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Rezk F, Åstrand H, Svensson-Björk R, Hasselmann J, Nyman J, Butt T, Bilos L, Pirouzram A, Acosta S. Multicenter parallel randomized trial evaluating incisional negative pressure wound therapy for the prevention of surgical site infection after lower extremity bypass. J Vasc Surg 2024; 79:931-940.e4. [PMID: 38042513 DOI: 10.1016/j.jvs.2023.11.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE Incisional negative pressure wound therapy (iNPWT) applied over all incisions after lower extremity bypass in the prevention of surgical site infections (SSIs) is unclear. The primary and secondary aims of this study were to investigate if prophylactic iNPWT after the elective lower extremity bypass prevents SSI and other surgical wound complications. METHODS This was a multicenter, parallel, randomized controlled trial. Patients undergoing elective lower extremity bypass in 3 hospitals were randomized to either iNPWT or standard dressings. SSIs or other wound complications were assessed within the first 90 days by wound care professionals blinded to the randomized result. The validated Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of deep tissues, Isolation of bacteria, and Stay (ASEPSIS) score was used to objectively assess the wounds. ASEPSIS score ≥21 is defined as an SSI. Unilateral and bilateral groups were analyzed with the Fisher exact test and the McNemar test, respectively. RESULTS In the unilateral group (n = 100), the incidence of SSI in the iNPWT group was 34.9% (15/43), compared with 40.3% (23/57) in the control group, according to the ASEPSIS score (P = .678). In the bilateral group (n = 7), the SSI rate was 14.3% (1/7) in the iNPWT group compared with 14.3% (1/7) in the control group (P = 1.00). In the unilateral group, there was a higher wound dehiscence rate in the control group (43.9%) compared with the iNPWT group (23.3%) (P = .0366). No serious iNPWT-related adverse events were recorded. CONCLUSIONS There was no reduction of SSI rates in leg incisions with iNPWT compared with standard dressings in patients undergoing elective lower extremity bypass, whereas iNPWT reduced the incidence of wound dehiscence.
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Affiliation(s)
- Francis Rezk
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Surgery, Region Jönköping County, Jönköping, Sweden.
| | - Håkan Åstrand
- Department of Surgery, Region Jönköping County, Jönköping, Sweden
| | | | | | - Johan Nyman
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Talha Butt
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Linda Bilos
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Artai Pirouzram
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
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Giusti JCG, Rossi FH, Cury MVM, Godoy MR, Palomo AT, Sacilotto R, Brochado Neto FC, Izukawa NM. Efficacy and safety of iliofemoral bypass using arm veins as an alternative conduit for chronic limb-threatening ischemia. J Vasc Surg 2023; 78:1021-1029.e3. [PMID: 37343730 DOI: 10.1016/j.jvs.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/08/2023] [Accepted: 06/11/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVE The use of basilic vein in iliofemoral revascularizations was previously described in the literature as an autologous option for the treatment of vascular prosthesis infection and as a primary conduit in patients at high risk of infectious surgical complications. However, the publications available include several different indications and are limited to case reports. Therefore, the aim of this study was to evaluate the outcomes of the use of arm veins as a safe and effective autologous alternative for iliofemoral reconstruction in patients with chronic limb-threatening ischemia (CLTI) and at high risk of prosthesis infection. METHODS We performed a multicenter, retrospective cohort study with 53 consecutive iliofemoral bypasses using arm veins as an alternative conduit. The procedures were performed between November 2013 and November 2021, exclusively for patients with CLTI classified as TASC aortoiliac C or D with increased risk of postoperative surgical infection. Demographic, clinical variables, and outcomes were collected from a prospective database. Main endpoints were amputation-free survival (AFS) and major adverse cardiovascular events. Secondary endpoints included primary and secondary patencies and overall survival. Cox regression analysis was used to identify the predictors of AFS. Postoperative surgical complications and 30-day mortality were also assessed. RESULTS The mean age was 64.2 ± 8.4 years, with a predominance of male gender. The median follow-up period was 615 days. All patients had CLTI, with a predominance of tissue loss (n = 51; 96.2%) and a median ankle-brachial index of 0.28. The basilic vein was utilized in most procedures (69.8%). Thirty-day major adverse cardiovascular events occurred in five cases (9.4%), and the 30-day mortality rate was 3.8%. The AFS, primary patency, secondary patency, and overall survival in 720 days were 71%, 72%, 89%, and 75%, respectively. Cox regression analysis revealed no association between the variables analyzed for AFS. There was no graft late infection nor pseudoaneurysmal degeneration. CONCLUSIONS Iliofemoral bypass using arm veins as an autologous conduit proved to be an effective and safe procedure with low incidence of postoperative cardiovascular complications and high rates of AFS in patients with CLTI. Also, this suggests that arm veins can be an interesting and suitable autologous alternative conduit for iliofemoral reconstructions, especially in cases in which a prosthesis should be avoided or when it is not available.
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Affiliation(s)
- Júlio César Gomes Giusti
- Department of Vascular and Endovascular Surgery, Hospital Municipal Dr. Carmino Caricchio - HMCC, São Paulo, São Paulo, Brazil.
| | - Fabio Henrique Rossi
- Department of Vascular and Endovascular Surgery, Instituto Dante Pazzanese de Cardiologia - IDPC, São Paulo, São Paulo, Brazil
| | - Marcus Vinicius Martins Cury
- Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual - HSPE, São Paulo, São Paulo, Brazil
| | - Marcos Roberto Godoy
- Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual - HSPE, São Paulo, São Paulo, Brazil
| | - Amanda Thurler Palomo
- Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual - HSPE, São Paulo, São Paulo, Brazil
| | - Roberto Sacilotto
- Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual - HSPE, São Paulo, São Paulo, Brazil
| | - Francisco Cardoso Brochado Neto
- Department of Vascular and Endovascular Surgery, Hospital Municipal Dr. Carmino Caricchio - HMCC, São Paulo, São Paulo, Brazil; Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual - HSPE, São Paulo, São Paulo, Brazil
| | - Nilo Mitsuru Izukawa
- Department of Vascular and Endovascular Surgery, Instituto Dante Pazzanese de Cardiologia - IDPC, São Paulo, São Paulo, Brazil
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Sarkar A, Nagarsheth KH. Deep Venous Arterialization for Limb Salvage. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00340-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Ilio-Deep Femoral Bypass – an Alternative Treatment Strategy to Critical Limb Ischemia (CLI). JOURNAL OF INTERDISCIPLINARY MEDICINE 2021. [DOI: 10.2478/jim-2021-0021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background: Critical limb ischemia is considered the most severe form of peripheral artery disease. High morbidity and mortality rates are associated with this pathology due to poor economic management of complications. Case summary: A 68-year-old female patient underwent a routine Doppler ultrasound which revealed the obstruction of both the common and superficial right femoral arteries, as well as the right deep femoral artery. In this case, an iliofemoral bypass was performed using the right deep femoral artery as the outflow artery. Conclusion: Revascularization of the deep femoral artery has a reasonable chance of preserving the ischemic lower limb whenever the common and superficial femoral arteries suffer major atherosclerotic blockages.
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Giusti JCG, Cury MVM, Rossi FH, Soares SP, Trento AF, Tartarotti SP, Brochado-Neto FC. Eversion Endarterectomy of the External Iliac Artery in Treating Chronic Limb-Threatening Ischemia in TASC II C and D Iliofemoral Occlusive Disease. Ann Vasc Surg 2021; 75:162-170. [PMID: 33556512 DOI: 10.1016/j.avsg.2021.01.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/13/2021] [Accepted: 01/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Endovascular treatment of iliofemoral occlusive disease is a challenging approach, especially for TransAtlantic Inter-Society C and D lesions. Therefore, the revascularization procedure in such situations is preferably performed by bypass graft surgery with synthetic materials. The purpose of this study is to report the feasibility and mid-term results of eversion endarterectomy of the external iliac artery (EEEIA), as an alternative autologous option. METHODS Retrospective study with 18 EEEIA performed between September 2015 and February 2020, exclusively for chronic limb-threatening ischemia treatment in patients with increased risk of postoperative surgical infection and inadvisable for endovascular treatment. Demographic, clinical variables and outcomes were collected from a prospective database. The main end points are: amputation-free survival (AFS) and 30-day mortality. Secondary end points include: primary patency (PP), cumulative patency (CP), overall survival (OS), and postoperative surgical complication. Kaplan-Meier analysis was used to estimate cumulative time of outcomes. RESULTS The mean age was 64.8 ± 8.3 years, with predominance of men. The median follow-up period was 1012 days, 95% confidence interval [119, 1365] days. Most had Rutherford 5 (n = 13, 72.2%) and mean ankle brachial index was 0.38 ± 0.22. The PP, CP, AFS, and OS in 730 days were 81%, 92%, 80%, and 88%, respectively. There was no 30-day mortality or postoperative surgical infection. CONCLUSIONS Iliofemoral reconstruction through EEEIA is an effective surgical procedure with good patency rates, AFS and OS. In addition, it can be considered an useful and safe option, especially in cases in which a prosthesis should be avoided.
