconstructable critical limb ischemia and describe the configuration used to achieve venosome directed revascularization in a patient with concomitant varicose veins.
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Affiliation(s)
- Tammam Harfouch
- Department of Cardiovascular Surgery-Cardiovascular Diseases Institute, Iasi, Romania
| | - Andrei Tarus
- Department of Cardiovascular Surgery-Cardiovascular Diseases Institute, Iasi, Romania.,"Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania
| | | | - Raluca Ozana Chistol
- "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Department of Medical Imaging-Cardiovascular Diseases Institute, Iasi, Romania
| | - Grigore Tinica
- Department of Cardiovascular Surgery-Cardiovascular Diseases Institute, Iasi, Romania.,"Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,The Academy of Romanian Scientists (AOSR), Bucharest, Romania.,The Academy of Sciences of Moldova, Chisinau, Republic of Moldova
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6
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Wong CK, Chihuri ST, Santo EG, White RA. Relevance of medical comorbidities for functional mobility in people with limb loss: retrospective explanatory models for a clinical walking measure and a patient-reported functional outcome. Physiotherapy 2020; 107:133-141. [PMID: 32026813 DOI: 10.1016/j.physio.2020.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Various modifiable and non-modifiable factors affect functional mobility, but subjective patient-reported and objective performance-based measures are rarely combined in explanatory analyses of functional mobility in people with limb loss. This study determined separate explanatory models for patient-reported function using the Prosthetic Evaluation Questionnaire Mobility Subscale (PEQ-MS), and performance-based 2-Minute Walk Test (2MWT). DESIGN Retrospective cross-sectional observational analysis. SETTING Wellness-walking program. PARTICIPANTS Three hundred five volunteers with lower limb loss participated. Sixty nine percent were men, mean age 56 (15) years. Fifty two percent had vascular amputation causes, 42% had surgical levels above the knee, and 82% had medical comorbidities. Walking levels included limited-household (21%), limited-community (30%), and independent-community (49%). Outcome measures included patient-reported PEQ-MS, Activities-specific Balance Confidence (ABC) and Houghton scales; and performance-based balance and walking. MAIN OUTCOMES Separate PEQ-MS and 2MWT multiple regression models fit using backward deletion. RESULTS Modifiable (balance ability, ABC, Houghton score; P<0.05) and non-modifiable factors (sex, amputation cause, surgical level; P<0.05) explained the variance in 2MWT (adjusted R2=0.685). Patient-reported and performance-based modifiable factors (Houghton score, 2MWT; P<0.001) explained PEQ-MS variance (adjusted R2=0.660). Integumentary (P=0.022) and cardiopulmonary (P<0.001) comorbidities explained an additional 4% of PEQ-MS variance, while surgical level was insignificant. CONCLUSIONS Both modifiable and non-modifiable factors explained prosthetic functional mobility. Performance-based walking was explained by modifiable factors including balance ability and confidence, prosthesis and walking aid use. Patient-reported function was also explained by prosthesis and walking aid use, walking speed and medical comorbidities. Modifiable factors for objective and subjective prosthetic mobility may provide a clinical roadmap for rehabilitation.
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Affiliation(s)
- Christopher K Wong
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, 617 West 168th Street, Georgian #311, New York, 10032 NY, USA.
| | - Stanford T Chihuri
- Center for Injury Epidemiology and Prevention, Columbia University Irving Medical Center, New York, NY, USA
| | - Elizabeth G Santo
- Program in Physical Therapy, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Ryan A White
- Program in Physical Therapy, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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7
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Iannuzzi JC, Boitano LT, Cooper MA, Watkins MT, Eagleton MJ, Clouse WD, Conte MS, Conrad MF. Risk score for nonhome discharge after lower extremity bypass. J Vasc Surg 2019; 71:889-895. [PMID: 31519514 DOI: 10.1016/j.jvs.2019.07.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/03/2019] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Patients undergoing lower extremity bypass (LEB) for peripheral artery disease require intensive health care resource utilization including rehabilitation and skilled nursing facilities. However, few studies have evaluated factors that lead to nonhome discharge (NHD) in this population of patients. This study sought to predict NHD by preoperative risk factors in patients undergoing LEB for peripheral artery disease using a novel risk score. METHODS The Vascular Study Group of New England database was queried for elective LEB for peripheral artery disease including claudication and critical limb ischemia from 2003 to 2017. Patients were excluded if the procedure was not elective, if they were not admitted from home, if they were bedridden, or if they died during the index admission. Only preoperative factors were considered in the analysis. The primary end point was NHD including rehabilitation and skilled nursing facilities. Data were split two-thirds for model derivation and one-third for validation. In the derivation cohort, bivariate analysis assessed the association of preoperative factors with NHD. A parsimonious manual stepwise binary logistic regression for NHD aimed at maximizing the C statistic while maintaining model simplicity was performed. A risk score was developed using the β coefficients and applied to the validation data set. The risk score performance was assessed using a C statistic and Hosmer-Lemeshow test for model fit. RESULTS There were 10,145 cases included with an overall NHD rate of 26.4% (n = 2676). Mean age was 66 years (range, 41-90 years). NHD patients were older (72 years vs 64 years; P < .01) and more frequently male (57.2% vs 42.8%; P < .01) and nonwhite (16.1% vs 9.9%; P < .01); they more frequently had tissue loss (54.2% vs 23.0%; P < .01), anemia (16.0% vs 5.3%; P < .01), severe cardiac comorbidity (21.8% vs 10.5%; P < .01), and insulin-dependent diabetes (33.3% vs 18.2%; P < .01). On multivariable analysis, factors associated with NHD included age, sex, nonwhite race, tissue loss, cardiac comorbidity, partial ambulatory deficit, and insulin-dependent diabetes. The C statistic was 0.78 in the derivation group and 0.79 in the validation group, with Hosmer-Lemeshow P > .999. The risk score ranged from 0 to 18, with a mean score of 4 (standard deviation ±3.5). The risk score was divided into low risk (0-4 points; n = 5272 [52%]; NHD = 10.1%]), moderate risk (5-9 points; n = 3663 [36.7%]; NHD = 36.7%), and high risk (≥10 points; n = 1210 [11.9%]; NHD = 66.1%). CONCLUSIONS This novel risk score was highly predictive for NHD after LEB for peripheral artery disease using only preoperative comorbidities. High-risk patients account for 12% of LEB but nearly a third of all patients requiring NHD. This risk score can be used preoperatively to determine high-risk patients for NHD, which may help improve preoperative counseling and hospital efficiency by allocating resources appropriately.
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Affiliation(s)
- James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, Calif.
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Michol A Cooper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Michael T Watkins
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, Calif
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass
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Vossen RJ, Philipszoon PC, Vahl AC, Montauban van Swijndregt AD, Leijdekkers VJ, Balm R. A Comparative Cost-Effectiveness Analysis of Percutaneous Transluminal Angioplasty With Optional Stenting and Femoropopliteal Bypass Surgery for Medium-Length TASC II B and C Femoropopliteal Lesions. J Endovasc Ther 2019; 26:172-180. [DOI: 10.1177/1526602819833646] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Purpose: To evaluate the total midterm costs and cost-effectiveness of percutaneous transluminal angioplasty with optional stenting (PTA/S) as initial treatment compared with femoropopliteal bypass (FPB) surgery in patients with medium-length TransAtlantic Inter-Society Consensus II (TASC) B and C femoropopliteal lesions. Materials and Methods: Over a period of 3 years, all hospital health care costs for 226 consecutive patients were calculated: 170 patients with a TASC B lesion and 56 patients with a TASC C lesion. In the 135-patient PTA/S group (mean age 69.9±10.9 years; 83 men), 108 (63.5%) patients had TASC B lesions and 27 (48.2%) patients had TASC C lesions. Ninety-one patients (mean age 68.4±10.9 years; 60 men) were treated with FPB for 62 TASC B and 29 TASC C femoropopliteal lesions. The main outcome measure was the primary patency rate at 3-year follow-up. Multiple imputation and bootstrapping techniques were used to analyze the data. The adjusted incremental cost-effectiveness ratios (ICERs) were calculated by dividing the difference in total costs by the difference in 3-year primary patency rate. Costs were expressed in euros (€), and cost differences are presented with the 95% confidence interval (CI). Results: Mean total costs per patient were €29,058 in the PTA/S treatment group vs €42,437 in the FPB group (mean adjusted difference –€14,820, 95% CI –€29,044 to −€5976). Differences in 3-year primary patency between PTA/S and FPB were small and nonsignificant (68.9% and 70.3%, respectively). An ICER of 563,716 was found, indicating that FPB costs €563,716 more per one extra patient reaching 3-year primary patency in comparison with PTA/S treatment. Conclusion: FPB in medium-length femoropopliteal lesions involved higher total costs when evaluated over a 3-year follow-up period. An endovascular-first approach is recommended, as this will result in cost minimization for patients with medium-length femoropopliteal disease.
