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Dogbe L, Zil-E-Ali A, Krause KJ, So K, Aziz F. Preoperative Chronic Steroid Use is Associated with Increased Incidence of Postoperative Mortality and Limb Loss following Peripheral Arterial Bypass Surgery for Chronic Limb Threatening Ischemia. Ann Vasc Surg 2024; 101:95-104. [PMID: 38154493 DOI: 10.1016/j.avsg.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/27/2023] [Accepted: 11/10/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Steroids are a commonly prescribed medication in the United States and have been associated with poor surgical and treatment outcomes. The objective of this study is to assess the relationship between chronic steroid use and surgical outcomes of femoropopliteal and femoral-distal bypasses in patients suffering from chronic limb threatening ischemia (CLTI). METHODS All adult patients undergoing femoropopliteal and femoral-distal bypasses with single segment autologous vein with an indication of CLTI in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2012 and 2021 were stratified between chronic preoperative steroid use (Group I) and no preoperative use (Group II). Primary outcomes of the study included 30-day mortality, amputation, and combined outcome of mortality and/or limb loss. Secondary outcomes included specific bypass related, cardiovascular, respiratory and renal outcomes. RESULTS A total of 8,324 patients (66.8% Male, 33.2% Females) underwent peripheral arterial bypass operations for the indication of chronic limb threatening ischemia. The median age was 68 years. Group I included 408 patients (4.9%) and Group II included 7,916 patients (95.1%). As compared to patients in Group II, those in Group I were more likely to be females (Group I: 42.2% vs. Group II: 32.8%), more likely to have co-existing chronic obstructive pulmonary disease (Group I: 20.6% vs. Group II: 11.8%), less likely to be diabetic (Group I: 45.9% vs. Group II: 48%), less likely to be smokers (Group I: 30.6% vs. Group II: 45.4%) and more likely to be in American Society of Anesthesiologists III or IV Classes (Group I: 98% vs. Group II: 96.5%) (all P < 0.05). Primary outcomes were as follows: 30-day mortality (Group I: 3.3% vs. Group II: 1.7%), amputation (Group I: 5.9% vs. Group II: 2.8%), 30-day mortality and/or amputation (Group I: 9.1% vs. Group II: 4.5%) (all P < 0.05). Among secondary outcomes, the following were found to be statistically significant: untreated loss of patency (Group I: 4.2% vs. Group II: 1.7%), significant bleeding (Group I: 26.2% vs. Group II: 16.5%), wound infection/complication (Group I: 18.6% vs. Group II: 15%), and return to operating room (Group I: 21.8% vs. Group II: 16.7%) (all P < 0.05). As compared to patients with an indication of tissue loss (Rutherford's class V and VI), patients in Group I with an indication of rest pain (Rutherford's class IV) were more likely to experience 30-day mortality, major amputation and a composite of mortality and amputation. Risk adjusted analysis showed that chronic steroid use has a statistically significant effect on 30-day mortality (adjusted odds ratio [AOR] 1.7, P = 0.05), amputation (AOR 2.05, P < 0.001), composite outcomes of mortality and amputation (AOR 1.959, P < 0.001), untreated loss of patency (AOR 2.31, P = 0.002), bleeding (AOR 1.33, P < 0.011) and unplanned return to the operating room (AOR 1.36, P = 0.014). CONCLUSIONS Chronic steroid use in patients undergoing femoropopliteal or femoral-distal bypass is associated with a higher risk of 30-day mortality, major amputation, readmission, bleeding, return to operating room, and untreated loss of patency. No significant difference in outcomes were appreciated in patients with chronic steroid use and with Rutherford class V or VI disease (tissue loss), suggesting that the effects of steroids may be less prominent in those with the most advanced peripheral arterial disease. These findings may aid physicians with risk stratification and preoperative discussions regarding open revascularization in patients receiving chronic steroid therapy. More studies including randomized trials are needed to guide perioperative management of steroids in this cohort.
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Affiliation(s)
- Leana Dogbe
- Office of Medical Education, Penn State University College of Medicine, Hershey, PA
| | - Ahsan Zil-E-Ali
- Division of Vascular Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Kayla J Krause
- Office of Medical Education, Penn State University College of Medicine, Hershey, PA
| | - Kristine So
- Division of Vascular Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Faisal Aziz
- Division of Vascular Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA.