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Affiliation(s)
- Júlio César Gomes Giusti
- Department of Vascular Surgery, Hospital Municipal Dr Carmino Caricchio, Tatuapé, São Paulo, São Paulo, Brazil.
| | - Marcus Vinícius Martins Cury
- Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual, São Paulo, São Paulo, Brazil
| | - Fábio Henrique Rossi
- Department of Vascular and Endovascular Surgery, Instituto Dante Pazzanese de Cardiologia, São Paulo, São Paulo, Brazil
| | - Samara Pontes Soares
- Department of Vascular Surgery, Hospital Municipal Dr Carmino Caricchio, Tatuapé, São Paulo, São Paulo, Brazil
| | - André Felipe Trento
- Department of Vascular Surgery, Hospital Municipal Dr Carmino Caricchio, Tatuapé, São Paulo, São Paulo, Brazil
| | - Sabrina Payne Tartarotti
- Department of Vascular Surgery, Hospital Municipal Dr Carmino Caricchio, Tatuapé, São Paulo, São Paulo, Brazil
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Lee KB, Macsata RA, Lala S, Sparks AD, Amdur RL, Ricotta JJ, Sidawy AN, Nguyen BN. Outcomes of open and endovascular interventions in patients with chronic limb threatening ischemia. Vascular 2020; 29:693-703. [PMID: 33190618 DOI: 10.1177/1708538120971972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Widespread adoption of endovascular therapy for the treatment of chronic limb-threatening ischemia has transformed the field of vascular surgery. In this modern era, we aimed to define where open surgical interventions are of greatest benefit for limb salvage. METHODS Patients who underwent interventions for chronic limb-threatening ischemia were identified in the vascular-targeted lower extremity National Surgical Quality Improvement Program database for open surgical interventions (OPEN) and endovascular surgical interventions (ENDO) from 2011 to 2017. Patients were further stratified based on the criteria of chronic limb-threatening ischemia (rest pain or tissue loss), and the location of the diseased arteries (femoropopliteal or tibioperoneal). The main outcomes measured included 30-day mortality, amputation, and major adverse cardiovascular events. RESULTS A total of 17,193 patients were revascularized for chronic limb-threatening ischemia: 10,532 were OPEN and 6661 were ENDO. OPEN had higher 30-day mortality, major adverse cardiovascular events, pulmonary, renal dysfunction, and wound complications. However, OPEN resulted in significantly lower 30-day major amputation (3.8% vs. 5.0%, odds ratio (OR): 0.83 [0.72-0.97], P = .018). Subgroup analysis revealed a higher mortality rate in OPEN was observed only in tibioperoneal intervention for tissue loss. Major adverse cardiovascular event was higher in OPEN for most subgroups. OPEN for patients with tissue loss had significantly lower amputation rate than ENDO in both femoropopliteal and tibioperoneal subgroups (3.7% vs. 5.1%, OR: 0.76 [0.59-0.98], P = .036, and 4.7% vs. 6.6%, OR: 0.74 [0.57-0.96], P = .024, respectively). The benefit of open surgery in reducing the amputation rate was not seen in patients with rest pain. CONCLUSIONS Open surgical intervention is associated with significantly better limb salvage than endovascular intervention in patients with tissue loss. Surgical options should be given more emphasis as the first-line option in this cohort of patients unless the cardiopulmonary risk is prohibitive.
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Affiliation(s)
- K Benjamin Lee
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Robyn A Macsata
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Salim Lala
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Andrew D Sparks
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Richard L Amdur
- Department of Surgery, George Washington University, Washington, DC, USA
| | - John J Ricotta
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Anton N Sidawy
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Bao-Ngoc Nguyen
- Department of Surgery, George Washington University, Washington, DC, USA
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Giannopoulos S, Lyden SP, Bisdas T, Micari A, Parikh SA, Jaff MR, Schneider PA, Armstrong EJ. Endovascular Intervention for the Treatment of Trans-Atlantic Inter-Society Consensus (TASC) D Femoropopliteal Lesions: A Systematic Review and Meta-Analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 22:52-65. [PMID: 32563709 DOI: 10.1016/j.carrev.2020.06.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/02/2020] [Accepted: 06/08/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE Advancements in the endovascular treatment of femoropopliteal atherosclerotic lesions have led to treatment of more complex lesions, particularly long lesions. The aim of this study was to determine the meta-analytic primary patency and need for re-intervention among patients treated for very long lesions (>200 mm) at the femoropopliteal segment and to identify potential risk factors for loss of patency. METHODS This study was performed according to the PRISMA guidelines. A random effects model meta-analysis was conducted, and the I-square was used to assess heterogeneity. RESULTS Fifty-one studies comprised of 3029 patients were included. The mean lesion length was 269 mm. The primary patency rate at 30 days, 6 m, 1-, 2- and 5-years of follow-up was 98%, 76%, 62%, 55%, and 39% respectively. The incidence of TLR was 16% at one year and 32% at two years. The secondary patency rate at 1, 2, 3 and 5 years was 85%, 71%, 64%, and 64% respectively. Heparin bonded ePTFE covered stents (69%) and paclitaxel eluting stents (73%) demonstrated higher 1-year primary patency rates than self-expanding nitinol stents (55%) or uncoated percutaneous transluminal angioplasty (PTA) with provisional stenting (54%). Lesions treated with a heparin bonded ePTFE covered stent had statistically significant higher odds of remaining patent at 1-year of follow-up (OR: 2.74; 95%CI: 1.63-4.61; p < 0.001) than lesions treated with BMS or PTA. Patients with long femoropopliteal lesions causing critical limb ischemia (CLI) developed restenosis or occlusion more often than patients treated for claudication (HR: 1.63; 95%CI: 1.06-2.49; p = 0.026) during an average follow-up of 26 months. CONCLUSION Primary stenting of femoropopliteal TASC D lesions using drug eluting stents or covered stents results in sustained patency over time. PTA or uncoated nitinol stents demonstrated lower patency rates. However, additional comparative studies are needed to determine the efficacy of newer technologies for the treatment of complex femoropopliteal lesions and provide evidence for the most optimal treatment approach.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic and Foundation, Cleveland, OH, USA
| | | | - Antonio Micari
- Division of Cardiology, Huamitas Gavazzeni, Bergamo, Italy
| | - Sahil A Parikh
- Center for Interventional Vascular Therapy, NY Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Michael R Jaff
- Department of Medicine, Newton-Wellesley Hospital, Newton, MA, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California at San Francisco, San Francisco, CA, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA.
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Darling JD, O'Donnell TFX, Deery SE, Norman AV, Vu GH, Guzman RJ, Wyers MC, Hamdan AD, Schermerhorn ML. Outcomes after first-time lower extremity revascularization for chronic limb-threatening ischemia in insulin-dependent diabetic patients. J Vasc Surg 2019; 68:1455-1464.e1. [PMID: 30360841 DOI: 10.1016/j.jvs.2018.01.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 01/06/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Historically, open surgical bypass provided a durable repair among diabetic patients with chronic limb-threatening ischemia (CLTI). In the current endovascular era, however, the difference in long-term outcomes between first-time revascularization strategies among patients with insulin-dependent diabetes mellitus (IDDM) is poorly understood. METHODS We reviewed the records of all patients with IDDM undergoing a first-time infrainguinal bypass graft (BPG) or percutaneous transluminal angioplasty with or without stenting (PTA/S) for CLTI at our institution from 2005 to 2014. We defined IDDM as use of chronic insulin administration at baseline to control blood glucose levels and recorded the most recent glycated hemoglobin value available within 3 months before the procedure and fasting blood glucose level on the day of the procedure. We compared rates of wound healing, restenosis, reintervention, major amputation, and mortality between BPG and PTA/S in our population using χ2, Kaplan-Meier, and Cox regression analyses. As a sensitivity analysis, we calculated propensity scores and employed inverse probability weighting to account for nonrandom assignment to BPG vs PTA/S. RESULTS Of 2869 infrainguinal revascularizations from 2005 to 2014, 655 limbs (316 BPG, 339 PTA/S) in 580 patients fit our criteria and underwent a first-time revascularization for CLTI. Patients undergoing BPG, compared with PTA/S, were similar in age (69 vs 68 years; P = .55), had similar rates of tissue loss (87% vs 91%; P = .07) and dialysis dependence (26% vs 28%; P = .55), were less likely to be hypertensive (84% vs 92%; P < .001), and were more likely to be current smokers (21% vs 14%; P = .02). There were no differences between BPG and PTA/S patients in mean glycated hemoglobin levels (8.1% vs 8.0%; P = .51) or mean fasting blood glucose levels (158 vs 150 mg/dL; P = .18). Although total hospital length of stay was significantly longer among BPG patients (11 vs 8 days; P < .001), perioperative complications did not differ, including acute kidney injury (19% vs 23%; P = .24), hematoma (6.0% vs 3.8%; P = .20), acute myocardial infarction (1.3% vs 2.1%; P = .43), and mortality (3.8% vs 3.0%; P = .55). BPG-first patients had significantly lower unadjusted 6-month rates of incomplete wound healing (49% vs 57%) and 5-year rates of restenosis (53% vs 72%) and reintervention (47% vs 58%; all P < .05). After adjustment, multivariable analysis suggested PTA/S-first intervention to be significantly associated with higher risk of restenosis (hazard ratio, 1.9; 95% confidence interval, 1.3-2.7) and reintervention (1.9 [1.2-2.7]). These results remained robust after inverse probability weighting. CONCLUSIONS Among patients with IDDM and CLTI, a bypass-first strategy is associated with similar 30-day outcomes and lower restenosis and reintervention rates. These data suggest that a bypass-first approach may best serve appropriately selected, anatomically suitable patients with IDDM and pedal ischemia that requires revascularization.