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Affiliation(s)
- Rianne J. Vossen
- Department of Vascular Surgery, Onze Lieve Vrouwe Gasthuis (OLVG) Amsterdam, the Netherlands
| | - Pilar C. Philipszoon
- Department of Health Sciences, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Anco C. Vahl
- Department of Vascular Surgery, Onze Lieve Vrouwe Gasthuis (OLVG) Amsterdam, the Netherlands
- Clinical Epidemiology, OLVG Amsterdam, the Netherlands
| | | | - Vanessa J. Leijdekkers
- Department of Vascular Surgery, Onze Lieve Vrouwe Gasthuis (OLVG) Amsterdam, the Netherlands
| | - Ron Balm
- Amsterdam Cardiovascular Sciences, Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
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9
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Vossen RJ, Vahl AC, Fokkema TM, Leijdekkers VJ, van Swijndregt ADM, Balm R. Endovascular therapy versus femoropopliteal bypass surgery for medium-length TASC II B and C lesions of the superficial femoral artery: An observational propensity-matched analysis. Vascular 2019; 27:542-552. [DOI: 10.1177/1708538119837134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objectives This study was designed to compare clinical outcomes of percutaneous transluminal angioplasty with optional stenting (PTA/s) and femoropopliteal bypass (FPB) surgery as primary invasive treatment in patients with medium-length superficial femoral artery (SFA) lesions. Methods We performed a single-center retrospective, observational analysis in all consecutive patients who had undergone initial invasive treatment for medium-length, TASC II B and TASC II C, SFA lesions from 2004 to 2015. Primary endpoints were primary and secondary clinical patency. Secondary endpoints were complication rates and number of amputations. Kaplan–Meier curves were used to compare patency rates in the two treatment groups. Multivariate Cox regression analysis was performed to adjust for confounding variables and propensity score matching analysis was used to balance treatment groups. Results A total of 362 patients with a mean observation period of 4.0 years (SD ± 2.6) were analyzed. In this group, 231 patients (64%) underwent PTA/s and 131 patients (36%) FPB surgery. There was no difference in primary clinical patency at one-, three- and five-year follow-up between the PTA/s and FPB group, with rates of 79% vs. 63%, 53% vs. 78% and 71% vs. 66%, respectively ( P = 0.46). Secondary clinical patency estimates were comparable, resulting in one-, three- and five-year secondary clinical patency rates of 88%, 76% and 67% in the PTA/s group versus 88%, 80% and 79% in the bypass group ( P = 0.40). Multivariate analysis revealed no significant differences between the PTA/s and FPB groups in terms of primary clinical patency (HR 1.4; 95% CI 0.9–2.2) and secondary clinical patency (HR 1.7; 95% CI 0.9–2.9). This was confirmed in the propensity score analysis. Hospital stay (4.8 vs. 10.3 days) and complication rate (2.6% vs. 18.3%) were significantly lower in the PTA/s group ( P = 0.00). The number of amputations was comparable ( P = 0.75). Conclusions The clinical success of endovascular therapy and surgery for medium-length SFA lesions is comparable. Taking into account the lower morbidity rate, shorter length of hospital stay and the less invasive character of PTA/s compared with bypass surgery, patients with medium-length SFA lesions are ideally treated by an endovascular-first approach.
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Affiliation(s)
- RJ Vossen
- Department of Vascular Surgery, OLVG Amsterdam, Amsterdam, The Netherlands
| | - AC Vahl
- Department of Vascular Surgery, OLVG Amsterdam, Amsterdam, The Netherlands
- Clinical Epidemiology OLVG Amsterdam, Amsterdam, The Netherlands
| | - TM Fokkema
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - VJ Leijdekkers
- Department of Vascular Surgery, OLVG Amsterdam, Amsterdam, The Netherlands
| | | | - R Balm
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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10
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Yeong XL, Chan ESY, Samuel M, Choong AMTL. Venous arterialization for the salvage of critically ischemic lower limbs. Hippokratia 2019. [DOI: 10.1002/14651858.cd013269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Xue Lun Yeong
- University of New South Wales; Level 5, Wallace Wurth Building 18 High Street Sydney NSW Australia 2052
| | - Edwin SY Chan
- Singapore Clinical Research Institute; Cochrane Singapore; Nanos Building #02-01 31 Biopolis Way Singapore Singapore 138669
| | - Miny Samuel
- NUS Yong Loo Lin School of Medicine; Dean's Office; NUHS Tower Block, Level 11 1E Kent Ridge Road Singapore Singapore 119228
| | - Andrew MTL Choong
- SingVaSC, Singapore Vascular Surgical Collaborative; Singapore Singapore
- National University of Singapore; Cardiovascular Research Institute; Singapore Singapore
- Yong Loo Lin School of Medicine, National University of Singapore; Department of Surgery; Singapore Singapore
- National University Heart Centre; Division of Vascular Surgery; Singapore Singapore
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11
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Antonios T, Barker A, Ibrahim I, Scarsbrook C, Smitham PJ, Goodier WD, Calder PR. A Systematic Review of Patient-reported Outcome Measures Used in Circular Frame Fixation. Strategies Trauma Limb Reconstr 2019; 14:34-44. [PMID: 32559266 PMCID: PMC7001598 DOI: 10.5005/jp-journals-10080-1413] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Clinical studies in orthopedics are using patient-reported outcome measures (PROMs) increasingly. PROMs are often being designed for a specific disease or an area of the body with the aim of being patient centered. As yet, none exists specifically for treatment with circular ring external fixation devices. AIM The purpose of this study is to provide a comprehensive systematic review of the published literature related to the use of PROMs in patients that underwent treatment with circular frames (Ilizarov or Hexapod Type Fixators). METHODS An online literature search was conducted for English language articles using the Scopus. RESULTS There were 534 published articles identified. After initial filtering for relevance and duplication, this figure reduced to 17, with no further articles identified through searching the bibliographies. Exclusion criteria removed two articles resulting in 15 articles included in the final review. Out of the 15 studies identified, a total of 10 different scoring measures where used. The majority of studies used a combination of joint/limb-specific and generic health PROMs with an average of 2.5 per study. No paper specifically discussed all eight PROMs criteria when justifying which PROMs they used. CONCLUSION Our findings indicate that none of the PROMs analyzed in this systematic review are truly representative of the health outcomes specific to this patient group and, therefore, propose that a PROM specific to this patient group needs to be developed. HOW TO CITE THIS ARTICLE Antonios T, Barker A, Ibrahim I, et al. A Systematic Review of Patient-reported Outcome Measures Used in Circular Frame Fixation. Strategies Trauma Limb Reconstr 2019;14(1):34-44.
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Affiliation(s)
- Tony Antonios
- Department of Trauma and Orthopaedics, King's College Hospital NHS Foundation Trust, London, UK
| | - Amy Barker
- Institute of Orthopaedics and Musculoskeletal Sciences, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, UK
| | - Inji Ibrahim
- Institute of Orthopaedics and Musculoskeletal Sciences, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, UK
| | - Christine Scarsbrook
- Institute of Orthopaedics and Musculoskeletal Sciences, University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, UK
| | - Peter J Smitham
- Institute of Orthopaedics and Musculoskeletal Sciences, University College London; Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, UK; Department of Trauma and Orthopaedics, Royal Adelaide Hospital, Port Road, Adelaide, South Australia, Australia
| | - W David Goodier
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, UK
| | - Peter R Calder
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, UK
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Vossen RJ, Vahl AC, Leijdekkers VJ, Montauban van Swijndregt AD, Balm R. Long-Term Clinical Outcomes of Percutaneous Transluminal Angioplasty with Optional Stenting in Patients with Superficial Femoral Artery Disease: A Retrospective, Observational Analysis. Eur J Vasc Endovasc Surg 2018; 56:690-698. [PMID: 30108029 DOI: 10.1016/j.ejvs.2018.06.063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 06/23/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVE The recent ESC guideline advises primary stent placement in superficial femoral arterial disease (SFAD). The aim of this study was to compare clinical outcomes of SFAD patients selected for stent placement with plain percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS A single centre retrospective, observational analysis was performed of all consecutive patients undergoing endovascular treatment for SFAD from 2004 to 2015. Primary endpoints were primary and secondary clinical patency rates in patients with or without stent placement. Secondary endpoints were recurrence rates and number of amputations. Kaplan-Meier curves were used to compare patency rates. Multivariable Cox regression analysis was performed to adjust for confounding variables and to identify variables associated with loss of patency. RESULTS A total of 389 patients were analysed with a median follow up of 42 months. Two hundred and fifty one patients (64.5%) were stented. Primary clinical patency rates at 1, 3, and 5 years were 82.8%, 71.0%, and 65.6% after PTA and 76.3%, 65.7%, and 58.1% after stent placement (PTA-S), respectively (p = .30). Secondary patency rates were also comparable for the PTA and PTA-S group resulting in 1, 3 and 5 year clinical secondary patency of 89.1%, 81.0%, and 76.3% in the PTA group versus 87.8%, 78.5%, and 71.9% in the PTA-S group (p = .58). Multivariable analysis revealed equal primary and secondary clinical patency between the treatment groups. The absolute re-intervention rate was 29.3%. The number of re-interventions and amputation rate did not significantly differ between the two groups (p = .41 and p = .75). CONCLUSIONS Selective stenting in patients with SFAD shows comparable results in long-term clinical outcomes in patients who were treated with plain PTA as well as patients who are selected for stent placement. An approach of selective stenting is justified.