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Brauckmann V, Block OM, Pardo LA, Lehmann W, Braatz F, Felmerer G, Mönnighoff S, Ernst J. Can Early Post-Operative Scoring of Non-Traumatic Amputees Decrease Rates of Revision Surgery? MEDICINA (KAUNAS, LITHUANIA) 2024; 60:565. [PMID: 38674211 PMCID: PMC11052005 DOI: 10.3390/medicina60040565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/03/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: Medical registries evolved from a basic epidemiological data set to further applications allowing deriving decision making. Revision rates after non-traumatic amputation are high and dramatically impact the following rehabilitation of the amputee. Risk scores for revision surgery after non-traumatic lower limb amputation are still missing. The main objective was to create an amputation registry allowing us to determine risk factors for revision surgery after non-traumatic lower-limb amputation and to develop a score for an early detection and decision-making tool for the therapeutic course of patients at risk for non-traumatic lower limb amputation and/or revision surgery. Materials and Methods: Retrospective data analysis was of patients with major amputations lower limbs in a four-year interval at a University Hospital of maximum care. Medical records of 164 patients analysed demographics, comorbidities, and amputation-related factors. Descriptive statistics analysed demographics, prevalence of amputation level and comorbidities of non-traumatic lower limb amputees with and without revision surgery. Correlation analysis identified parameters determining revision surgery. Results: In 4 years, 199 major amputations were performed; 88% were amputated for non-traumatic reasons. A total of 27% of the non-traumatic cohort needed revision surgery. Peripheral vascular disease (PVD) (72%), atherosclerosis (69%), diabetes (42%), arterial hypertension (38%), overweight (BMI > 25), initial gangrene (47%), sepsis (19%), age > 68.2 years and nicotine abuse (17%) were set as relevant within this study and given a non-traumatic amputation score. Correlation analysis revealed delayed wound healing (confidence interval: 64.1% (47.18%; 78.8%)), a hospital length of stay before amputation of longer than 32 days (confidence interval: 32.3 (23.2; 41.3)), and a BKA amputation level (confidence interval: 74.4% (58%; 87%)) as risk factors for revision surgery after non-traumatic amputation. A combined score including all parameters was drafted to identify non-traumatic amputees at risk for revision surgery. Conclusions: Our results describe novel scoring systems for risk assessment for non-traumatic amputations and for revision surgery at non-traumatic amputations. It may be used after further prospective evaluation as an early-warning system for amputated limbs at risk of revision.
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Affiliation(s)
- Vesta Brauckmann
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany;
| | - Ole Moritz Block
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center, 37075 Göttingen, Germany (L.A.P.J.); (W.L.); (F.B.); (G.F.)
| | - Luis A. Pardo
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center, 37075 Göttingen, Germany (L.A.P.J.); (W.L.); (F.B.); (G.F.)
| | - Wolfgang Lehmann
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center, 37075 Göttingen, Germany (L.A.P.J.); (W.L.); (F.B.); (G.F.)
| | - Frank Braatz
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center, 37075 Göttingen, Germany (L.A.P.J.); (W.L.); (F.B.); (G.F.)
- Orthobionics Study Programme, Private University of Applied Sciences, 37073 Göttingen, Germany;
| | - Gunther Felmerer
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center, 37075 Göttingen, Germany (L.A.P.J.); (W.L.); (F.B.); (G.F.)
| | - Sebastian Mönnighoff
- Orthobionics Study Programme, Private University of Applied Sciences, 37073 Göttingen, Germany;
| | - Jennifer Ernst
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany;
- Department of Trauma Surgery, Orthopedic Surgery and Plastic Surgery, University Medical Center, 37075 Göttingen, Germany (L.A.P.J.); (W.L.); (F.B.); (G.F.)