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Affiliation(s)
- Jeremy D Darling
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | | | - Giap H Vu
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Raul J Guzman
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Allen D Hamdan
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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Yuksel A, Velioglu Y, Cayir MC, Kumtepe G, Gurbuz O. Current Status of Arterial Revascularization for the Treatment of Critical Limb Ischemia in Infrainguinal Atherosclerotic Disease. Int J Angiol 2018; 27:132-137. [PMID: 30154631 DOI: 10.1055/s-0037-1620242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Critical limb ischemia (CLI) is the most severe form of peripheral arterial disease (PAD) that may result in limb loss and even death; thus, the fast and proper treatment should be employed as earlier as possible to prevent these catastrophic consequences. Arterial revascularization is almost always an indispensable treatment option for CLI. Although both endovascular and surgical revascularization procedures have an important role, nowadays, the hybrid revascularization as a combination of these revascularization procedures has also gained increasing popularity in the treatment of patients with CLI. This review provides an update on the arterial revascularization strategies for the treatment of CLI.
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Affiliation(s)
- Ahmet Yuksel
- Department of Cardiovascular Surgery, Bursa State Hospital, Bursa, Turkey
| | - Yusuf Velioglu
- Department of Cardiovascular Surgery, Abant Izzet Baysal University Faculty of Medicine, Bolu, Turkey
| | | | - Gencehan Kumtepe
- Department of Cardiovascular Surgery, Balıkesir University Faculty of Medicine, Balıkesir, Turkey
| | - Orcun Gurbuz
- Department of Cardiovascular Surgery, Balıkesir University Faculty of Medicine, Balıkesir, Turkey
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Smoking Habits of Patients Undergoing Treatment for Intermittent Claudication in the Vascular Quality Initiative. Ann Vasc Surg 2017; 44:261-268. [DOI: 10.1016/j.avsg.2017.04.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 04/28/2017] [Indexed: 12/29/2022]
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Schreuder SM, Hendrix YMGA, Reekers JA, Bipat S. Predictive Parameters for Clinical Outcome in Patients with Critical Limb Ischemia Who Underwent Percutaneous Transluminal Angioplasty (PTA): A Systematic Review. Cardiovasc Intervent Radiol 2017; 41:1-20. [PMID: 28924874 PMCID: PMC5735197 DOI: 10.1007/s00270-017-1796-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 09/06/2017] [Indexed: 01/27/2023]
Abstract
Purpose To identify possible risk factors in predicting clinical outcome in critical limb ischemia (CLI) patients undergoing percutaneous transluminal angioplasty (PTA). Materials and Methods PubMed and EMBASE were searched for studies analyzing CLI and clinical outcome after PTA from January 2006 to April 2017. Outcome measures were ulcer healing, amputation free survival (AFS)/limb salvage and overall survival. Data on predictive factors for ulcer healing, AFS/limb salvage and survival were extracted. Results Ten articles with a total of 2448 patients were included, all cohorts and based on prospective-designed databases. For ulcers, it seems that complete healing can be achieved in most of the patients within 1 year. No significant predictive factors were found. AFS/limb salvage: AFS rates for 1, 2 and 3 years ranged from 49.5 to 75.2%, 37 to 58% and 22 to 59%, respectively. Limb salvage rates for 1, 2 and 3 years ranged from 71 to 95%, 54 to 93.3% and 32 to 92.7%, respectively. All studies had different univariate and multivariate outcomes for predictive factors; however, age and diabetes were significant predictors in at least three studies. Survival: Survival rates for 1, 2 and 3 years ranged from 65.4 to 91.5%, 45.7 to 76% and 37.3 to 83.1%, respectively. Different predictive factors were found; however, age was found in 2 out of 5 studies reporting on predictive factors. Conclusions In several studies two factors, age and diabetes, were found as predictive factors for AFS/limb salvage and survival in patients with CLI undergoing PTA. Therefore, we believe that these factors should be taken into account in future research. Level of Evidence Level 2a.
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Affiliation(s)
- Sanne M Schreuder
- Department of Radiology and Nuclear Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Yvette M G A Hendrix
- Department of Radiology and Nuclear Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jim A Reekers
- Department of Radiology and Nuclear Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Shandra Bipat
- Department of Radiology and Nuclear Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Janczak D, Malinowski M, Bąkowski W, Krakowska K, Marschollek K, Marschollek P, Chabowski M. Comparison of the Incidence of Complications and Secondary Surgical Interventions Necessary in Patients with Chronic Lower Limb Ischemia Treated by Both Open and Endovascular Surgeries. Ann Thorac Cardiovasc Surg 2017; 23:135-140. [PMID: 28496017 DOI: 10.5761/atcs.oa.16-00282] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Peripheral arterial disease (PAD) affects 3%-10% of the population before the age of 70 years and 15%-20% after that age.The aim of the study was to compare the incidence of complications and secondary interventions in patients who underwent each type of treatment. METHODS We analyzed 734 medical records of the Department of Surgery at the 4th Military Teaching Hospital in Wroclaw, In total, 394 were operated on with open surgery; an endarterectomy (59.39%), a vascular prosthesis implantation (31.01%), or both of these techniques (6.6%), and 340 patients had angioplasty with (50.59%) or without stenting (49.41%). RESULTS There were no statistically significant differences in the incidence of corresponding complications. The exception was the infection of the wound; significantly fewer were reported in the case of endovascular procedures (p = 0.0087). There were 12 occasions (3.53%) during endovascular surgeries when intraoperative conversion or re-operation using the open method occurred. In the case of open surgery, the mean hospital stay was 7.77 days (median: 8, mode: 8), while for endovascular management it was equal to 4.68 days (median: 4, mode: 3), p <0.0001. CONCLUSION The endovascular method results in a similar re-operation rate and number of complications as open surgery.
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Affiliation(s)
- Dariusz Janczak
- Division of Surgical Specialties, Department of Clinical Nursing, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland.,Department of Surgery, 4th Military Teaching Hospital, Wroclaw, Poland
| | - Maciej Malinowski
- Division of Surgical Specialties, Department of Clinical Nursing, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland.,Department of Surgery, 4th Military Teaching Hospital, Wroclaw, Poland
| | - Wojciech Bąkowski
- Department of Surgery, 4th Military Teaching Hospital, Wroclaw, Poland
| | | | - Karol Marschollek
- Department of Surgery, 4th Military Teaching Hospital, Wroclaw, Poland
| | - Paweł Marschollek
- Department of Surgery, 4th Military Teaching Hospital, Wroclaw, Poland
| | - Mariusz Chabowski
- Division of Surgical Specialties, Department of Clinical Nursing, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland.,Department of Surgery, 4th Military Teaching Hospital, Wroclaw, Poland
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Darling JD, McCallum JC, Soden PA, Guzman RJ, Wyers MC, Hamdan AD, Verhagen HJ, Schermerhorn ML. Predictive ability of the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system after first-time lower extremity revascularizations. J Vasc Surg 2017; 65:695-704. [PMID: 28073665 DOI: 10.1016/j.jvs.2016.09.055] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 09/29/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The Society for Vascular Surgery (SVS) Wound, Ischemia and foot Infection (WIfI) classification system was proposed to predict 1-year amputation risk and potential benefit from revascularization. Our goal was to evaluate the predictive ability of this scale in a real-world selection of patients undergoing a first-time lower extremity revascularization for chronic limb-threatening ischemia (CLTI). METHODS From 2005 to 2014, 1336 limbs underwent a first-time lower extremity revascularization for CLTI, of which 992 had sufficient data to classify all three WIfI components (wound, ischemia, and foot infection). Limbs were stratified into the SVS WIfI clinical stages (from 1 to 4) for 1-year amputation risk estimation, a novel WIfI composite score from 0 to 9 (that weighs all WIfI variables equally), and a novel WIfI mean score from 0 to 3 (that can incorporate limbs missing any of the three WIfI components). Outcomes included major amputation; revascularization, major amputation, or stenosis (>3.5× step-up by duplex; RAS) events; and death. Predictors were identified using Cox regression models and Kaplan-Meier survival estimates. RESULTS Of the 1336 first-time procedures performed, 992 limbs were classified in all three WIfI components (524 endovascular and 468 bypass; 26% rest pain and 74% tissue loss). Cox regression demonstrated that a one-unit increase in the WIfI clinical stage increases the risk of major amputation (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.7-3.2) and RAS events in all limbs (HR, 1.2; 95% CI, 1.1-1.3). Separate models of the entire cohort, a bypass-only cohort, and an endovascular-only cohort showed that a one-unit increase in the WIfI mean score is associated with an increase in the risk of major amputation (all three cohorts: HR, 5.3 [95% CI, 3.6-6.8], 4.1 [2.4-6.9], and 6.6 [3.8-11.6], respectively) and RAS events (all three cohorts: HR, 1.7 [95% CI, 1.4-2.0], 1.9 [1.4-2.6], and 1.4 [1.1-1.9], respectively). The novel WIfI composite and WIfI mean scores were the only consistent predictors of death among the three cohorts, with the WIfI mean score proving most strongly predictive in the entire cohort (HR, 1.4; 95% CI, 1.1-1.7), the bypass-only cohort (HR, 1.5; 95% CI, 1.1-1.9), and the endovascular-only cohort (HR, 1.4; 95% CI, 1.0-1.8). Although the individual WIfI wound component was able to predict mortality among all patients (HR, 1.1; 95% CI, 1.0-1.2) and bypass-only patients (HR, 1.2; 95% CI, 1.1-1.3), neither the additional individual WIfI components nor the WIfI clinical stage were able to significantly predict mortality among any cohort. CONCLUSIONS This study supports the ability of the SVS WIfI classification system to predict major amputation; however, the novel WIfI mean and WIfI composite scores predict amputation, RAS events, and mortality more consistently than any other current WIfI scoring system. The WIfI mean score allows inclusion of all limbs, and both novel scoring systems are easier to conceptualize, give equal weight to each WIfI component, and may provide clinicians more effective comparisons in outcomes between patients.