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Affiliation(s)
- Rianne J Vossen
- Department of Vascular Surgery, OLVG, Amsterdam, The Netherlands.
| | - Anco C Vahl
- Department of Vascular Surgery, OLVG, Amsterdam, The Netherlands
| | | | | | - Ron Balm
- Department of Vascular Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
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Flugelman MY, Halak M, Yoffe B, Schneiderman J, Rubinstein C, Bloom AI, Weinmann E, Goldin I, Ginzburg V, Mayzler O, Hoffman A, Koren B, Gershtein D, Inbar M, Hutoran M, Tsaba A. Phase Ib Safety, Two-Dose Study of MultiGeneAngio in Patients with Chronic Critical Limb Ischemia. Mol Ther 2017; 25:816-825. [PMID: 28143739 DOI: 10.1016/j.ymthe.2016.12.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 12/10/2016] [Accepted: 12/15/2016] [Indexed: 01/22/2023] Open
Abstract
Critical limb ischemia (CLI) is the most severe presentation of peripheral arterial disease. We developed cell-based therapy entailing intra-arterial injection of autologous venous endothelial cells (ECs) modified to express angiopoietin 1, combined with autologous venous smooth muscle cells (SMCs) modified to express vascular endothelial growth factor. This combination promoted arteriogenesis in animal models and was safe in patients with limiting claudication. In an open-label, phase Ib study, we assessed the safety and efficacy of this therapy in CLI patients who failed or were unsuitable for surgery or intravascular intervention. Of 23 patients enrolled, 18 with rest pain or non-healing ulcers (Rutherford categories 4 and 5) were treated according to protocol, and 5 with significant tissue loss (Rutherford 6) were treated under compassionate treatment. Patients were assigned randomly to receive 1 × 107 or 5 × 107 (EC-to-SMC ratio, 1:1) of the cell combination. One-year amputation-free survival rate was 72% (13/18) for Rutherford 4 and 5 patients; all 5 patients with Rutherford 6 underwent amputation. Of the 12 with unhealing ulcers at dosing, 6 had complete healing and 2 others had >66% reduction in ulcer size. Outcomes did not differ between the dose groups. No severe adverse events were observed related to the therapy.
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Affiliation(s)
- Moshe Y Flugelman
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, Haifa 3436212, Israel; Rappaport Faculty of Medicine, Technion IIT, Haifa 3200003, Israel; VESSL Therapeutics Ltd., Haifa 3436212, Israel.
| | - Moshe Halak
- Department of Vascular Surgery, Chaim Sheba Medical Center, Ramat Gan 5265601, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Boris Yoffe
- Department of General and Vascular Surgery, Barzilai Medical Center, Ashkelon 7830604, Israel; The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8499000, Israel
| | - Jacob Schneiderman
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Chen Rubinstein
- Departments of Vascular Surgery and Radiology, Hadassah University Hospital, Jerusalem 91120, Israel
| | - Allan-Isaac Bloom
- Departments of Vascular Surgery and Radiology, Hadassah University Hospital, Jerusalem 91120, Israel
| | - Eran Weinmann
- Department of Vascular Surgery, Kaplan Medical Center, Rehovot 76100, Israel
| | - Ilya Goldin
- Department of Vascular Surgery, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
| | - Victor Ginzburg
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8499000, Israel; Department of Vascular Surgery, Soroka Medical Center, Beer-Sheva 8410101, Israel
| | - Olga Mayzler
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8499000, Israel; Department of Vascular Surgery, Soroka Medical Center, Beer-Sheva 8410101, Israel
| | - Aaron Hoffman
- Rappaport Faculty of Medicine, Technion IIT, Haifa 3200003, Israel; Department of Vascular Surgery, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Belly Koren
- VESSL Therapeutics Ltd., Haifa 3436212, Israel
| | | | | | | | - Adili Tsaba
- Rappaport Faculty of Medicine, Technion IIT, Haifa 3200003, Israel; VESSL Therapeutics Ltd., Haifa 3436212, Israel
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Cairols MA. Intervention Should not be the Thermopylae to Avoid Amputation: Commentary on "Not All Patients with Critical Limb Ischaemia Require Revascularisation". Eur J Vasc Endovasc Surg 2017; 53:307-308. [PMID: 28089406 DOI: 10.1016/j.ejvs.2016.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 12/13/2016] [Indexed: 10/20/2022]
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Lin MJ, Baky F, Housley BC, Kelly N, Pletcher E, Balshi JD, Stawicki SP, Evans DC. Temporal variability of readmission determinants in postoperative vascular surgery patients. J Postgrad Med 2017; 62:216-222. [PMID: 27763477 PMCID: PMC5105205 DOI: 10.4103/0022-3859.188548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Introduction: Clinical information continues to be limited regarding changes in the temporal risk profile for readmissions during the initial postoperative year in vascular surgery patients. We set out to describe the associations between demographics, clinical outcomes, comorbidity indices, and hospital readmissions in a sample of patients undergoing common extremity revascularization or dialysis access (ERDA) procedures. We hypothesized that factors independently associated with readmission will evolve from “short-term” to “long-term” determinants at 30-, 180-, and 360-day postoperative cutoff points. Methods: Following IRB approval, medical records of patients who underwent ERDA at two institutions were retrospectively reviewed between 2008 and 2014. Abstracted data included patient demographics, procedural characteristics, the American Society of Anesthesiologists score, Goldman Criteria for perioperative cardiac assessment, the Charlson comorbidity index, morbidity, mortality, and readmission (at 30-, 180-, and 360-days). Univariate analyses were performed for readmissions at each specified time point. Variables reaching statistical significance of P < 0.20 were included in multivariate analyses for factors independently associated with readmission. Results: A total of 450 of 744 patients who underwent ERDA with complete medical records were included. Patients underwent either an extremity revascularization (e.g. bypass or endarterectomy, 406/450) or a noncatheter dialysis access procedure (44/450). Sample characteristics included 262 (58.2%) females, mean age 61.4 ± 12.9 years, 63 (14%) emergent procedures, and median operative time 164 min. Median hospital length of stay (index admission) was 4 days. Cumulative readmission rates at 30-, 180-, and 360-day were 12%, 27%, and 35%, respectively. Corresponding mortality rates were 3%, 7%, and 9%. Key factors independently associated with 30-, 180-, and 360-day readmissions evolved over the study period from comorbidity and morbidity-related issues in the short-term to cardiovascular and graft patency issues in the long-term. Any earlier readmission elevated the risk of subsequent readmission. Conclusions: We noted important patterns in the temporal behavior of hospital readmission risk in patients undergoing ERDA. Although factors independently associated with readmission were not surprising (e.g. comorbidity profile, cardiovascular status, and graft patency), the knowledge of temporal trends described in this study may help determine clinical risk profiles for individual patients and guide readmission reduction strategies. These considerations will be increasingly important in the evolving paradigm of value-based healthcare.
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Affiliation(s)
- M J Lin
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - F Baky
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - B C Housley
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - N Kelly
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - E Pletcher
- Temple University School of Medicine - St. Luke's University Hospital Campus, Bethlehem, PA, USA
| | - J D Balshi
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - S P Stawicki
- Department of Surgery; Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
| | - D C Evans
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
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Not All Patients with Critical Limb Ischaemia Require Revascularisation. Eur J Vasc Endovasc Surg 2016; 53:371-379. [PMID: 27919605 DOI: 10.1016/j.ejvs.2016.10.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 10/22/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVES International guidelines recommend revascularisation as the preferred treatment for patients with critical limb ischaemia (CLI). Most contemporary research focuses on the outcome of invasive procedures for CLI, but little is known about the outcome of conservative management. Amputation free survival (AFS) and overall survival (OS) was investigated in patients with CLI who did or did not receive revascularisation, and characteristics associated with clinical outcomes were explored. METHODS This was a retrospective cohort study of consecutive patients with chronic CLI between 2010 and 2014 in a Dutch university hospital. CLI was defined as the presence of ischaemic rest pain or tissue loss in conjunction with an absolute systolic ankle pressure < 50 mmHg or a toe pressure < 30 mmHg. Patients were divided into invasive (revascularisation within 6 weeks), deferred invasive (revascularisation after 6 weeks), or permanently conservative treatment groups. Univariable and multivariable survival analyses were used to identify factors associated with AFS and OS. RESULTS The majority (66.7%; N = 96) of the identified 144 patients with CLI (mean age 71.2 years; median follow-up 99 weeks) underwent revascularisation within 6 weeks of diagnosis. Deferred invasive treatment was provided in 18.1% (N = 26) patients and 22 patients (15.3%) were treated permanently conservatively. AFS and OS did not differ significantly between the three groups (Breslow-Wilcoxon p = .16 for AFS and p = .09 for OS). Age, chronic obstructive pulmonary disease (COPD), and heart disease were significant independent predictors of AFS. Age, COPD, and hypertension were significant independent predictors of OS. Treatment was not a significant predictor of either AFS or OS. CONCLUSIONS Not all patients with CLI require revascularisation to achieve an AFS that is similar to patients undergoing revascularisation, although the efficacy of conservative versus invasive treatment in CLI patients is still unclear. Further prospective studies should determine subgroups of patients in whom revascularisation may be omitted.
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Wu R, Tang S, Wang M, Li Z, Yao C, Wang S. Drug-eluting balloon versus standard percutaneous transluminal angioplasty in infrapopliteal arterial disease: A meta-analysis of randomized trials. Int J Surg 2016; 35:88-94. [DOI: 10.1016/j.ijsu.2016.09.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 07/07/2016] [Accepted: 09/11/2016] [Indexed: 11/29/2022]
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Reporting standards of the Society for Vascular Surgery for endovascular treatment of chronic lower extremity peripheral artery disease. J Vasc Surg 2016; 64:e1-e21. [DOI: 10.1016/j.jvs.2016.03.420] [Citation(s) in RCA: 204] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 03/12/2016] [Indexed: 12/13/2022]
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Costa LDO, Souza DÚF, Fonseca WM, Gonçalves BCC, Gomes GB, Cruz LARD, Reis Júnior NNA, Leite JOM. Evidências para o uso da avaliação nutricional subjetiva global nos pacientes com doença arterial periférica. J Vasc Bras 2016. [DOI: 10.1590/1677-5449.001215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo A desnutrição é uma doença extremamente prevalente em pacientes internados, chegando a acometer 50% deles, 47% dos pacientes cirúrgicos e entre 39 e 73% dos portadores de doença arterial periférica, com grande impacto na morbimortalidade desses pacientes. A desnutrição possui grande relevância no desfecho clínico desses pacientes durante a internação, estando associada a maior incidência de infecções, demora na cicatrização das feridas, diminuição do status de deambulação, maior tempo de internação e mortalidade. Entretanto, o diagnóstico de desnutrição ou risco nutricional desses pacientes tem sido um desafio. A avaliação nutricional subjetiva global revelou-se, até o momento, o padrão ouro como método de triagem de pacientes cirúrgicos internados devido à sua praticidade e acurácia. O objetivo deste trabalho é revisar métodos utilizados na avaliação do estado nutricional e da triagem nutricional de pacientes internados e caracterizar a importância dessa avaliação nos desfechos clínicos dos pacientes com arteriopatias.