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3
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Kokkinidis DG, Schizas D, Pargaonkar S, Karamanis D, Mylonas KS, Hasemaki N, Palaiodimos L, Varrias D, Tzavellas G, Siasos G, Klonaris C, Kharawala A, Chlorogiannis DD, Georgopoulos S, Bakoyiannis C. Differences between Lower Extremity Arterial Occlusion vs. Stenosis and Predictors of Successful Endovascular Interventions. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2029. [PMID: 38004078 PMCID: PMC10673017 DOI: 10.3390/medicina59112029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: In patients with peripheral artery disease, there is insufficient understanding of characteristics that predict successful revascularization of the lower extremity (LE) chronic total occlusions (CTOs) and baseline differences in demographic, clinical, and angiographic characteristics in patients with LE CTO vs. non-CTO. We aim to explore these differences and predictors of successful revascularization among CTO patients. Materials and Methods: Two vascular centers enrolled LE-CTO patients who underwent endovascular revascularization. Data on demographics, clinical, angiographic, and interventional characteristics were collected. LE non-CTO arterial stenosis patients were compared. A total of 256 patients with LE revascularization procedures were studied; among them, 120 had CTOs and 136 had LE stenosis but no CTOs. Results: Aspirin use (Odds ratio, OR: 3.43; CI 1.32-8.88; p = 0.011) was a positive predictor whereas a history of malignancy (OR: 0.27; CI 0.09-0.80; p = 0.018) was a negative predictor of successful crossing in the CTO group. The CTO group had a higher history of myocardial infarction (29.2 vs. 18.3%, p = 0.05), end-stage renal disease (19.2 vs. 9.6%, p = 0.03), and chronic limb-threatening ischemia as the reason for revascularization (64.2 vs. 22.8%, p < 0.001). They were more likely to have advanced TransAtlantic Inter-Society Consensus (TASC) stages, multi-vessel revascularization procedures, longer lesions, and urgent treatment. Conclusions: The use of aspirin is a positive predictor whereas a history of malignancy is a negative predictor for successful crossing in CTO lesions. Additionally, LE-CTO patients have a higher incidence of comorbidities, which is expected given their higher disease burden. Successful endovascular re-vascularization can be associated with baseline clinical variables.
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Affiliation(s)
- Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Dimitrios Schizas
- First Department of Surgery, Laikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Sumant Pargaonkar
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Dimitrios Karamanis
- Department of Economics, University of Piraeus, 18534 Piraeus, Greece
- Department of Health Informatics, Rutgers School of Health Professions, Newark, NJ 07107, USA
| | - Konstantinos S Mylonas
- First Department of Surgery, Laikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Natasha Hasemaki
- First Department of Surgery, Laikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Leonidas Palaiodimos
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Dimitrios Varrias
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Georgios Tzavellas
- Department of Vascular Surgery, Ball Memorial Hospital, Muncie, IN 47303, USA
| | - Gerasimos Siasos
- 3rd Department of Cardiology, Sotiria General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Christos Klonaris
- First Department of Surgery, Laikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Amrin Kharawala
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY 10461, USA
| | | | - Sotirios Georgopoulos
- First Department of Surgery, Laikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
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Higashino N, Iida O, Ishihara T, Hata Y, Toyoshima T, Tsukizawa T, Nishian K, Fujihara M, Kawasaki D, Mano T. Angiographic patterns of restenosis after drug-coated balloon angioplasty for femoropopliteal lesions and 1-year prognosis after repeat endovascular therapy. Catheter Cardiovasc Interv 2023; 102:1114-1121. [PMID: 37855184 DOI: 10.1002/ccd.30856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/19/2023] [Accepted: 10/05/2023] [Indexed: 10/20/2023]
Abstract
AIM The aim of the current study sought to investigate the angiographic patterns of restenosis after drug-coated balloon (DCB) angioplasty for femoropopliteal (FP) lesions and which repeat endovascular therapy (EVT) for DCB restenosis would provide more freedom from recurrent restenosis. METHODS This retrospective multicenter study included 119 limbs (chronic limb-threatening ischemia [CLTI]: 55%, lesion length: 136.9 ± 89.6 mm, chronic total occlusion: 25%) of 95 patients (diabetes mellitus: 70%, hemodialysis: 56%) who were diagnosed with DCB restenosis between January 2018 and December 2019. The cases were classified into three groups based on angiographic patterns of restenosis: Class I: focal lesions ≤50 mm, Class II: diffuse lesions >50 mm, and Class III: totally occluded lesions. The DCB restenosis patterns and frequency and predictors of recurrent restenosis after repeated EVT (re-EVT) were investigated. RESULTS The mean follow-up duration was 29.8 ± 9.5 months. Groups I, II, and III comprised of 30 (25.2%), 55 (46.2%), and 34 (29.0%) cases, respectively. The overall rate of 1-year freedom from recurrent restenosis was 58.2%. One-year rate of freedom from recurrent restenosis after repeat DCB was not statistically different from that after scaffolding (71.1% vs. 74.6%, respectively, p = 0.911); however, it was significantly better than that after noncoated balloon angioplasty (repeat DCB vs. noncoated balloon angioplasty: 71.1% vs. 25.7%, respectively, p < 0.001). Multivariate analysis demonstrated that CLTI (hazard ratio [HR]: 5.15, p < 0.001) and re-EVT with noncoated balloon (HR: 3.16, p < 0.001) were significantly associated with recurrent restenosis; however, Class III pattern of DCB restenosis was not associated with recurrent restenosis (HR: 1.04, p = 0.918). CONCLUSIONS This study revealed the angiographic patterns of restenosis after DCB therapy for FP lesions and the 1-year rate of recurrent restenosis after repeat revascularization. Repeat DCB therapy demonstrated acceptable 1-year recurrent restenosis rates.