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Affiliation(s)
- Jeremy D Darling
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - John C McCallum
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Raul J Guzman
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Allen D Hamdan
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Hence J Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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Salinas HM, Khan SI, McCormack MC, Fernandes JR, Gfrerer L, Watkins MT, Redmond RW, Austen WG. Prevention of vein graft intimal hyperplasia with photochemical tissue passivation. J Vasc Surg 2017; 65:190-196. [DOI: 10.1016/j.jvs.2015.11.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 11/15/2015] [Indexed: 10/22/2022]
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15
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Meltzer AJ, Sedrakyan A, Isaacs A, Connolly PH, Schneider DB. Comparative effectiveness of peripheral vascular intervention versus surgical bypass for critical limb ischemia in the Vascular Study Group of Greater New York. J Vasc Surg 2016; 64:1320-1326.e2. [DOI: 10.1016/j.jvs.2016.02.069] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/14/2016] [Indexed: 11/16/2022]
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16
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Gentile F, Lundberg G, Hultgren R. Outcome for Endovascular and Open Procedures in Infrapopliteal Lesions for Critical Limb Ischemia: Registry Based Single Center Study. Eur J Vasc Endovasc Surg 2016; 52:643-649. [DOI: 10.1016/j.ejvs.2016.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 07/11/2016] [Indexed: 10/21/2022]
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17
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Menard MT, Farber A, Assmann SF, Choudhry NK, Conte MS, Creager MA, Dake MD, Jaff MR, Kaufman JA, Powell RJ, Reid DM, Siami FS, Sopko G, White CJ, Rosenfield K. Design and Rationale of the Best Endovascular Versus Best Surgical Therapy for Patients With Critical Limb Ischemia (BEST-CLI) Trial. J Am Heart Assoc 2016; 5:JAHA.116.003219. [PMID: 27402237 PMCID: PMC5015366 DOI: 10.1161/jaha.116.003219] [Citation(s) in RCA: 133] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Critical limb ischemia (CLI) is increasing in prevalence, and remains a significant source of mortality and limb loss. The decision to recommend surgical or endovascular revascularization for patients who are candidates for both varies significantly among providers and is driven more by individual preference than scientific evidence. METHODS AND RESULTS The Best Endovascular Versus Best Surgical Therapy for Patients With Critical Limb Ischemia (BEST-CLI) Trial is a prospective, randomized, multidisciplinary, controlled, superiority trial designed to compare treatment efficacy, functional outcomes, quality of life, and cost in patients undergoing best endovascular or best open surgical revascularization. Approximately 140 clinical sites in the United States and Canada will enroll 2100 patients with CLI who are candidates for both treatment options. A pragmatic trial design requires consensus on patient eligibility by at least 2 investigators, but leaves the choice of specific procedural strategy within the assigned revascularization approach to the individual treating investigator. Patients with suitable single-segment of saphenous vein available for potential bypass will be randomized within Cohort 1 (n=1620), while patients without will be randomized within Cohort 2 (n=480). The primary efficacy end point of the trial is Major Adverse Limb Event-Free Survival. Key secondary end points include Re-intervention and Amputation-Free-Survival and Amputation Free-Survival. CONCLUSIONS The BEST-CLI trial is the first randomized controlled trial comparing endovascular therapy to open surgical bypass in patients with CLI to be carried out in North America. This landmark comparative effectiveness trial aims to provide Level I data to clarify the appropriate role for both treatment strategies and help define an evidence-based standard of care for this challenging patient population. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02060630.
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Affiliation(s)
- Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA
| | | | - Niteesh K Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Mark A Creager
- Dartmouth-Hitchcock Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Michael D Dake
- Department of Cardiothoracic Surgery, Stanford Hospital and Clinics, Stanford, CA
| | - Michael R Jaff
- Fireman Vascular Center, Massachusetts General Hospital, Boston, MA
| | | | - Richard J Powell
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Diane M Reid
- National Heart, Lung and Blood Institute, Bethesda, MD
| | | | - George Sopko
- National Heart, Lung and Blood Institute, Bethesda, MD
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Arhuidese I, Malas M, Obeid T, Massada K, Khaled A, Alzahrani A, Samaha G, Reifsnyder T. Outcomes after open infrainguinal bypass in patients with scleroderma. J Vasc Surg 2016; 64:117-23. [DOI: 10.1016/j.jvs.2015.12.057] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 12/23/2015] [Indexed: 02/05/2023]
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19
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Torres-Blanco Á, Edo-Fleta G, Gómez-Palonés F, Molina-Nácher V, Ortiz-Monzón E. Mid-Term Outcomes of Endovascular Treatment for TASC-II D Femoropopliteal Occlusive Disease with Critical Limb Ischemia. Cardiovasc Intervent Radiol 2015. [DOI: 10.1007/s00270-015-1175-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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20
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Farber A, Rosenfield K, Menard M. The BEST-CLI trial: a multidisciplinary effort to assess which therapy is best for patients with critical limb ischemia. Tech Vasc Interv Radiol 2015; 17:221-4. [PMID: 25241324 DOI: 10.1053/j.tvir.2014.08.012] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Critical limb ischemia (CLI) is the most severe form of peripheral arterial disease and is associated with a significant risk of limb loss. It is currently treated with limb revascularization by a variety of specialists. Although both open vascular bypass and endovascular therapy are offered to patients with infrainguinal peripheral arterial disease and CLI, significant disagreement exists as to which therapy works best in candidates for both types of intervention. Persistent clinical equipoise in combination with a paucity of comparative effectiveness data to guide treatment of CLI has led to a multidisciplinary effort to organize the Best Endovascular versus Best Surgical Therapy in patients with CLI (BEST-CLI) trial. The BEST-CLI trial is a pragmatic, multicenter, open label, randomized trial that compares best endovascular therapy with best open surgical treatment in patients eligible for both treatments. This trial is highly innovative in both its design and its collaborative nature. BEST-CLI aims to provide urgently needed clinical guidance for CLI management by using (1) a pragmatic design comparing the effectiveness of established techniques while allowing for the introduction of newer therapies as they become available; (2) a novel primary end point that includes limb amputation rates, repeat intervention, and mortality; (3) a multidisciplinary structure that fosters cooperation among interventional cardiologists, interventional radiologists, vascular surgeons, and vascular medicine specialists; and (4) novel techniques to evaluate the cost-effectiveness and quality-of-life outcomes of the 2 treatment strategies being tested.