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20
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Tsai TT, Rehring TF, Rogers RK, Shetterly SM, Wagner NM, Gupta R, Jazaeri O, Hedayati N, Jones WS, Patel MR, Ho PM, Go AS, Magid DJ. The Contemporary Safety and Effectiveness of Lower Extremity Bypass Surgery and Peripheral Endovascular Interventions in the Treatment of Symptomatic Peripheral Arterial Disease. Circulation 2015; 132:1999-2011. [PMID: 26362632 PMCID: PMC4652630 DOI: 10.1161/circulationaha.114.013440] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 09/08/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Treatment for symptomatic peripheral artery disease includes lower extremity bypass surgery (LEB) and peripheral endovascular interventions (PVIs); however, limited comparative effectiveness data exist between the 2 therapies. We assessed the safety and effectiveness of LEB and PVI in patients with symptomatic claudication and critical limb ischemia. METHODS AND RESULTS In a community-based clinical registry at 2 large integrated healthcare delivery systems, we compared 883 patients undergoing PVI and 975 patients undergoing LEB between January 1, 2005 and December 31, 2011. Rates of target lesion revascularization were greater for PVI than for LEB in patients presenting with claudication (12.3±2.7% and 19.0±3.5% at 1 and 3 years versus 5.2±2.4% and 8.3±3.1%, log-rank P<0.001) and critical limb ischemia (19.1±4.8% and 31.6±6.3% at 1 and 3 years versus 10.8±2.5% and 16.0±3.2%, log-rank P<0.001). However, in comparison with PVI, LEB was associated with increased rates of complications up to 30 days following the procedure (37.1% versus 11.9%, P<0.001). There were no differences in amputation rates between the 2 groups. Findings remained consistent in sensitivity analyses by using propensity methods to account for treatment selection. CONCLUSIONS In patients with symptomatic peripheral artery disease, in comparison with LEB, PVI was associated with fewer 30-day procedural complications, higher revascularization rates at 1 and 3 years, and no difference in subsequent amputations.
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Affiliation(s)
- Thomas T Tsai
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.).
| | - Thomas F Rehring
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - R Kevin Rogers
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - Susan M Shetterly
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - Nicole M Wagner
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - Rajan Gupta
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - Omid Jazaeri
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - Nasim Hedayati
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - W Schuyler Jones
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - Manesh R Patel
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - P Michael Ho
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - Alan S Go
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
| | - David J Magid
- From Institute for Health Research, Kaiser Permanente Colorado, Denver (T.T.T., T.F.R., S.M.S., N.M.W., P.M.H., D.J.M.); University of Colorado, Denver (T.T.T., T.F.R., R.K.R., R.G., O.J., P.M.H., D.J.M.); UC Davis Health System, Davis, CA (N.H.); Duke Clinical Research Institute, Durham, NC (W.S.J., M.R.P.); Denver VA Medical Center, Denver, CO (P.M.H.); and Division of Research, Kaiser Permanente Northern California, Oakland (A.S.G.)
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Kordzadeh A, Askari A, Panayiotopoulos YP. Validation of the Guy's scoring system in patient selection for femoro-distal bypass grafting to a single calf or pedal artery. Vascular 2015; 24:295-303. [PMID: 26088618 DOI: 10.1177/1708538115591929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES First external validation of a preoperative scoring system (Guy's) in patient selection for femoro-distal bypass grafting to single calf or pedal artery in critical limb ischemia (Fontaine III & IV/Rutherford grade IV, V & VI). MATERIAL AND METHODS A prospective study of 76 (n = 76) consecutive femoro-crural/pedal bypass grafts on 72 individuals (n = 72) from 2008 to 2011 with 36 months mean follow-up was performed. All cases were scored against a previously designed and published scoring system (ranging from 0 to 10) based on: inflow, outflow, graft material, flow type, patent pedal vessels and diabetes mellitus. RESULTS Preoperative score of 0-4 (n = 37) demonstrated the primary patency of 27% at 10.3 months. This value for intermediate group 5-7 (n = 34) was 70.6% at 18.9 months. The high-score group 8-10 (n = 4) showed the longest primary patency (80%) at 27.3 months. Kaplan-Meier survival analysis exhibited a consistent and significant difference in primary assisted, secondary patency and overall limb/foot salvage amongst all individual scoring groups (p < 0.001). CONCLUSION This study validates and complements the Guy's scoring system and provides a platform for the identification of critical limb ischemia patients in whom the result of femoro-crural/distal bypass grafting is so poor that primary amputation may be both clinically and economically more justified.
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Affiliation(s)
- Ali Kordzadeh
- Department of Vascular and Endovascular Surgery, Mid Essex Hospital Services NHS Trust, Broomfield Hospital, Essex, UK
| | - Alan Askari
- Department of Vascular and Endovascular Surgery, Mid Essex Hospital Services NHS Trust, Broomfield Hospital, Essex, UK
| | - Yiannis P Panayiotopoulos
- Department of Vascular and Endovascular Surgery, Mid Essex Hospital Services NHS Trust, Broomfield Hospital, Essex, UK
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Suckow BD, Goodney PP, Nolan BW, Veeraswamy RK, Gallagher P, Cronenwett JL, Kraiss LW. Domains that Determine Quality of Life in Vascular Amputees. Ann Vasc Surg 2015; 29:722-30. [PMID: 25725279 DOI: 10.1016/j.avsg.2014.12.005] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 12/08/2014] [Accepted: 12/17/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although patients with critical limb ischemia (CLI) commonly undergo major limb amputation, the quality of life (QOL) of this group remains poorly described. Therefore, we sought to describe which domains vascular amputees consider important in determining their health-related QOL. METHODS We performed 4 focus groups in patients who had major lower extremity amputations resulting from CLI. They were conducted at 4 distinct centers across the United States to ensure broad geographic, socioeconomic, and ethnic representation. RESULTS Of 26 patients (mean age, 64 years), 19 (73%) were Caucasian, 6 (23%) were African American, and 1 (4%) was Native American. Nearly, three-quarter of patients were men (n = 19, 73%) and had a high-school education or more (n = 19, 73%). Overall, 8 (31%) were double amputees and 17 (65%) had diabetes. Time since amputation varied across patients and ranged from 3 months to more than 27 years (mean, 4.3 years). Patients stated that their current QOL was determined by impaired mobility (65%), pain (60%), progression of disease in the remaining limb (55%), and depression/frustration (54%). Across 26 patients, more than half (n = 16, 62%) described multiple prior revascularization procedures. Although most felt that their physician did his/her best to salvage the affected leg (85%), a sizable minority would have preferred an amputation earlier in their CLI treatment course (27%). Furthermore, when asked how their care might have been improved, patients reported that facilitating peer support (88%), more extensive rehabilitation and prosthetist involvement (71%), earlier mention of amputation as a possible outcome (54%), and the early discontinuation of narcotics (54%) were potential areas of improvement. CONCLUSIONS Although QOL in vascular amputees seems primarily determined by mobility impairment, pain, and emotional perturbation, our focus groups identified that physician-controlled factors such as the timing of amputation, informed decision making, and postamputation support may also play an important role. The assessment of patient preferences regarding maintenance of mobility at the cost of increased pain versus relief of pain with amputation at a cost of diminished mobility is central to shared decision making in CLI treatment.
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Affiliation(s)
- Bjoern D Suckow
- Division of Vascular Surgery, University of Utah School of Medicine, Salt Lake City, UT.
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth Medical School, Hanover, NH
| | - Brian W Nolan
- Section of Vascular Surgery, Dartmouth Medical School, Hanover, NH
| | - Ravi K Veeraswamy
- Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | | | | | - Larry W Kraiss
- Division of Vascular Surgery, University of Utah School of Medicine, Salt Lake City, UT
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Hussey K, Chandramohan S. Contemporary treatment for critical ischemia: the evidence for interventional radiology or surgery. Semin Intervent Radiol 2014; 31:300-6. [PMID: 25435654 DOI: 10.1055/s-0034-1393965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This article is a review of the evidence regarding the management of patients with critical limb ischemia. The aim of the study is to discuss the definition, incidence, and clinical importance of critical limb ischemia, as well as the aims of treatment in terms of quality of life and limb salvage. Endovascular and surgical treatments should not be viewed as competing therapies. In fact, these are complementary techniques each with strengths and weaknesses. The authors will propose a strategy based on the available evidence for deciding the optimal approach to management of patients with critical limb ischemia.