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Affiliation(s)
- Naoko Higashino
- Kansai Rosai Hospital, Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Osamu Iida
- Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
| | - Takayuki Ishihara
- Kansai Rosai Hospital, Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Yosuke Hata
- Kansai Rosai Hospital, Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Taku Toyoshima
- Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
| | - Tomofumi Tsukizawa
- Department of Cardiology, Kishiwada Tokushukai Hospital, Kishiwada, Osaka, Japan
| | - Kunihiko Nishian
- Department of Cardiology, Morinomiya Hospital, Morinomiya, Osaka, Japan
| | - Masahiko Fujihara
- Department of Cardiology, Kishiwada Tokushukai Hospital, Kishiwada, Osaka, Japan
| | - Daizo Kawasaki
- Department of Cardiology, Morinomiya Hospital, Morinomiya, Osaka, Japan
| | - Toshiaki Mano
- Kansai Rosai Hospital, Cardiovascular Center, Amagasaki, Hyogo, Japan
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Yu X, Wang B, Qiu C, He Y, Chen T, Zhu Q, Li Z, Wu Z. A systematic review and meta-analysis of primary bypass surgery compared with bypass surgery after endovascular treatment in peripheral artery disease patients. J Vasc Surg 2023; 78:1335-1345.e4. [PMID: 37453586 DOI: 10.1016/j.jvs.2023.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/23/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Both bypass surgery and endovascular treatment are well-recognized interventions for the treatment of peripheral artery disease; however, the effect of failed endovascular treatment on subsequent surgeries remains controversial. A systematic review was conducted to compare the outcomes of primary bypass and bypass surgery after endovascular treatment. METHODS Three academic databases (Embase, PubMed, and Scopus) were searched from their inception to August 2022. Two independent investigators searched for studies that reported the outcomes of primary bypass surgery and bypass surgery after endovascular treatment in patients with peripheral artery disease. Abstracts and full-text studies were screened independently using duplicate data abstraction. Dichotomous outcome measures were reported using a random-effects model to generate a summary odds ratio (OR) and 95% confidence interval (CI). The risk of bias was assessed using the Newcastle-Ottawa Scale. RESULTS Seventeen retrospective observational studies were selected from 3911 articles and included 8064 patients, 6252 of whom underwent primary bypass surgery and 1812 underwent bypass surgery after endovascular treatment. The mean age was 69.0 years and 61.2% (n = 4938) were male. For perioperative outcomes, the 30-day results showed no difference in mortality (OR, 0.76; 95% CI, 0.53-1.10), or amputation (OR, 0.89; 95% CI, 0.67-1.20). For short- to mid-term outcomes, primary patency did not differ at 6 months (OR, 0.98; 95% CI, 0.81-1.19), 1 year (OR, 1.12; 95% CI, 0.97-1.30), or 2 years (OR, 1.17; 95% CI, 0.85-1.61) follow-up. Amputation-free survival did not differ at 6 months (OR, 1.03; 95% CI, 0.82-1.30), 1 year (OR, 1.09; 95% CI, 0.89-1.32), 2 years (OR, 1.18; 95% CI, 0.93-1.50), or 3 years (OR, 1.09; 95% CI, 0.84-1.40) of follow-up. No significant difference was found in overall survival or second patency. CONCLUSIONS This meta-analysis of retrospective, nonrandomized, observational studies suggests that prior endovascular treatment of lower extremity arterial disease does not result in worse perioperative, short-term, or mid-term clinical outcomes of subsequent infrainguinal bypass surgery compared with patients without prior endovascular treatment.