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Affiliation(s)
- Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA.
| | | | - Matthew Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women׳s Hospital, Boston, MA
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21
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Strøm M, Konge L, Lönn L, Schroeder TV, Rørdam P. Amputation-Free Survival after Crural Percutaneous Transluminal Angioplasty for Critical Limb Ischemia. Scand J Surg 2015; 105:42-8. [DOI: 10.1177/1457496915571403] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 01/12/2015] [Indexed: 11/15/2022]
Abstract
Background and Aim: To evaluate the amputation-free survival after below the knee percutaneous transluminal angioplasty in a consecutive group of patients with critical ischemia of the lower extremity. Materials and Methods: A total of 70 consecutive patients with critical ischemia were treated with below the knee percutaneous transluminal angioplasty at the vascular center at Rigshospitalet with the purpose of limb salvage. All patients were deemed unfit for major surgery due to anatomical limitations or severe co-morbidity, and no prior attempts of revascularization were performed. Follow-up clinical examinations were performed within 6 weeks and after 1 year. All medical records were crosschecked with the national vascular registry ensuring a valid 1-year status in 97% of the patients. Results: A total of 15 major amputations were performed during follow-up, with 11 amputations performed within the first year. Complications after percutaneous transluminal angioplasty were rare. Cumulative mortality after 1 and 2 years was 22% and 34%, respectively. Amputation-free survival at 1 and 2 years of follow-up was 68% and 58%, respectively. There were no association between known risk factors such as diabetes, ischemic ulcers, cardiac disease, history of smoking, major amputation, or overall amputation. Conclusion: Below the knee percutaneous transluminal angioplasty in patients with end-stage peripheral arterial disease and critical limb ischemia is a safe procedure in relieving critical ischemia, reducing the short-term rate of a major amputation as opposed to best medical treatment alone.
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Affiliation(s)
- M. Strøm
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Centre for Clinical Education, The Capital Region of Denmark, Copenhagen, Denmark
| | - L. Konge
- Centre for Clinical Education, The Capital Region of Denmark, Copenhagen, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - L. Lönn
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- University of Copenhagen, Copenhagen, Denmark
- Department of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - T. V. Schroeder
- Centre for Clinical Education, The Capital Region of Denmark, Copenhagen, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - P. Rørdam
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
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Toth C, Klarik Z, Kiss F, Toth E, Hargitai Z, Nemeth N. Early postoperative changes in hematological, erythrocyte aggregation and blood coagulation parameters after unilateral implantation of polytetrafluoroethylene vascular graft in the femoral artery of beagle dogs. Acta Cir Bras 2014; 29:320-7. [PMID: 24863320 DOI: 10.1590/s0102-86502014000500006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 03/18/2014] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The failure of small-caliber vascular grafts still means a serious problem. Concerning the early postoperative complications we aimed to investigate the hemostaseological and hemorheological aspects of this issue in a canine model. METHODS In the Control group only anesthesia was induced. In the Grafted group under general anesthesia a 3.5-cm segment was resected unilaterally from the femoral artery and replaced with a PTFE graft (diameter: 3 mm). On the 1st-3rd-5th-7th and 14th postoperative days the skin temperature of both hind limbs was measured, and blood sampling occurred for hematological, hemostaseological and hemorheological tests. RESULTS The skin temperature of the operated versus intact limbs did not differ. In the Grafted group leukocyte count was elevated by the 1st postoperative day, while platelet count increased over the entire follow-up period. Fibrinogen concentration rose on the 1st-5th days, activated partial thromboplastin time increased on the 3rd-7th days. Erythrocyte aggregation was enhanced significantly on the 1st-5th days. In specimens taken on the 14th day, histologically we found matured thrombus narrowing the graft lumen. CONCLUSIONS Small-caliber PTFE graft implantation into the femoral artery caused significant changes in several hemostaseological and hemorheological parameters. However, better clarifying the factors leading to early thrombosis of these grafts needs further studies.
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Affiliation(s)
- Csaba Toth
- Institute of Surgery, Faculty of Medicine, University of Debrecen, Hungary
| | - Zoltan Klarik
- Institute of Surgery, Faculty of Medicine, University of Debrecen, Hungary
| | - Ferenc Kiss
- Institute of Surgery, Faculty of Medicine, University of Debrecen, Hungary
| | - Eniko Toth
- Institute of Surgery, Faculty of Medicine, University of Debrecen, Hungary
| | - Zoltan Hargitai
- Department of Pathology, Kenezy Hospital, University of Debrecen, Hungary
| | - Norbert Nemeth
- Institute of Surgery, Kenezy Hospital, University of Debrecen, Hungary
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Successful lower extremity salvage with free flap after endovascular angioplasty in peripheral arterial occlusive disease. J Plast Reconstr Aesthet Surg 2014; 67:1136-43. [DOI: 10.1016/j.bjps.2014.04.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 03/26/2014] [Accepted: 04/29/2014] [Indexed: 11/19/2022]
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Ma T, Ma J. Femorofemoral Bypass to the Deep Femoral Artery for Limb Salvage after Prior Failed Percutaneous Endovascular Intervention. Ann Vasc Surg 2014; 28:1463-8. [DOI: 10.1016/j.avsg.2014.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 01/28/2014] [Accepted: 02/08/2014] [Indexed: 10/25/2022]
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Grenville JL, Tan KT, Moshonov H, Rajan DK. Endovascular first strategy for de novo TransAtlantic Inter-Society Consensus C and D femoro-popliteal disease: mid-term outcomes from a single tertiary referral center. Vascular 2014; 23:31-40. [PMID: 24695358 DOI: 10.1177/1708538114529564] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Describe outcomes after endovascular intervention of TransAtlantic Inter-Society Consensus C and D femoro-popliteal disease. MATERIALS AND METHODS Retrospective cohort study. Patient demographics, ankle-brachial indices, and lesion details were analyzed from a prospectively maintained database. In all, 980 limbs treated with percutaneous transluminal angioplasty±stenting of the femoro-popliteal segment between 2005 and 2012 were reviewed. Seventy-six patients representing 83 limbs with de novo TransAtlantic Inter-Society Consensus C and D lesions measuring ≥15 cm continuously were identified (mean age 71.3±12.1 years, 62% male). RESULTS Twenty-five (30.1%) limbs were treated for severe claudication and 58 (69.9%) for critical limb ischemia. The mean pre-procedural ankle-brachial index was 0.47±0.19. The mean lesion length was 22.9±4.82 cm. Seventy patients representing 77 limbs were available for a mean follow-up length of 19.5 months (range 0-79). The mean post-procedural ankle-brachial index was 0.71±0.28. Primary, assisted-primary, and secondary patency rates were 68.1%, 72.7%, and 83.3% at 6 months, 55.3%, 63.6%, and 58.3% at 12 months, and 38.2%, unavailable, and 10.4% at 24 months, respectively. CONCLUSIONS Angioplasty-first strategy for TransAtlantic Inter-Society Consensus C and D lesions of the femoro-popliteal artery can be safely performed. However, patency drastically decreases after 12 months suggesting further improvements are required to achieve longer-term clinical benefit.
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Affiliation(s)
- Jeffrey Lorne Grenville
- Diagnostic Radiology Program, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Kong Teng Tan
- Department of Medical Imaging, The University Health Network, Toronto, Ontario, Canada
| | - Hadas Moshonov
- Department of Medical Imaging, The University Health Network, Toronto, Ontario, Canada
| | - Dheeraj Kumar Rajan
- Department of Medical Imaging, The University Health Network, Toronto, Ontario, Canada
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Zeller T, Baumgartner I, Scheinert D, Brodmann M, Bosiers M, Micari A, Peeters P, Vermassen F, Landini M. IN.PACT Amphirion paclitaxel eluting balloon versus standard percutaneous transluminal angioplasty for infrapopliteal revascularization of critical limb ischemia: rationale and protocol for an ongoing randomized controlled trial. Trials 2014. [PMID: 24552184 DOI: 10.1186/1745-6215-15-63.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The effectiveness and durability of endovascular revascularization therapies for chronic critical limb ischemia (CLI) are challenged by the extensive burden of infrapopliteal arterial disease and lesion-related characteristics (e.g., severe calcification, chronic total occlusions), which frequently result in poor clinical outcomes. While infrapopliteal vessel patency directly affects pain relief and wound healing, sustained patency and extravascular care both contribute to the ultimate "patient-centric" outcomes of functional limb preservation, mobility and quality of life (QoL). METHODS/DESIGN IN.PACT DEEP is a 2:1 randomized controlled trial designed to assess the efficacy and safety of infrapopliteal arterial revascularization between the IN.PACT Amphirion™ paclitaxel drug-eluting balloon (IA-DEB) and standard balloon angioplasty (PTA) in patients with Rutherford Class 4-5-6 CLI. DISCUSSION This multicenter trial has enrolled 358 patients at 13 European centers with independent angiographic core lab adjudication of the primary efficacy endpoint of target lesion late luminal loss (LLL) and clinically driven target lesion revascularization (TLR) in major amputation-free surviving patients through 12-months. An independent wound core lab will evaluate all ischemic wounds to assess the extent of healing and time to healing at 1, 6, and 12 months. A QoL questionnaire including a pain scale will assess changes from baseline scores through 12 months. A Clinical Events Committee and Data Safety Monitoring Board will adjudicate the composite primary safety endpoints of all-cause death, major amputation, and clinically driven TLR at 6 months and other trial endpoints and supervise patient safety throughout the study. All patients will be followed for 5 years. A literature review is presented of the current status of endovascular treatment of CLI with drug-eluting balloon and standard PTA. The rationale and design of the IN.PACT DEEP Trial are discussed. IN.PACT DEEP is a milestone, prospective, randomized, robust, independent core lab-adjudicated CLI trial that will evaluate the role of a new infrapopliteal revascularization technology, the IA-DEB, compared to PTA. It will assess the overall impact on infrapopliteal artery patency, limb salvage, wound healing, pain control, QoL, and patient mobility. The 1-year results of the adjudicated co-primary and secondary endpoints will be available in 2014. TRIAL REGISTRATION NCT00941733.