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Affiliation(s)
- Keith Hussey
- Department of Vascular Surgery, Western Infirmary of Glasgow, Glasgow, Scotland, United Kingdom
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Percutaneous transluminal angioplasty versus primary stenting in infrapopliteal arterial disease: a meta-analysis of randomized trials. J Vasc Surg 2014; 59:1711-20. [PMID: 24836770 DOI: 10.1016/j.jvs.2014.03.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 03/09/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND Percutaneous transluminal angioplasty (PTA) and primary stenting are commonly used endovascular therapeutic procedures for the treatment of infrapopliteal arterial occlusive disease. However, which procedure is more beneficial for patients with infrapopliteal arterial occlusive disease is unknown. METHODS AND RESULTS We performed a meta-analysis, searching PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, ISI Web of Knowledge, and relevant websites without language or publication date restrictions for randomized trials that compared primary stenting with PTA in patients with infrapopliteal arterial occlusive disease. The keywords were "stents," "angioplasty," "infrapopliteal," "tibial arteries," and "below knee." We selected immediate technical success, primary and secondary patency, limb salvage, and patient survival as the outcomes of this meta-analysis. On the basis of the inclusion criteria, we identified six prospective randomized trials. One-year outcomes did not show any significant differences between the PTA and primary stenting groups, respectively: technical success (93.3% vs 96.2%; odds ratio [OR], 0.59; 95% confidence interval [CI], 0.24-1.47; P = .25), primary patency (57.1% vs 65.7%; OR, 0.95; 95% CI, 0.35-2.58; P = .92), secondary patency (73.5% vs 57.6%; OR, 2.08; 95% CI, 0.81-5.34; P = .13), limb salvage (82.2% vs 87.5%; OR, 0.64; 95% CI, 0.29-1.41; P = .27), and patient survival (84.0% vs 87.5%; OR, 0.79; 95% CI, 0.40-1.55; P = .49). CONCLUSIONS For infrapopliteal arterial occlusive disease, primary stenting has the same 1-year benefits as PTA. There is insufficient evidence to support the superiority of either method. Primary stenting is associated with a trend toward higher primary patency and lower secondary patency. Further large-scale prospective randomized trials should produce more reliable results.
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Landry GJ, Esmonde NO, Lewis JR, Azarbal AF, Liem TK, Mitchell EL, Moneta GL. Objective measurement of lower extremity function and quality of life after surgical revascularization for critical lower extremity ischemia. J Vasc Surg 2014; 60:136-42. [PMID: 24613190 PMCID: PMC8022890 DOI: 10.1016/j.jvs.2014.01.067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 01/29/2014] [Accepted: 01/29/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Outcomes of revascularization for critical limb ischemia (CLI) have historically been patency, limb salvage, and survival. Functional status and quality of life have not been well described. This study used functional and quality of life assessments to measure patient-centered outcomes after revascularization for CLI. METHODS The study observed 18 patients (age, 65 ± 11 years) prospectively before and after lower extremity bypass for CLI. Patients completed the Short Physical Performance Battery, which measures walking speed, leg strength, and balance, as well as performed a 6-minute walk, and calorie expenditure was measured by an accelerometer. Isometric muscle strength was assessed with the Muscle Function Evaluation chair (Metitur, Helsinki, Finland). Quality of life instruments included the 36-Item Short Form Health Survey and the Vascular Quality of Life questionnaire. Patients' preoperative status was compared with 4-month postoperative status. RESULTS Muscle Function Evaluation chair measurements of ipsilateral leg strength demonstrated a significant increase in knee flexion from 64 ± 62 N to 135 ± 133 N (P = .038) and nearly significant increase in knee extension from 120 ± 110 N to 186 ± 85 N (P = .062) and ankle plantar flexion from 178 ± 126 N to 267 ± 252 N (P = .078). In the contralateral leg, knee flexion increased from 71 ± 96 N to 149 ± 162 N (P = .028) and knee extension from 162 ± 112 N to 239 ± 158 N (P = .036). Absolute improvements were noted in 6-minute walk distance, daily calorie expenditure, and individual domains and overall Short Physical Performance Battery scores, and upper extremity strength decreased, although none were significant. The Vascular Quality of Life questionnaire captured significant improvement in all individual domains and overall score (P < .015). Significant improvement was noted only for bodily pain (P = .011) on the 36-Item Short Form Health Survey. CONCLUSIONS Despite lack of statistical improvement in most functional test results, revascularization for CLI results in improved patient-perceived leg function. Significant improvements in isometric muscle strength may explain the measured improvement in quality of life after revascularization for CLI.
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Affiliation(s)
- Gregory J Landry
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore.
| | - Nick O Esmonde
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Jason R Lewis
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Amir F Azarbal
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Timothy K Liem
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Erica L Mitchell
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Gregory L Moneta
- Division of Vascular Surgery, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
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Karakoyun R, Köksoy C, Şener Z, Gündüz U, Karakaş B, Karakoyun M. Comparison of quality of life in patients with peripheral arterial disease caused by atherosclerosis obliterans or Buerger's disease. Cardiovasc J Afr 2014; 25:124-9. [PMID: 25000442 PMCID: PMC4120127 DOI: 10.5830/cvja-2014-017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 04/01/2014] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Buerger's disease and atherosclerosis obliterans (ASO) are two peripheral arterial diseases (PAD) that are frequently encountered. The aim of this study was to compare quality of life (QOL) in patients with Buerger's disease and ASO. METHODS We prospectively followed 86 patients who were admitted to our hospital due to ASO or Buerger's disease. Their ischaemia was evaluated according to the clinical category chronic limb ischaemia at the time of hospital admission and at six and 12 months. The QOL was measured at the time of hospital admission and at six and 12 months with the Short Form Health Status Survey (SF-36) and Vascular Quality of Life Questionnaire (VASCUQOL). RESULTS A total of 86 patients with ASO or Buerger's disease (47 and 39, respectively) were included in the study. Pain parameters from both SF-36 and VASCUQOL scores were lower in patients with Buerger's disease at the time of hospital admission and at six months. The impairment in QOL was found to be proportional to the extent of chronic limb ischaemia. Conversely, when patients with critical limb ischaemia were evaluated, no difference was observed between those with ASO or Buerger's disease in terms of QOL. Amputations were found to have a negative effect on quality of life. CONCLUSION Buerger's disease had a more pronounced negative effect on QOL than ASO, particularly in terms of pain score. When critical limb ischaemia was considered, ASO and Buerger's disease impaired quality of life at the same rate.
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Affiliation(s)
- Rojbin Karakoyun
- Division of Vascular Surgery, Department of General Surgery, Faculty of Medicine, Ankara University, Ankara, Turkey.
| | - Cüneyt Köksoy
- Division of Vascular Surgery, Department of General Surgery, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Zeynep Şener
- Division of Vascular Surgery, Department of General Surgery, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Umut Gündüz
- Department of Surgery, Antalya Training and Research Hospital, Antalya, Turkey
| | - Baris Karakaş
- Department of Surgery, Antalya Training and Research Hospital, Antalya, Turkey
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Statistical or Clinical Improvement? Determining the Minimally Important Difference for the Vascular Quality of Life Questionnaire in Patients with Critical Limb Ischemia. Eur J Vasc Endovasc Surg 2014; 47:180-6. [DOI: 10.1016/j.ejvs.2013.10.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 10/08/2013] [Indexed: 11/23/2022]
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Keo HH, Duval S, Baumgartner I, Oldenburg NC, Jaff MR, Goldman J, Peacock JM, Tretinyak AS, Henry TD, Luepker RV, Hirsch AT. The FReedom from Ischemic Events-New Dimensions for Survival (FRIENDS) registry: design of a prospective cohort study of patients with advanced peripheral artery disease. BMC Cardiovasc Disord 2013; 13:120. [PMID: 24354507 PMCID: PMC3878262 DOI: 10.1186/1471-2261-13-120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 12/02/2013] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Advanced lower extremity peripheral artery disease (PAD), whether presenting as acute limb ischemia (ALI) or chronic critical limb ischemia (CLI), is associated with high rates of cardiovascular ischemic events, amputation, and death. Past research has focused on strategies of revascularization, but few data are available that prospectively evaluate the impact of key process of care factors (spanning pre-admission, acute hospitalization, and post-discharge) that might contribute to improving short and long-term health outcomes. METHODS/DESIGN The FRIENDS registry is designed to prospectively evaluate a range of patient and health system care delivery factors that might serve as future targets for efforts to improve limb and systemic outcomes for patients with ALI or CLI. This hypothesis-driven registry was designed to evaluate the contributions of: (i) pre-hospital limb ischemia symptom duration, (ii) use of leg revascularization strategies, and (iii) use of risk-reduction pharmacotherapies, as pre-specified factors that may affect amputation-free survival. Sequential patients would be included at an index "vascular specialist-defined" ALI or CLI episode, and patients excluded only for non-vascular etiologies of limb threat. Data including baseline demographics, functional status, co-morbidities, pre-hospital time segments, and use of medical therapies; hospital-based use of revascularization strategies, time segments, and pharmacotherapies; and rates of systemic ischemic events (e.g., myocardial infarction, stroke, hospitalization, and death) and limb ischemic events (e.g., hospitalization for revascularization or amputation) will be recorded during a minimum of one year follow-up. DISCUSSION The FRIENDS registry is designed to evaluate the potential impact of key factors that may contribute to adverse outcomes for patients with ALI or CLI. Definition of new "health system-based" therapeutic targets could then become the focus of future interventional clinical trials for individuals with advanced PAD.