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Affiliation(s)
- Xinyu Yu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Bing Wang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chenyang Qiu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yangyan He
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Tianchi Chen
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qianqian Zhu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhenjiang Li
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ziheng Wu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
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Krishnaswamy A, Isogai T, Brilakis ES, Nanjundappa A, Ziada KM, Parikh SA, Rodés-Cabau J, Windecker S, Kapadia SR. Same-Day Discharge After Elective Percutaneous Transcatheter Cardiovascular Interventions. JACC Cardiovasc Interv 2023; 16:1561-1578. [PMID: 37438024 DOI: 10.1016/j.jcin.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 04/23/2023] [Accepted: 05/08/2023] [Indexed: 07/14/2023]
Abstract
Percutaneous transcatheter interventions have evolved as standard therapies for a variety of cardiovascular diseases, from revascularization for atherosclerotic vascular lesions to the treatment of structural cardiac diseases. Concomitant technological innovations, procedural advancements, and operator experience have contributed to effective therapies with low complication rates, making early hospital discharge safe and common. Same-day discharge presents numerous potential benefits for patients, providers, and health care systems. There are several key elements that are shared across the spectrum of interventional cardiology procedures to create a successful same-day discharge pathway. These include appropriate patient and procedure selection, close postprocedural observation, predischarge assessments specific for each type of procedure, and the existence of a patient support system beyond hospital discharge. This review provides the rationale, available data, and a framework for same-day discharge across the spectrum of coronary, peripheral, and structural cardiovascular interventions.
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Affiliation(s)
- Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Aravinda Nanjundappa
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Khaled M Ziada
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sahil A Parikh
- Division of Cardiology and Center for Interventional Vascular Therapy, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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7
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Smith JA, Yang L, Chen L, Kumins N, Cho JS, Harth K, Wong V, Kashyap V, Colvard B. Trends and outcomes associated with intravascular ultrasound use during femoropopliteal revascularization in the Vascular Quality Initiative. J Vasc Surg 2023; 78:209-216.e1. [PMID: 36944390 DOI: 10.1016/j.jvs.2023.03.028] [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: 11/11/2022] [Revised: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Intravascular ultrasound (IVUS) use in lower extremity interventions is growing in popularity owing to its imaging in the axial plane, superior detail in imaging lesion characteristics, and its enhanced ability to delineate lesion severity and extent compared with catheter angiograms. However, there are conflicting data regarding whether IVUS affects outcomes. The purpose of this study was to assess the effect associated with IVUS implementation in femoropopliteal interventions. METHODS This retrospective cohort study used Vascular Quality Initiative data. Patients undergoing an index endovascular femoropopliteal revascularization from 2016 to 2021 were included. Patients were differentiated by whether or not IVUS was used to assess the femoropopliteal segment during intervention (no IVUS, IVUS). Propensity score matching, based on preoperative demographics and measures of disease severity was used. Primary outcomes were major amputation-free survival (AFS), femoropopliteal reintervention-free survival (RFS), and primarily patent survival (PPS) at 12 months. RESULTS IVUS use grew steadily throughout the study period, comprising 0.6% of interventions in 2016 and increasing to 8.2% of interventions by 2021; growth was most dramatic in ambulatory surgical center or office-based laboratory settings where IVUS use grew from 4.4% to 43% to 47% of interventions. In unmatched cohorts, patients receiving interventions using IVUS tended to have lower prevalence of multiple cardiovascular comorbidities (eg, congestive heart failure, hypertension, diabetes, and dialysis dependence) and presented more often with claudication and less often with chronic limb-threatening ischemia (CLTI). Intraoperatively, IVUS was used more often in complex femoropopliteal lesions (Transatlantic Intersociety grade D vs A), and more often in conjunction with stenting and/or atherectomy. IVUS use was associated with improved AFS, but similar RFS and PPS at 12 months. However, in multivariable analysis IVUS was not associated with any of the primary outcomes independently; rather, all outcomes were influenced primarily by CLTI, dialysis dependence, and prior major amputation status; technical outcomes (ie, RFS and PPS loss) were further driven by complexity of lesion (worse in Transatlantic Intersociety grade D vs A lesions) and treatment setting (ie, ambulatory surgical center or office-based laboratory setting associated with increased hazard for RFS and PPS loss). CONCLUSIONS IVUS implementation in femoropopliteal interventions is growing, with rapid adoption among interventions in ambulatory surgical centers and office-based laboratories. IVUS was not associated with an effect on technical outcomes at 12 months; improvement in major AFS was observed; however, multivariable analysis suggests this finding may be an effect of confounding by multiple factors highly associated with IVUS use, namely, in patients with lower prevalence of CLTI, dialysis dependence, and prior major amputations, thus conveying baseline lower risk for major amputation and death.