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Affiliation(s)
- Thomas Zeller
- Department of Angiology, Universitäts Herzzentrum Freiburg Bad Krozingen, Bad Krozingen, Germany.
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Zeller T, Baumgartner I, Scheinert D, Brodmann M, Bosiers M, Micari A, Peeters P, Vermassen F, Landini M. IN.PACT Amphirion paclitaxel eluting balloon versus standard percutaneous transluminal angioplasty for infrapopliteal revascularization of critical limb ischemia: rationale and protocol for an ongoing randomized controlled trial. Trials 2014; 15:63. [PMID: 24552184 PMCID: PMC3936931 DOI: 10.1186/1745-6215-15-63] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 01/28/2014] [Indexed: 11/10/2022] Open
Abstract
Background The effectiveness and durability of endovascular revascularization therapies for chronic critical limb ischemia (CLI) are challenged by the extensive burden of infrapopliteal arterial disease and lesion-related characteristics (e.g., severe calcification, chronic total occlusions), which frequently result in poor clinical outcomes. While infrapopliteal vessel patency directly affects pain relief and wound healing, sustained patency and extravascular care both contribute to the ultimate “patient-centric” outcomes of functional limb preservation, mobility and quality of life (QoL). Methods/Design IN.PACT DEEP is a 2:1 randomized controlled trial designed to assess the efficacy and safety of infrapopliteal arterial revascularization between the IN.PACT Amphirion™ paclitaxel drug-eluting balloon (IA-DEB) and standard balloon angioplasty (PTA) in patients with Rutherford Class 4-5-6 CLI. Discussion This multicenter trial has enrolled 358 patients at 13 European centers with independent angiographic core lab adjudication of the primary efficacy endpoint of target lesion late luminal loss (LLL) and clinically driven target lesion revascularization (TLR) in major amputation-free surviving patients through 12-months. An independent wound core lab will evaluate all ischemic wounds to assess the extent of healing and time to healing at 1, 6, and 12 months. A QoL questionnaire including a pain scale will assess changes from baseline scores through 12 months. A Clinical Events Committee and Data Safety Monitoring Board will adjudicate the composite primary safety endpoints of all-cause death, major amputation, and clinically driven TLR at 6 months and other trial endpoints and supervise patient safety throughout the study. All patients will be followed for 5 years. A literature review is presented of the current status of endovascular treatment of CLI with drug-eluting balloon and standard PTA. The rationale and design of the IN.PACT DEEP Trial are discussed. IN.PACT DEEP is a milestone, prospective, randomized, robust, independent core lab-adjudicated CLI trial that will evaluate the role of a new infrapopliteal revascularization technology, the IA-DEB, compared to PTA. It will assess the overall impact on infrapopliteal artery patency, limb salvage, wound healing, pain control, QoL, and patient mobility. The 1-year results of the adjudicated co-primary and secondary endpoints will be available in 2014. Trial registration NCT00941733
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Affiliation(s)
- Thomas Zeller
- Department of Angiology, Universitäts Herzzentrum Freiburg Bad Krozingen, Bad Krozingen, Germany.
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Baumann F, Engelberger RP, Willenberg T, Do DD, Kalka C, Baumgartner I, Diehm N. Infrapopliteal lesion morphology in patients with critical limb ischemia: implications for the development of anti-restenosis technologies. J Endovasc Ther 2013; 20:149-56. [PMID: 23581754 DOI: 10.1583/1545-1550-20.2.149] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE To angiographically evaluate infrapopliteal arterial lesion morphology in a consecutive series of patients presenting with critical limb ischemia (CLI) and undergoing infrapopliteal angioplasty. METHODS A prospective analysis was undertaken of a consecutive series of CLI patients undergoing endovascular therapy in a tertiary referral center in the year 2011. Morphological assessment of baseline angiograms obtained prior to revascularization included lesion length, assessment of calcification using a semi-quantitative scoring system, and reference vessel diameter (RVD) measurement. Delta RVDs were assessed subtracting distal RVDs from proximal RVDs. A total of 197 infrapopliteal lesions in 105 CLI patients (n=106 limbs) were assessed. Of these, 136 lesions were treated by endovascular means. RESULTS The average length of treated lesions was 87.1±43.8 mm in stenoses and 124.0±78.3 mm in chronic occlusions (p<0.001). Mean RVD proximal to the lesions was 1.88 mm whereas it was 1.66 mm distal to the lesions (p≤0.03). Mean arterial calcification was 1.15. CONCLUSION This prospective angiographic series underlines the complex nature and extensive longitudinal involvement of infrapopliteal lesions in CLI patients. These findings should be taken into consideration for anti-restenosis concepts in this challenging subgroup of peripheral artery disease patients.
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Affiliation(s)
- Frederic Baumann
- Clinical and Interventional Angiology, Swiss Cardiovascular Center, Inselspital, University Hospital of Bern, Switzerland
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Benjamin MM, Roberts WC. Facts and principles learned at the 39th Annual Williamsburg Conference on Heart Disease. Proc AMIA Symp 2013; 26:124-36. [PMID: 23543967 DOI: 10.1080/08998280.2013.11928935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Mina M Benjamin
- Departments of Internal Medicine (Benjamin, Roberts) and Pathology (Roberts), and the Baylor Heart and Vascular Institute (Roberts), Baylor University Medical Center at Dallas
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Lo RC, Darling J, Bensley RP, Giles KA, Dahlberg SE, Hamdan AD, Wyers M, Schermerhorn ML. Outcomes following infrapopliteal angioplasty for critical limb ischemia. J Vasc Surg 2013; 57:1455-63; discussion 1463-4. [PMID: 23375610 DOI: 10.1016/j.jvs.2012.10.109] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 10/24/2012] [Accepted: 10/25/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Infrapopliteal angioplasty (percutaneous transluminal angioplasty [PTA]) is routinely used to treat critical limb ischemia (CLI) despite limited data on long-term outcomes. METHODS We reviewed all patients undergoing infrapopliteal PTA for CLI from 2004 to 2012 stratified by TransAtlantic Inter-Society Consensus (TASC) class. Outcomes included restenosis, primary patency, reintervention (w/PTA or bypass), amputation, procedural complications, wound healing, and survival. RESULTS Infrapopliteal PTA (stenting 14%, multilevel intervention 50%) was performed in 459 limbs of 413 patients (59% male) with a technical success of 93% and perioperative complications in 11%. TASC class was 16% A, 22% B, 27% C, and 34% D. Multilevel interventions were performed in 50% of limbs and were evenly distributed among all TASC classes. All technical failures were TASC D lesions. Mean follow-up was 15 months; 5-year survival was 49%. One- and 5-year primary patency was 57% and 38% and limb salvage was 84% and 81%, respectively. Restenosis was associated with TASC C (hazard ratio [HR], 2.2; 95% CI, 1.2-3.9; P = .010) and TASC D (HR, 2.4; 95% CI, 1.3-4.4; P = .004) lesions. Amputation rates were higher in patients who were not candidates for bypass (HR, 4.4; 95% CI, 2.6-7.5; P < .001) and with TASC D lesions (HR, 3.8; 95% CI, 1.1-12.5; P = .03). Unsuitability for bypass was also predictive of repeat PTA (HR, 1.8; 95% CI, 1.0-3.4; P = .047). Postoperative clopidogrel use was associated with lower rates of any revascularization (HR, 0.46; 95% CI, 0.25-0.83; P = .011). CONCLUSIONS Infrapopliteal PTA is effective primary therapy for TASC A, B, and C lesions. Surgical bypass should be offered to patients with TASC D disease who are suitable candidates. Multilevel intervention does not adversely affect outcome.