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Affiliation(s)
- Hong H Keo
- Division of Angiology, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Sue Duval
- Vascular Medicine Program, Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Iris Baumgartner
- Swiss Cardiovascular Center, Division of Angiology, University Hospital Bern, Bern, Switzerland
| | - Niki C Oldenburg
- Vascular Medicine Program, Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Michael R Jaff
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - JoAnne Goldman
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - James M Peacock
- Minnesota Department of Health, Heart Disease and Stroke Prevention Unit, Saint Paul, MN, USA
| | - Alexander S Tretinyak
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Timothy D Henry
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Russell V Luepker
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Alan T Hirsch
- Vascular Medicine Program, Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, USA
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Changes in functional status after treatment of critical limb ischemia. J Vasc Surg 2013; 58:957-65.e1. [PMID: 24075105 DOI: 10.1016/j.jvs.2013.04.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/08/2013] [Accepted: 04/11/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study evaluated changes in functional status with the Academic Medical Center Linear Disability Score (ALDS) and in quality of life with the Vascular Quality of Life Questionnaire (VascuQol) in patients treated for critical limb ischemia (CLI). METHODS We conducted a prospective observational cohort study in a single academic center that included consecutive patients with CLI who presented between May 2007 and May 2010. The ALDS and VascuQol questionnaires were administered before treatment (baseline) and after treatment at 6 and 12 months of follow-up. Changes in functional status (ALDS) and quality of life (VascuQol) scores after 6 and 12 months, compared with baseline, were tested with the appropriate statistical tests, with significance set at P < .05. RESULTS The study included 150 patients, 96 (64%) were men, and mean (± standard deviation) age was 68.1 (± 12.4) years. The primary treatment was endovascular in 98 (65.3%), surgical in 36 (24%), conservative in 11 (7.3%), or a major amputation in five (3.3%). The ALDS was completed by 112 patients after 12 months. At that time, the median ALDS score had increased by 10 points (median, 83; range, 12-89; P = .001) in patients who achieved limb salvage, which corresponds with more difficult outdoor and indoor activities. In patients with a major amputation, the median ALDS score decreased by 14 points (median, 55; range, 16-89; P = .117) after 12 months, which corresponds with domestic activities only. VascuQol scores improved significantly in all separate domains for the limb salvage group (P < .001). All VascuQol scores, except for the activity and social domains, increased significantly after amputation. CONCLUSIONS Our study confirms the clinical validity of the ALDS in patients treated for CLI and shows that it is a valuable and sophisticated instrument to measure changes in functional status in these patients.
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Mills JL, Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN, Andros G. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg 2013; 59:220-34.e1-2. [PMID: 24126108 DOI: 10.1016/j.jvs.2013.08.003] [Citation(s) in RCA: 980] [Impact Index Per Article: 89.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 08/09/2013] [Accepted: 08/13/2013] [Indexed: 02/08/2023]
Abstract
Critical limb ischemia, first defined in 1982, was intended to delineate a subgroup of patients with a threatened lower extremity primarily because of chronic ischemia. It was the intent of the original authors that patients with diabetes be excluded or analyzed separately. The Fontaine and Rutherford Systems have been used to classify risk of amputation and likelihood of benefit from revascularization by subcategorizing patients into two groups: ischemic rest pain and tissue loss. Due to demographic shifts over the last 40 years, especially a dramatic rise in the incidence of diabetes mellitus and rapidly expanding techniques of revascularization, it has become increasingly difficult to perform meaningful outcomes analysis for patients with threatened limbs using these existing classification systems. Particularly in patients with diabetes, limb threat is part of a broad disease spectrum. Perfusion is only one determinant of outcome; wound extent and the presence and severity of infection also greatly impact the threat to a limb. Therefore, the Society for Vascular Surgery Lower Extremity Guidelines Committee undertook the task of creating a new classification of the threatened lower extremity that reflects these important considerations. We term this new framework, the Society for Vascular Surgery Lower Extremity Threatened Limb Classification System. Risk stratification is based on three major factors that impact amputation risk and clinical management: Wound, Ischemia, and foot Infection (WIfI). The implementation of this classification system is intended to permit more meaningful analysis of outcomes for various forms of therapy in this challenging, but heterogeneous population.
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Affiliation(s)
- Joseph L Mills
- Division of Vascular and Endovascular Surgery, Southern Arizona Limb Salvage Alliance, University of Arizona Health Sciences Center, Tucson, Ariz.
| | - Michael S Conte
- University of California San Francisco, San Francisco, Calif
| | - David G Armstrong
- Division of Vascular and Endovascular Surgery, Southern Arizona Limb Salvage Alliance, University of Arizona Health Sciences Center, Tucson, Ariz
| | | | | | - Anton N Sidawy
- George Washington University School of Medicine and Health Sciences, Washington, D.C
| | - George Andros
- Amputation Prevention Center, Valley Presbyterian Medical Center, Van Nuys, Calif
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Hawkins AT, Henry AJ, Crandell DM, Nguyen LL. A systematic review of functional and quality of life assessment after major lower extremity amputation. Ann Vasc Surg 2013; 28:763-80. [PMID: 24495325 DOI: 10.1016/j.avsg.2013.07.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 07/17/2013] [Accepted: 07/18/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND When judging the success or failure of major lower extremity (MLE) amputation, the assessment of appropriate functional and quality of life (QOL) outcomes is paramount. The heterogeneity of the scales and tests in the current literature is confusing and makes it difficult to compare results. We provide a primer for outcome assessment after amputation and assess the need for the additional development of novel instruments. METHODS MEDLINE, EMBASE, and Google Scholar were searched for all studies using functional and QOL instruments after MLE amputation. Assessment instruments were divided into functional and QOL categories. Within each category, they were subdivided into global and amputation-specific instruments. An overall assessment of instrument quality was obtained. RESULTS The initial search revealed 746 potential studies. After a review of abstracts, 102 were selected for full review, and 40 studies were then included in this review. From the studies, 21 different assessment instruments were used 63 times. There were 14 (67%) functional measures and 7 (33%) QOL measures identified. Five (36%) of the functional instruments and 3 (43%) of the QOL measures were specific for MLE amputees. Sixteen instruments were used >1 time, but only 5 instruments were used >3 times. An additional 5 instruments were included that were deemed important by expert opinion. The 26 assessment instruments were rated. Fourteen of the best-rated instruments were then described. CONCLUSIONS The heterogeneity of instruments used to measure both functional and QOL outcomes make it difficult to compare MLE amputation outcome studies. Future researchers should seek to use high-quality instruments. Clinical and research societies should endorse the best validated instruments for future use in order to strengthen overall research in the field.
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Affiliation(s)
- Alexander T Hawkins
- Center for Surgery and Public Health, Boston, Massachusetts; Brigham & Women's Hospital, Boston, Massachusetts; Massachusetts General Hospital, Boston, Massachusetts
| | | | - David M Crandell
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Louis L Nguyen
- Center for Surgery and Public Health, Boston, Massachusetts; Brigham & Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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Todd KE, Ahanchi SS, Maurer CA, Kim JH, Chipman CR, Panneton JM. Atherectomy offers no benefits over balloon angioplasty in tibial interventions for critical limb ischemia. J Vasc Surg 2013; 58:941-8. [PMID: 23755978 DOI: 10.1016/j.jvs.2013.04.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 04/07/2013] [Accepted: 04/10/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Endovascular adjuncts, like atherectomy, were developed to improve outcomes of endovascular arterial interventions. The true impact of atherectomy on endovascular outcomes remains to be determined, and little data exist on the influence of atherectomy on tibial interventions. Our study compares early and late outcomes of tibial intervention with angioplasty vs atherectomy-assisted interventions. METHODS We completed a retrospective review of all tibial interventions between 2008 and 2010. Outcomes were analyzed using single and multivariate analysis, Cox regression, and Kaplan-Meier curves. Primary outcomes were primary, primary assisted, and secondary patency rates, as well as limb salvage and survival rates. RESULTS Over a 2-year period, 480 tibial interventions were completed for 421 patients. Eighty-seven percent (n = 418) of interventions were performed for critical limb ischemia (CLI) and 13% (n = 62) for claudication. The CLI cohort of 418 interventions was analyzed. These patients had a mean age of 71 years with a mean follow-up time of 16 ± 15 months (range, 0-59 months). Of the 418 interventions, 339 underwent percutaneous transluminal angioplasty (PTA): 333 PTA alone, six PTA + stent. The remaining 79 interventions received atherectomy: 33 laser, 13 directional, and 33 orbital either alone or in conjunction with PTA (11 atherectomy only, 68 atherectomy + PTA). The groups did not differ significantly in terms of demographics, risk factors, or technical success. The atherectomy group had more TASC B lesions (54% vs 38%; P = .013), while the PTA-alone group had more TASC D lesions (25% vs 13%; P = .004). TASC A and C lesions did not differ significantly between the groups. No significant differences existed with respect to the early (30-day) outcomes of loss of patency (11% vs 13%; P = .699), complications (8% vs 13%; P = .292), or major amputation (17% vs 13%; P = .344) in the PTA-alone group vs the atherectomy-assisted group. Kaplan-Meier analysis revealed no difference for all primary outcomes of PTA alone vs the atherectomy-assisted group at 12 and 36 months: primary patency (69%, 55% vs 61%, 46%; P = .158), primary assisted patency (83%, 71% vs 85%, 67%; P = .801), secondary patency (94%, 89% vs 95%, 89%; P = .892), limb salvage (79%, 70% vs 81%, 77%; P = .485), or survival (77%, 56% vs 80%, 50%; P = .944). CONCLUSIONS The adjunctive use of atherectomy offered no improvement in primary outcomes over PTA alone in either early or late outcomes in CLI patients who underwent endovascular tibial interventions. Considering the additional cost and increased procedural time, these findings put into question the routine use of adjunctive atherectomy.