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Affiliation(s)
- Justin A Smith
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH.
| | - Lucy Yang
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Lin Chen
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Norman Kumins
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Karem Harth
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Virginia Wong
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Vikram Kashyap
- Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Benjamin Colvard
- Division of Vascular Surgery and Endovascular Therapy, Harrington Heart and Vascular Institute, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
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8
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Ramkumar N, Suckow BD, Behrendt CA, Mackenzie TA, Sedrakyan A, Brown JR, Goodney PP. Association between sex and long-term outcomes of endovascular treatment for peripheral artery disease. Catheter Cardiovasc Interv 2023; 101:877-887. [PMID: 36924009 DOI: 10.1002/ccd.30617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 02/23/2023] [Accepted: 02/25/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Endovascular peripheral vascular intervention (PVI) has become the primary revascularization technique used for peripheral artery disease (PAD). Yet, there is limited understanding of long-term outcomes of PVI among women versus men. In this study, our objective was to investigate sex differences in the long-term outcomes of patients undergoing PVI. METHODS We performed a cohort study of patients undergoing PVI for PAD from January 1, 2010 to September 30, 2015 using data in the Vascular Quality Initiative (VQI) registry. Patients were linked to fee-for-service Medicare claims to identify late outcomes including major amputation, reintervention, major adverse limb event (major amputation or reintervention [MALE]), and mortality. Sex differences in outcomes were evaluated using cumulative incidence curves, Gray's test, and mixed effects Cox proportional hazards regression accounting for patient and lesion characteristics using inverse probability weighted estimates. RESULTS In this cohort of 15,437 patients, 44% (n = 6731) were women. Women were less likely to present with claudication than men (45% vs. 49%, p < 0.001, absolute standardized difference, d = 0.08) or be able to ambulate independently (ambulatory: 70% vs. 76%, p < 0.001, d = 0.14). There were no major sex differences in lesion characteristics, except for an increased frequency of tibial artery treatment in men (23% vs. 18% in women, p < 0.001, d = 0.12). Among patients with claudication, women had a higher risk-adjusted rate of major amputation (hazard ratio [HR] = 1.72, 95% confidence interval [CI]: 1.18-2.49), but a lower risk of mortality (HR = 0.86, 95% CI: 0.75-0.99). There were no sex differences in reintervention or MALE for patients with claudication. However, among patients with chronic limb-threatening ischemia, women had a lower risk-adjusted hazard of major amputation (HR = 0.79, 95% CI: 0.67-0.93), MALE (HR = 0.86, 95% CI: 0.78-0.96), and mortality (HR = 0.86, 95% CI: 0.79-0.94). CONCLUSION There is significant heterogeneity in PVI outcomes among men and women, especially after stratifying by symptom severity. A lower overall mortality in women with claudication was accompanied by a higher risk of major amputation. Men with chronic limb-threatening ischemia had a higher risk of major amputation, MALE, and mortality. Developing sex-specific approaches to PVI that prioritizes limb outcomes in women can improve the quality of vascular care for men and women.