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Affiliation(s)
- Ruby C Lo
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass 02215, USA
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Lepäntalo MJ, Houbballah R, Raux M, LaMuraglia G. Lower extremity bypass vs endovascular therapy for young patients with symptomatic peripheral arterial disease. J Vasc Surg 2012; 56:545-54. [DOI: 10.1016/j.jvs.2012.06.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Neville R, Lidsky M, Capone A, Babrowicz J, Rahbar R, Sidawy A. An Expanded Series of Distal Bypass Using the Distal Vein Patch Technique to Improve Prosthetic Graft Performance in Critical Limb Ischemia. Eur J Vasc Endovasc Surg 2012; 44:177-82. [DOI: 10.1016/j.ejvs.2012.04.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2012] [Accepted: 04/16/2012] [Indexed: 11/24/2022]
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Houbballah R, Raux M, LaMuraglia G. Part Two: Against the Motion. Endovascular Therapy is the Preferred Treatment for Patients <65 Years Old with Symptomatic Infrainguinal Arterial Disease. Eur J Vasc Endovasc Surg 2012; 44:116-9. [DOI: 10.1016/j.ejvs.2012.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Part One: For the Motion. Lower Extremity Bypass versus Endovascular Therapy for Young Patients with Symptomatic Peripheral Arterial Disease. Eur J Vasc Endovasc Surg 2012; 44:112-5. [DOI: 10.1016/j.ejvs.2012.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Fernández-Samos Gutiérrez R. El modelo angiosoma en la estrategia de revascularización de la isquemia crítica. ANGIOLOGIA 2012. [DOI: 10.1016/j.angio.2012.03.003] [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]
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Scatena A, Petruzzi P, Ferrari M, Rizzo L, Cicorelli A, Berchiolli R, Goretti C, Bargellini I, Adami D, Iacopi E, Del Corso A, Cioni R, Piaggesi A. Outcomes of three years of teamwork on critical limb ischemia in patients with diabetes and foot lesions. INT J LOW EXTR WOUND 2012; 11:113-9. [PMID: 22665920 DOI: 10.1177/1534734612448384] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To evaluate the outcomes of a multidisciplinary team working on diabetic foot (DF) patients with critical limb ischemia (CLI) in a specialized center, the authors retrospectively traced all the patients admitted in their department in 3 consecutive years with a diagnosis of CLI. From January 2006 to December 2008, 245 consecutive DF patients with CLI according the TransAtlantic interSociety Consensus II criteria were included in the study. Treatment strategy was decided by a team of diabetologists, inteventional radiologists, and vascular surgeons. Technical and clinical success, mortality, and ulcer recurrence were evaluated at 6 months and at a mean follow-up of 19.5 ± 13.4 months. Percutaneous transluminal angioplasty (PTA) was performed in 189 (77%) patients, whereas medical treatment, open surgical revascularization (OSR), and primary amputation were performed in 44 (18.3%), 11 (4.3%), and 1 (0.5%) patients, respectively. Revascularization was successful in 227/233 (97.4%) patients. At follow-up, the overall clinical success rate was 60.4%; it was significantly (P = .001) higher after revascularization (75.9%) compared with medical treatment (48.3%). During follow-up, surgical interventions in the foot were 1.5 ± 0.4 in those treated with PTA, 1.6 ± 0.5 in those treated with OSR, and 0.3 ± 0.8 in those receiving medical therapy (P < .05 compared with the others). Ulcer recurrence occurred in 29 (11.8%) patients: 4 (1.6%) in PTA, 2 (0.8%) in OSR, and 23 (9.4%) in the medical therapy group (P < .05). Major amputation rate was 9.3%, being significantly (P = .04) lower after revascularization (5.2%) compared with medical therapy alone (13.8%). Cumulative mortality rate was 10.6%. In conclusion, this study confirms the positive role of a PTA-first approach for revascularizing the complex cases of DF with CLI in a teamwork management strategy.
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Affiliation(s)
- Alessia Scatena
- Diabetic Foot Section, Department of Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Schaper NC, Andros G, Apelqvist J, Bakker K, Lammer J, Lepantalo M, Mills JL, Reekers J, Shearman CP, Zierler RE, Hinchliffe RJ. Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot. Diabetes Metab Res Rev 2012; 28 Suppl 1:218-24. [PMID: 22271741 DOI: 10.1002/dmrr.2255] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The International Working Group on the Diabetic Foot (IWDGF) has produced in 2011 a guideline on the diagnosis and treatment of peripheral arterial disease in patients with diabetes and a foot ulcer. This document, together with a systematic review that provided the background information on management, was produced by a multidisciplinary working group of experts in the field and was endorsed by the IWDGF. This progress report is based on these two documents and earlier consensus texts of the IWDGF on the diagnosis and management of diabetic foot ulcers. Its aim is to give the clinician clear guidance on when and how to diagnose peripheral arterial disease in patients with diabetes and a foot ulcer and when and which treatment modalities should be considered, taking both risks and benefits into account.
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Affiliation(s)
- N C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands.
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Abisi S, Kapur R, Braithwaite B, Habib S. The Feasibility of Reentry Device in Recanalization of TASC C and D Iliac Occlusions. Vasc Endovascular Surg 2011; 45:352-5. [DOI: 10.1177/1538574411401762] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aim: To determine the feasibility of subintimal angioplasty (SIA), aided by reentry device in iliac artery occlusions. Methods: Forty-eight patients with severe claudication (Fontaine-III, n = 24) or critical limb ischaemia (Fontaine-IV, n = 24) had SIA, aided with a reentry device, for chronic iliac occlusions TASC C (n =28) and D (n = 20). The primary outcome was arterial patency at duplex follow-up. Secondary outcomes were primary failure, postprocedural complications, stent use, late occlusions, and length of hospital stay. Results: The patency rate was 89% at a mean follow-up of 13 (±11) months. There were 2 primary failures, no postprocedural complications, and 5 late occlusions. Almost 80% of patients were ready for discharge within 24 hours. Conclusions: Subintimal angioplasty with a reentry device for long iliac occlusions provides a feasible option with excellent results and short hospital stay. A randomized trial of SIA of iliac occlusion versus open reconstruction is now required.
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Affiliation(s)
- Said Abisi
- Department of Vascular and Endovascular Surgery, Nottingham University Hospital, Nottingham, UK,
| | - Rakesh Kapur
- Department of Vascular and Endovascular Surgery, Nottingham University Hospital, Nottingham, UK
| | - Bruce Braithwaite
- Department of Vascular and Endovascular Surgery, Nottingham University Hospital, Nottingham, UK
| | - Said Habib
- Department of Interventional Radiology, Nottingham University Hospital, Nottingham, UK
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Conrad MF, Crawford RS, Hackney LA, Paruchuri V, Abularrage CJ, Patel VI, Lamuraglia GM, Cambria RP. Endovascular management of patients with critical limb ischemia. J Vasc Surg 2011; 53:1020-5. [PMID: 21211929 DOI: 10.1016/j.jvs.2010.10.088] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 10/15/2010] [Accepted: 10/15/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although percutaneous intervention (PTA) is considered first-line therapy for peripheral vascular disease in many scenarios, its role in critical limb ischemia (CLI), wherein anatomic disease is more extensive, remains unclear. In the present study, late (5-year) clinical and patency data for PTA in CLI are defined. METHODS From January 2002 to December 2007, 409 patients underwent infrainguinal PTA ± stent for CLI (Rutherford IV-VI) of 447 limbs. Primary patency, assisted patency, limb salvage, and survival were assessed using Kaplan-Meier. Predictors of patency, limb salvage, and death were determined using multivariate models. RESULTS Demographics included age (70 ± 12 years old), diabetes (65.8%), and dialysis dependence (13%). The superficial femoral artery was treated in 58% of the patients, 16% were limited to the crural vessels, 38% had multilevel treatment, and stents were placed in 26%. Eighty percent of patients received postprocedure clopidogrel. Mean follow-up was 28 months (0-83). Five-year primary and assisted patency were 31% ± 0.04 and 75% ± 0.04, respectively. Limb salvage at 5 years was 74% ± 0.038. Sixty-three patients had major amputations. Survival at 5 years was 39% ± 0.03. Multivariate analysis identified dialysis dependence (P = .0005; 2.7 [1.6-4.8]), ≤1 vessel runoff (P = .02; 1.5 [1.1-2.0]), and warfarin use (P = .001; 1.7 [1.25-2.3]) as negative predictors of primary patency, but none of these were negative predictors of assisted patency. Dialysis dependence (P = .006; 2.5 [1.3-4.8]), female gender (P = .02; 2.0 [1.1-3.7]), and ≤1 vessel run-off (P = .04; 1.8 [1.0-3.2]) predicted limb loss. Dialysis dependence (P = .0003; 2.3 [1.5-3.5]), diabetes (P = .04; 1.5 [0.5-2.1]), and poor run-off (P = .04; 1.6 [1.2-2.1]) were predictors of mortality. CONCLUSION Although primary patency is low, excellent limb salvage rates can be achieved in patients with CLI through close follow-up and secondary interventions. These data, and the 12% annual death rate, validate PTA as first-line therapy in patients with CLI.
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Affiliation(s)
- Mark F Conrad
- Massachusetts General Hospital, Vascular and Endovascular Surgery, 15 Parkman Street, WAC 440, Boston, MA 02114, USA.