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Affiliation(s)
- Kevin E Todd
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va
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Failure of Surgical and Endovascular Infrainguinal and Iliac Procedures in the Management of Peripheral Arterial Disease Using Data from Electronic Medical Records. J Vasc Interv Radiol 2013; 24:378-91, 391.e1-3. [DOI: 10.1016/j.jvir.2012.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 11/19/2012] [Accepted: 11/20/2012] [Indexed: 11/18/2022] Open
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Morgenroth DC, Czerniecki JM. The complexities surrounding decisions related to prosthetic fitting in elderly dysvascular amputees. PM R 2012; 4:540-2. [PMID: 22814735 DOI: 10.1016/j.pmrj.2012.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 05/15/2012] [Indexed: 10/28/2022]
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Setacci C, Sirignano P, Setacci F. Commentary: The ENABLER-P Balloon Catheter System: a new and exciting tool for recanalization of femoropopliteal CTOs. J Endovasc Ther 2012; 19:140-3. [PMID: 22545875 DOI: 10.1583/11-3664c.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Carlo Setacci
- Vascular and Endovascular Surgery Unit, Department of Surgery, University of Siena, Siena, Italy.
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Chisci E, Perulli A, Iacoponi F, Setacci F, de Donato G, Palasciano G, Cappelli A, Setacci C. Benefit of Revascularisation to Critical Limb Ischaemia Patients Evaluated by a Patient-oriented Scoring System. Eur J Vasc Endovasc Surg 2012; 43:540-7. [DOI: 10.1016/j.ejvs.2012.01.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 01/25/2012] [Indexed: 11/30/2022]
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Suckow BD, Goodney PP, Cambria RA, Bertges DJ, Eldrup-Jorgensen J, Indes JE, Schanzer A, Stone DH, Kraiss LW, Cronenwett JL. Predicting functional status following amputation after lower extremity bypass. Ann Vasc Surg 2012; 26:67-78. [PMID: 22176876 PMCID: PMC3339378 DOI: 10.1016/j.avsg.2011.07.014] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 07/15/2011] [Accepted: 07/23/2011] [Indexed: 11/22/2022]
Abstract
BACKGROUND Some patients who undergo lower extremity bypass (LEB) for critical limb ischemia ultimately require amputation. The functional outcome achieved by these patients after amputation is not well known. Therefore, we sought to characterize the functional outcome of patients who undergo amputation after LEB, and to describe the pre- and perioperative factors associated with independent ambulation at home after lower extremity amputation. METHODS Within a cohort of 3,198 patients who underwent an LEB between January, 2003 and December, 2008, we studied 436 patients who subsequently received an above-knee (AK), below-knee (BK), or minor (forefoot or toe) ipsilateral or contralateral amputation. Our main outcome measure consisted of a "good functional outcome," defined as living at home and ambulating independently. We calculated univariate and multivariate associations among patient characteristics and our main outcome measure, as well as overall survival. RESULTS Of the 436 patients who underwent amputation within the first year following LEB, 224 of 436 (51.4%) had a minor amputation, 105 of 436 (24.1%) had a BK amputation, and 107 of 436 (24.5%) had an AK amputation. The majority of AK (75 of 107, 72.8%) and BK amputations (72 of 105, 70.6%) occurred in the setting of bypass graft thrombosis, whereas nearly all minor amputations (200 of 224, 89.7%) occurred with a patent bypass graft. By life-table analysis at 1 year, we found that the proportion of surviving patients with a good functional outcome varied by the presence and extent of amputation (proportion surviving with good functional outcome = 88% no amputation, 81% minor amputation, 55% BK amputation, and 45% AK amputation, p = 0.001). Among those analyzed at long-term follow-up, survival was slightly lower for those who had a minor amputation when compared with those who did not receive an amputation after LEB (81 vs. 88%, p = 0.02). Survival among major amputation patients did not significantly differ compared with no amputation (BK amputation 87%, p = 0.14, AK amputation 89%, p = 0.27); however, this part of the analysis was limited by its sample size (n = 212). In multivariable analysis, we found that the patients most likely to remain ambulatory and live independently despite undergoing a lower extremity amputation were those living at home preoperatively (hazard ratio [HR]: 6.8, 95% confidence interval [CI]: 0.94-49, p = 0.058) and those with preoperative statin use (HR: 1.6, 95% CI: 1.2-2.1, p = 0.003), whereas the presence of several comorbidities identified patients less likely to achieve a good functional outcome: coronary disease (HR: 0.6, 95% CI: 0.5-0.9, p = 0.003), dialysis (HR: 0.5, 95% CI: 0.3-0.9, p = 0.02), and congestive heart failure (HR: 0.5, 95% CI: 0.3-0.8, p = 0.005). CONCLUSIONS A postoperative amputation at any level impacts functional outcomes following LEB surgery, and the extent of amputation is directly related to the effect on functional outcome. It is possible, based on preoperative patient characteristics, to identify patients undergoing LEB who are most or least likely to achieve good functional outcomes even if a major amputation is ultimately required. These findings may assist in patient education and surgical decision making in patients who are poor candidates for lower extremity bypass.
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Affiliation(s)
- Bjoern D Suckow
- Division of Vascular Surgery, University of Utah Hospital, University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
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Setacci C, Sirignano P. Commentary. Subintimal angioplasty of femoropopliteal artery occlusions: the long-term results. Eur J Vasc Endovasc Surg 2011; 42 Suppl 1:S16-8. [PMID: 21855013 DOI: 10.1016/j.ejvs.2011.06.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- C Setacci
- Department of Vascular and Endovascular Surgery, University of Sienna, Viale Bracci 1, Siena, Italy
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Frans FA, Bipat S, Reekers JA, Legemate DA, Koelemay MJW. Systematic review of exercise training or percutaneous transluminal angioplasty for intermittent claudication. Br J Surg 2011; 99:16-28. [DOI: 10.1002/bjs.7656] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2011] [Indexed: 11/08/2022]
Abstract
Abstract
Background
The aim was to summarize the results of all randomized clinical trials (RCTs) comparing percutaneous transluminal angioplasty (PTA) with (supervised) exercise therapy ((S)ET) in patients with intermittent claudication (IC) to obtain the best estimates of their relative effectiveness.
Methods
A systematic review was performed of relevant RCTs identified from the MEDLINE, Embase and Cochrane Library databases. Eligible RCTs compared PTA with (S)ET, included patients with IC due to suspected or known aortoiliac and/or femoropopliteal artery disease, and compared their effectiveness in terms of functional outcome and/or quality of life (QoL).
Results
Eleven of 258 articles identified (reporting data on eight randomized clinical trials) met the inclusion criteria. One trial included patients with isolated aortoiliac artery obstruction, three trials studied those with femoropopliteal artery obstruction and five included those with combined lesions. Two trials compared PTA with advice on ET, four PTA with SET, two PTA plus SET with SET and two PTA plus SET with PTA. Although the endpoints in most trials comprised walking distances and QoL, pooling of data was impossible owing to heterogeneity. Generally, the effectiveness of PTA and (S)ET was equivalent, although PTA plus (S)ET improved walking distance and some domains of QoL scales compared with (S)ET or PTA alone.
Conclusion
As IC is a common healthcare problem, defining the optimal treatment strategy is important. A combination of PTA and exercise (SET or ET advice) may be superior to exercise or PTA alone, but this needs to be confirmed. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- F A Frans
- Department of Radiology, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Vascular Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - S Bipat
- Department of Radiology, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J A Reekers
- Department of Radiology, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D A Legemate
- Department of Vascular Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M J W Koelemay
- Department of Vascular Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Abstract
Diagnosis and treatment of critical limb ischemia (CLI) is increasingly important as the average age of the world population and the incidence of diabetes and metabolic syndrome increases. Fortunately, most patients will not progress to this stage of peripheral arterial disease, yet if left untreated, there is a high risk of future cardiovascular events. At the point of ischemic rest pain or tissue loss, there are significant implications for morbidity and mortality. There is a high prevalence of multisegment occlusive disease in the CLI patient with the infrapopliteal vessels frequently involved. Revascularization of the affected limb is of utmost importance as the prospects of wound healing and relief of ischemic rest pain are poor without reestablishing continuous flow to the distal extremity. With the advent of endovascular devices designed to treat this vexing problem, the ability to successfully treat this difficult patient population with less procedural morbidity has been greatly enhanced.
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Norvell DC, Turner AP, Williams RM, Hakimi KN, Czerniecki JM. Defining successful mobility after lower extremity amputation for complications of peripheral vascular disease and diabetes. J Vasc Surg 2011; 54:412-9. [PMID: 21531528 DOI: 10.1016/j.jvs.2011.01.046] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 01/13/2011] [Accepted: 01/17/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Information about longer-term functional outcomes following lower extremity amputation for peripheral vascular disease and diabetes remains limited. This study examined factors associated with mobility success during the first year following amputation. METHODS Prospective cohort study of 87 amputees experiencing a first major unilateral amputation surgery. Seventy-five (86%) participants completed 12-month follow-up interview. RESULTS Twenty-eight subjects (37%) achieved mobility success, defined as returning to or exceeding a baseline level of mobility on the locomotor capability index (LCI-5). Forty-three subjects (57%) were satisfied with their mobility. Individuals who were 65 years of age and older (risk difference [RD] = -0.52; 95% confidence interval [CI]: -0.75, -0.29), reported a current alcohol use disorder (RD = -0.37; 95% CI: -0.48, -0.26), had a history of hypertension (RD = -0.23; 95% CI: -0.43, -0.03) or treatment for anxiety or depression (RD = -0.39; 95% CI: -0.50, -0.28) were less likely to achieve mobility success. Mobility success was associated with mobility satisfaction (RD = 0.36; 95% CI: 0.20, 0.53) and satisfaction with life (RD = 0.28; 95% CI: 0.06, 0.50). Although higher absolute mobility at 12 months was also associated with mobility satisfaction and overall life satisfaction, 50% of individuals who achieved success with low to moderate 12-month mobility function reported they were satisfied with their mobility. CONCLUSION Defining success after amputation in relation to an individual's specific mobility prior to the development of limb impairment which led to amputation provides a useful, patient-centered measure that takes other aspects of health, function, and impairment into account.