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Affiliation(s)
- Niveditta Ramkumar
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Bjoern D Suckow
- Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | - Todd A Mackenzie
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Art Sedrakyan
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York, USA
| | - Jeremiah R Brown
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Philip P Goodney
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
- Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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9
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Chow CY, Mathlouthi A, Zarrintan S, Swafford EP, Siracuse JJ, Malas MB. Outcomes of elective peripheral endovascular interventions for peripheral arterial disease performed in hospital outpatient departments, ambulatory surgical centers and office-based labs. J Vasc Surg 2023; 77:1732-1740. [PMID: 36738852 DOI: 10.1016/j.jvs.2023.01.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND A recent shift in the location where peripheral endovascular interventions (PVI) are performed has occurred, from traditional settings such as hospital outpatient departments (HOPD), to ambulatory surgical centers (ASC) and outpatient-based laboratories (OBL). Different settings may influence the safety and efficacy of the PVI, as well as how it is done. This study aims to compare the postprocedural outcomes and intraprocedural details between the three settings. METHODS The Vascular Quality Initiative database was queried for all elective infrainguinal PVIs for occlusive peripheral arterial disease between January 2016 and December 2021. The primary outcomes were rates of postprocedural hospital admissions, postprocedural medical complications, and access site complications. Secondary outcomes included technical success and intraprocedural details, such as types and number of devices used, amount of contrast, and fluoroscopy time. The χ2 test, analysis of variance, and multivariate logistic regression were used to analyze the outcomes. RESULTS A total of 66,101 PVI cases (HOPD, 57,062 [83.33%]; ASC, 4591 [6.95%]; OBL, 4448 [6.73%]) were included in the study. There were 445 cases requiring hospital admission (HOPD, 398 [0.70%]; ASC, 26 [0.57%]; OBL, 21 [0.47%]; P = .126). There were no significant differences in cardiac, pulmonary, or renal complications. Access site complications occurred in less than 1.7% of all cases and were significantly higher in OBLs when compared with ASCs (adjusted odds ratio [aOR], 3.70; 95% confidence interval [CI], 1.70-8.03; P = .001) and significantly lower in ASCs in comparison to HOPDs (aOR, 0.27; 95% CI, 0.18-0.41; P < .001). Technical success occurred in at least 92% of all cases, regardless of setting. There was a 16-fold increase in the use of atherectomy devices in an OBL vs HOPD setting (aOR, 16.79; 95% CI, 11.77-23.95; P < .001) and a five-fold increase in the use of atherectomy devices in an ASC vs HOPD setting (aOR, 5.37; 95% CI, 2.47-11.65; P < .001). There was a five-fold decrease in the use of special balloons in an OBL vs HOPD setting (aOR, 0.20; 95% CI, 0.10-0.39; P < .001) and a four-fold decrease when comparing ASCs with HOPDs (aOR, 0.25; 95% CI, 0.12-0.51; P < .001). CONCLUSIONS Elective PVIs performed in any outpatient setting proved to be safe and technically successful. However, there are significant differences in the way PVIs are performed in each setting, such as the greater use of atherectomy devices in OBLs and greater use of special balloons in HOPDs. Long-term studies are needed to evaluate the durability and reintervention outcomes and understand factors associated with practice pattern variability across these different settings.
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Affiliation(s)
- Christopher Y Chow
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Miami, Miami, FL
| | - Asma Mathlouthi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Sina Zarrintan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | | | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, School of Medicine, Boston, MA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA.
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10
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Vasilchenko E, Zoloev G, Karapetian K, Puzin S. Trends in the incidence rates of lower limb amputation due to nondiabetic peripheral artery disease in a large industrial city in Western Siberia, Russia: A review from 1996 to 2019. Prosthet Orthot Int 2022; 46:619-624. [PMID: 36515907 DOI: 10.1097/pxr.0000000000000151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 03/14/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND lower limb amputation (LLA) is a growing problem in the population with and without diabetes mellitus. Monitoring the incidence rates of LLA is important for health care planning and has implications for the future problems of medical and social care. OBJECTIVE This study aimed to determine the trends in incidence rates of LLA due to nondiabetic peripheral artery disease in Novokuznetsk, Western Siberia, Russia. STUDY DESIGN An observational study. METHODS Data on all transtibial and transfemoral amputations performed in inpatient facilities in Novokuznetsk from 1996 to 2019 were derived from the regional Register of patients with limb amputations. The rates were calculated per 100,000 population. RESULTS A total of 2448 persons with amputations due to nondiabetic peripheral artery disease were included in this study (3191 amputations). The overall incidence rate of LLA in Novokuznetsk increased from 14.6 in 1996 to 30.4 in 2019. The proportion of persons older than 60 years increased from 15.5% in 1996 to 20.3% in 2019. CONCLUSION The expected aging of the population and increasing incidence of LLA are relevant issues in Russia. These findings can contribute to improving healthcare services and the development of prevention programs to reverse the alarming trend.