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Yan BP, Moran D, Hynes BG, Kiernan TJ, Yu CM. Advances in Endovascular Treatment of Critical Limb Ischemia. Circ J 2011; 75:756-65. [DOI: 10.1253/circj.cj-11-0103] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Bryan P Yan
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital & Institute of Vascular Medicine, The Chinese University of Hong Kong
| | - Darragh Moran
- Department of Cardiology, Cork University Hospital, University College Cork School of Medicine
| | - Brian G Hynes
- Section of Interventional Cardiology and Vascular Medicine, Massachusetts General Hospital
| | - Thomas J Kiernan
- Department of Cardiology, Cork University Hospital, University College Cork School of Medicine
| | - Cheuk-Man Yu
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital & Institute of Vascular Medicine, The Chinese University of Hong Kong
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Alexandrescu V, Ngongang C, Vincent G, Ledent G, Hubermont G. Deep calf veins arterialization for inferior limb preservation in diabetic patients with extended ischaemic wounds, unfit for direct arterial reconstruction: preliminary results according to an angiosome model of perfusion. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2010; 12:10-9. [PMID: 21241966 DOI: 10.1016/j.carrev.2009.12.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Accepted: 12/16/2009] [Indexed: 11/27/2022]
Abstract
AIM OF THE STUDY The study proposes to evaluate the limb salvage in diabetic ischemic limbs with foot wounds, where all types of common arterial reconstructions have previously failed or were impracticable, by using the "SAVES" technique (selective arterio-venous endoluminal switch) for deep calf veins arterialization upon an angiosomes model of distribution. MATERIALS AND METHODS Since January 2001 until September 2009, a series of 26 limbs with threatening ischemic wounds in 25 diabetic patients at high risk for major amputation and no feasible conventional revascularizations, were treated by the hybrid (surgical and endovascular) SAVES technique and were retrospectively reviewed. The method consists in selective arterialization of the deep calf veins with synchronous endoluminal exclusion of the collaterals, guided by an angiosomes- model of vascularization. There were 12 limbs treated by preferential anterior tibial veins arterialization, 11 with revascularizations in the posterior tibial and three others targeting the peroneal-related territorial wound distribution. RESULTS The initial technical success was achieved in 21 of 26 limbs (80%) with 0% 30-day perioperative mortality rate. The cumulative primary and secondary patency were: 66%, 60% and 48%, at 12, 24 and 36 months, respectively. Limb salvage revealed 73% at one year and steady 73% afterwards, while the clinical success was: 68%, 60% and 60% at identical time intervals. CONCLUSION Selective deep calf venous arterialization oriented by an angiosome model for reperfusion may represent a complementary alternative for limb salvage in extreme situations, inoperable by direct arterial methods. Larger groups of study are needed to ascertain these preliminary observations.
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Affiliation(s)
- Vlad Alexandrescu
- Department of Surgery, Princesse Paola Hospital, Marche-en-Famenne, Belgium.
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Endovascular Management of Critical Limb Ischemia. Eur J Vasc Endovasc Surg 2010; 39:756-61. [DOI: 10.1016/j.ejvs.2010.02.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 02/16/2010] [Indexed: 11/21/2022]
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Abstract
OBJECTIVE The objective of this randomized study was to compare the efficacy of the CHIVA method for the treatment of varicose veins with respect to the standard treatment of stripping. CONTEXT Varicose veins are a sign of chronic venous disorder. For over a century, varicose veins have been treated with surgical ablative techniques, with stripping being the standard treatment. Currently, postsurgical varicose veins recurrence (20%-80%) is a common, complex, and costly problem. Ambulatory Conservative Hemodynamic Management of Varicose Veins (CHIVA) is a new option for treating chronic venous disorder. METHODS In this open-label, randomized controlled trial, 501 adult patients with primary varicose veins were treated in a single center. They were assigned to an experimental group, the CHIVA method (n = 167) and 2 control groups: stripping with clinic marking (n = 167) and stripping with duplex marking (n = 167). The outcome measure was clinical recurrence within 5 years, assessed clinically by previously trained independent observers. Duplex ultrasonography was also used to assess recurrences and causes. RESULTS In an intention-to-treat analysis, clinical outcomes in the CHIVA group were better (44.3% cure, 24.6% improvement, 31.1% failure) than in both the stripping with clinic marking (21.0% cure, 26.3% improvement, 52.7% failure) and stripping with duplex marking (29.3% cure, 22.8% improvement, 47.9% failure) groups. The ordinal odds ratio between the stripping with clinic marking and CHIVA groups, of recurrence at 5 years of follow-up, was 2.64, (95% confidence interval [CI]: 1.76-3.97, P < 0.001). The ordinal odds ratio of recurrence at 5-years of follow-up, between the stripping with duplex marking and CHIVA group, was 2.01 (95% CI: 1.34-3.00, P < 0.001). This trial is registered at ISRCTN and carries the following ID number: ISRCTN52861672, available at: http://isrctn.org. CONCLUSIONS The present results indicate that, thanks to specific venous hemodynamic evaluation, the CHIVA method is more effective than stripping with clinical marking or stripping with duplex marking to treat varicose veins. When carrying out a stripping intervention, Duplex marking does not improve the clinical results of this ablative technique.
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Lawrence P, Chandra A. When should Open Surgery be the Initial Option for Critical Limb Ischaemia? Eur J Vasc Endovasc Surg 2010; 39 Suppl 1:S32-7. [DOI: 10.1016/j.ejvs.2009.11.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Accepted: 11/26/2009] [Indexed: 10/20/2022]
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Kalish J, Hamdan A. Management of diabetic foot problems. J Vasc Surg 2010; 51:476-86. [DOI: 10.1016/j.jvs.2009.08.043] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 08/11/2009] [Accepted: 08/12/2009] [Indexed: 01/20/2023]
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Feinglass J, Sohn MW, Rodriguez H, Martin GJ, Pearce WH. Perioperative outcomes and amputation-free survival after lower extremity bypass surgery in California hospitals, 1996-1999, with follow-up through 2004. J Vasc Surg 2009; 50:776-783.e1. [PMID: 19595538 DOI: 10.1016/j.jvs.2009.05.050] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Revised: 05/20/2009] [Accepted: 05/21/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE There are very few population-based studies of long-term outcomes after lower extremity (LE) bypass graft surgery. This study analyzes perioperative and long-term limb salvage and amputation-free survival outcomes for patients undergoing initial aortoiliac or femoropopliteal bypass graft surgery in California hospitals from 1996 to 1999. METHODS Administrative data with encrypted identifiers were used to identify a chronologically first, index admission of all patients undergoing LE bypass procedures for occlusive disease from 1996 to 1999. A 1993 to 1995 look-back period was used to exclude patients who had undergone prior bypass surgery or amputation procedures. Patients with incident procedures were then followed forward to determine subsequent hospitalizations and vital status through 2004. The study comprised 28,128 patients discharged from 345 California hospitals with a median 61.5-month follow-up. Risk factors included demographic characteristics, comorbid conditions, admission type, gangrene or ulceration, operation level, hospital LE bypass surgery volume, and year of discharge. Logistic regression was used to analyze 30-day outcomes, and Kaplan-Meier analysis and Cox proportional hazard models were used to analyze amputation-free survival. RESULTS Overall 30-day mortality was 4.3, and the 30-day major amputation rate was 2.6%. Limb salvage was 81.9% at 5 years and 76.4% at 9 years. Amputation-free survival was 51.5% at 5 years and 34.1% at 9 years. Risk factors were generally similar for both perioperative and late outcomes. Advanced age, higher comorbidity level, gangrene, and emergency or nursing home admission conferred significantly greater risk. Hospital volume was associated with both perioperative and late outcomes. African American and Hispanic patients had much higher amputation rates but did not have higher mortality risk after controlling for baseline severity of illness. CONCLUSIONS Long-term outcomes of LE bypass surgery were superior for high-volume hospital patients. Graft surveillance and risk factor follow-up care provide a major opportunity for quality improvement efforts. The contrast between traditional limb salvage and amputation-free survival outcomes raises questions about the value of surgical treatment, particularly for patients with limited life expectancy and without coding of tissue loss or critical limb ischemia.
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Affiliation(s)
- Joe Feinglass
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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Bown MJ, Bolia A, Sutton AJ. Subintimal angioplasty: meta-analytical evidence of clinical utility. Eur J Vasc Endovasc Surg 2009; 38:323-37. [PMID: 19570689 DOI: 10.1016/j.ejvs.2009.05.014] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Accepted: 05/22/2009] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to determine accurate estimates of the success rate of subintimal angioplasty in terms of ability to recanalise occluded vessels, patency over time and limb salvage rates. DESIGN A meta-analysis of published literature. MATERIALS All studies reporting unique patient data published in English language between 1989 and 2008. METHODS Separate meta-analyses were performed for immediate technical success, 12-month patency rates and 12-month limb salvage rates. Longer-term outcomes were analyzed in separate meta-analyses. Meta-regression was applied to determine whether any of these outcomes had improved over time. RESULTS Pooled estimates for technical success, primary patency at 12 months and limb salvage at 12 months were 85.7% (95% confidence interval: 83.3%-87.7%, 2810 limbs), 55.8% (95% confidence interval: 47.9%-63.4%, 1342 limbs), and 89.3% (95% confidence interval: 85.5%-92.2%, 2810 limbs), respectively. Regression analysis demonstrated no significant change in outcomes over time. There was some evidence of publication bias, however, after adjusting for this there was little change in the pooled outcome estimates. CONCLUSIONS This study demonstrates that the outcomes for subintimal angioplasty are good and that this method should be considered as an alternative to surgical bypass.
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Affiliation(s)
- M J Bown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
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Lazarides MK. The Impact of Interventional Management on Healing of Ischemic Foot Lesions. INT J LOW EXTR WOUND 2009; 8:64-6. [DOI: 10.1177/1534734609334884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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