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Lara-Hernández R, Lozano-Vilardell P. Isquemia crítica de miembros inferiores: una enfermedad cada vez más prevalente. Med Clin (Barc) 2011; 136:106-8. [DOI: 10.1016/j.medcli.2010.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2010] [Accepted: 09/07/2010] [Indexed: 10/18/2022]
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Cieri E, Lenti M, De Rango P, Isernia G, Marucchini A, Cao P. Functional ability in patients with critical limb ischaemia is unaffected by successful revascularisation. Eur J Vasc Endovasc Surg 2010; 41:256-63. [PMID: 21130005 DOI: 10.1016/j.ejvs.2010.10.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Accepted: 10/25/2010] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Patient- and society-oriented measures of outcome have a critical role in determining the effectiveness of any treatment in patients with critical limb ischaemia (CLI). In particular, the impact of an intervention on patient's dependency and functional performance is relevant but is largely unknown. The aim of the study was to investigate whether the limitations encountered in the activities of daily living (ADLs) measured with the Katz Index (KI) in patients with CLI were changed by the treatment. METHODS During the period 2006-2008, 248 consecutive patients undergoing repair for CLI were investigated with an ADL questionnaire for assessing KI before and after a mean of 16.19 months from treatment. Changes in KI were stratified by type of treatment and outcome. RESULTS There were 165 males and 83 females, mean age 73.3 ± 8.3 years; 125 patients showed tissue loss and 123 rest pain alone, 98 received surgical bypass and 150 endovascular repair. Pre-operative KI mean was 10.42. At the post-operative assessment, there was significant worsening in patients' functional outcome (mean KI decreased to 9.78) despite relief of pain (81.5%), tissue healing (72%), good vessel patency (83.8%) and low amputation rate (9.7%). Deterioration of KI was not significantly higher in patients undergoing endovascular repair. Patients receiving major amputation started with worse pre-operative functional score (KI mean 9.42) and did further deteriorate (KI mean 7.71) after demolition surgery. However, patients who received successful revascularisation showed deterioration in the dependence index. CONCLUSIONS Successful vascular treatment is not associated with improved functional ability in patients with CLI, especially when already highly dependent in their activities. Large nationwide preventive and educational programmes should be implemented to prevent irreversible and severe health deterioration in populations with CLI.
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Affiliation(s)
- E Cieri
- Vascular and Endovascular Surgery, Hospital SM Misericordia, University of Perugia, 06134 Perugia, Italy
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Sprengers RW, Teraa M, Moll FL, de Wit GA, van der Graaf Y, Verhaar MC. Quality of life in patients with no-option critical limb ischemia underlines the need for new effective treatment. J Vasc Surg 2010; 52:843-9, 849.e1. [PMID: 20598482 DOI: 10.1016/j.jvs.2010.04.057] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Revised: 04/19/2010] [Accepted: 04/20/2010] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To provide a solid baseline reference for quality of life (QoL) in patients with no-option critical limb ischemia (CLI). CLI is associated with surgery, endovascular interventions, hospitalization, and a poor prognosis. An increasing number of clinical trials are, therefore, investigating new treatment strategies (eg, therapeutic neovascularization) in patients with CLI. QoL serves as an important secondary endpoint in many of these trials, but solid reference QoL data for patients with no-option CLI are lacking. METHODS The Medical Outcomes Study Short Form 36 (SF-36) and the EuroQol-5D (EQ-5D) questionnaires were used to obtain baseline QoL scores from 47 patients with no-option CLI participating in a therapeutic neovascularization trial. To allow for easy comparability, a norm-based scoring (NBS) method was used to report the results of the SF-36. Scores of patients with CLI were furthermore compared with scores of patients with milder forms of peripheral arterial disease (PAD) and with patients with cardiovascular risk factors only. Determinants of QoL in patients with PAD were identified using multiple linear regression methods. RESULTS Patients with no-option CLI reported QoL scores below the general population mean on every health dimension of the SF-36. Physical functioning, role physical functioning, and bodily pain were affected most intensively. These poor physical QoL scores were further underlined when compared with other patients with milder forms of PAD or patients with cardiovascular risk factors only. Patients with CLI scored poorly on the pain/discomfort and the usual activities domain of the EQ-5D. Diabetes, female gender, body mass index, and the ankle-brachial index at rest were significant determinants of the QoL in PAD on multivariate analysis. CONCLUSION The QoL data of patients with no-option CLI using NBS methods for the SF-36 provide a baseline reference for ongoing clinical trials on new treatment strategies. Our data stress the need for new revascularization therapies in patients with no-option CLI.
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Affiliation(s)
- Ralf W Sprengers
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Alaiti MA, Ishikawa M, Costa MA. Bone marrow and circulating stem/progenitor cells for regenerative cardiovascular therapy. Transl Res 2010; 156:112-29. [PMID: 20801408 DOI: 10.1016/j.trsl.2010.06.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Revised: 06/23/2010] [Accepted: 06/23/2010] [Indexed: 12/22/2022]
Abstract
Cardiovascular disease is the leading cause of death and disability in the Western world. In addition to the advancement of current therapeutic approaches to reduce the associated morbidity and mortality, regenerative medicine and cell-based therapy have been areas of continuous investigation. Circulating and bone-marrow-derived stem or endothelial progenitor cells are an attractive source for regenerative therapy in the cardiovascular field. In this review, we highlight the advantages and limitations of this approach with a focus on key observations from animal studies and clinical trials.
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Affiliation(s)
- Mohamad Amer Alaiti
- Division of Cardiovascular Medicine, Harrington-McLaughlin Heart and Vascular Institute, University Hospitals, Case Western Reserve University, Cleveland, OH 44106-5038, USA.
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Forbes JF, Adam DJ, Bell J, Fowkes FGR, Gillespie I, Raab GM, Ruckley CV, Bradbury AW. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: Health-related quality of life outcomes, resource utilization, and cost-effectiveness analysis. J Vasc Surg 2010; 51:43S-51S. [DOI: 10.1016/j.jvs.2010.01.076] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 10/27/2009] [Accepted: 01/24/2010] [Indexed: 11/26/2022]
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Hernández-Lahoz Ortiz I, Paz-Esquete J, Vázquez-Lago J, García-Casas R. Calidad de vida en pacientes revascularizados por isquemia crítica de miembros inferiores. ANGIOLOGIA 2010. [DOI: 10.1016/s0003-3170(10)70015-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Varu VN, Hogg ME, Kibbe MR. Critical limb ischemia. J Vasc Surg 2010; 51:230-41. [PMID: 20117502 DOI: 10.1016/j.jvs.2009.08.073] [Citation(s) in RCA: 235] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Accepted: 08/16/2009] [Indexed: 11/30/2022]
Abstract
Critical limb ischemia (CLI) continues to be a significantly morbid disease process for the aging population. Rigid guidelines for the management of patients with CLI are inappropriate due to the complexities that are involved in optimally treating these patients. A thin line exists in the decision process between medical management vs surgical management by revascularization or amputation, and the perception of "success" in this patient population is evolving. This review explores these issues and examines the challenges the treating physician will face when managing the care of patients with CLI. The epidemiology and natural history of CLI is discussed, along with the pathophysiology of the disease process. A review of the literature in regards to the different treatment modalities is presented to help the physician optimize therapy for patients with CLI. New scoring systems to help predict outcomes in patients with CLI undergoing revascularization or amputation are discussed, and an overview of the current status of patient-oriented outcomes is provided. Finally, we briefly examine emerging therapies for the treatment of CLI and provide an algorithm to help guide the practicing physician on how to approach the critically ischemic limb with regard to the complicated issues surrounding these patients.
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Affiliation(s)
- Vinit N Varu
- Division of Vascular Surgery, Northwestern University, Chicago, Ill 60611, USA
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Sprengers RW, Moll FL, Verhaar MC. Stem cell therapy in PAD. Eur J Vasc Endovasc Surg 2010; 39 Suppl 1:S38-43. [PMID: 20153223 DOI: 10.1016/j.ejvs.2009.12.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Accepted: 12/02/2009] [Indexed: 01/02/2023]
Abstract
Critical limb ischemia (CLI) continues to form a substantial burden on Western health care. Despite recent advances in surgical and radiological vascular techniques, a large number of patients is not eligible for these revascularisation procedures and faces amputation as their ultimate treatment option. Growth factor therapy and stem cell therapy - both therapies focussing on augmenting postnatal neovascularisation - have raised much interest in the past decade. Based on initial pre-clinical and clinical results, both therapies appear to be promising strategies to augment neovascularisation and to reduce symptoms and possibly prevent amputation in CLI patients. However, the underlying mechanisms of postnatal neovascularisation are still incompletely understood. Both fundamental research as well as large randomised trials are needed for further optimisation of these treatment options, and will hopefully lead to needed advances in the treatment of no-option CLI patients in the near future.
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Affiliation(s)
- R W Sprengers
- Department of Vascular Surgery, Utrecht, The Netherlands.
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50
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Moneta GL, Landry GJ, Nguyen LL. Does Lower-Extremity Bypass Improve Quality of Life? Is it Cost Effective? Semin Vasc Surg 2009; 22:275-80. [DOI: 10.1053/j.semvascsurg.2009.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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