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Affiliation(s)
- Elena Vasilchenko
- Federal State Budgetary Institution "Novokuznetsk Scientific and Practical Centre for Medical and Social Expertise and Rehabilitation of Disabled Persons," Ministry of Labour and Social Protection of the Russian Federation Novokuznetsk, Russian Federation
| | | | - Karine Karapetian
- Federal State Budgetary Institution "Novokuznetsk Scientific and Practical Centre for Medical and Social Expertise and Rehabilitation of Disabled Persons," Ministry of Labour and Social Protection of the Russian Federation Novokuznetsk, Russian Federation
| | - Sergey Puzin
- Federal State Budgetary Scientific Institution "Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology" Moscow, Russian Federation
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11
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Brown CS, Eton RE, Yaser JM, Syrjamaki JD, Corriere M, Henke PK, Englesbe MJ, Osborne NH. Assessment of Patterns of Atherectomy Use. J Am Heart Assoc 2022; 11:e023356. [DOI: 10.1161/jaha.121.023356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Atherectomy has become the fastest growing catheter‐based peripheral vascular intervention performed in the United States, and overuse has been linked to increased reimbursement, but the patterns of use have not been well characterized.
Methods and Results
We used Blue Cross Blue Shield of Michigan Preferred Provider Organization and Medicare fee‐for‐service professional claims data from the Michigan Value Collaborative for patients undergoing office‐based laboratory atherectomy in 2019 to calculate provider‐specific rates of atherectomy use, reimbursement, number of vessels treated, and number of atherectomies per patient. We also calculated the rate that each provider converted a new patient visit to an endovascular procedure within 90 days. Correlations between parameters were assessed with simple linear regression. Providers completing ≥20 office‐based laboratory atherectomies and ≥20 new patient evaluations during the study period were included. A total of 59 providers performing 4060 office‐based laboratory atherectomies were included. Median professional reimbursement per procedure was $4671.56 (interquartile range [IQR], $2403.09–$7723.19) from Blue Cross Blue Shield of Michigan and $14 854.49 (IQR, $9414.80–$18 816.33) from Medicare, whereas total professional reimbursement from both payers ranged from $2452 to $6 880 402 per year. Median 90‐day conversion rate was 5.0% (IQR, 2.5%–10.0%), whereas the median provider‐level average number of vessels treated per patient was 1.20 (IQR, 1.13–1.31) and the median provider‐level average number of treatments per patient was 1.38 (IQR, 1.26–1.63). Total annual reimbursement for each provider was directly correlated with new patient‐procedure conversion rate (
R
2
=0.47;
P
<0.001), mean number of vessels treated per patient (
R
2
=0.31;
P
<0.001), and mean number of treatments per patient (
R
2
=0.33;
P
<0.001).
Conclusions
A minority of providers perform most procedures and are reimbursed substantially more per procedure compared with most providers. Procedural conversion rate, number of vessels, and number of treatments per patient represent potential policy levers to curb overuse.
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Affiliation(s)
- Craig S. Brown
- Section of General Surgery, Department of Surgery University of Michigan Ann Arbor MI
- Center for Healthcare Outcomes and Policy Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Ryan E. Eton
- Section of General Surgery, Department of Surgery University of Michigan Ann Arbor MI
- Center for Healthcare Outcomes and Policy Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Jessica M. Yaser
- Center for Healthcare Outcomes and Policy Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - John D. Syrjamaki
- Center for Healthcare Outcomes and Policy Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Matthew A. Corriere
- Center for Healthcare Outcomes and Policy Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
- Section of Vascular Surgery, Department of Surgery University of Michigan Ann Arbor MI
| | - Peter K. Henke
- Section of Vascular Surgery, Department of Surgery University of Michigan Ann Arbor MI
| | - Michael J. Englesbe
- Section of General Surgery, Department of Surgery University of Michigan Ann Arbor MI
- Center for Healthcare Outcomes and Policy Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Nicholas H. Osborne
- Center for Healthcare Outcomes and Policy Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
- Section of Vascular Surgery, Department of Surgery University of Michigan Ann Arbor MI
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12
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Nienaber JJ, Smith CY, Cha S, Correa M, Rowse PG, Bailey KR, Kalra M. Population-Based Trends in Amputations and Revascularizations for Peripheral Artery Disease From 1990 to 2009. Mayo Clin Proc 2022; 97:919-930. [PMID: 35177249 PMCID: PMC9081231 DOI: 10.1016/j.mayocp.2021.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 09/23/2021] [Accepted: 10/14/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine trends in amputations and revascularizations for peripheral artery disease (PAD) in a well-defined population. METHODS A population-based cohort study of Olmsted County, Minnesota, residents with PAD undergoing amputation or revascularization was conducted between January 1, 1990, and December 31, 2009. Population-level 5-year incidence trends for endovascular, open surgical, and hybrid revascularizations and major and minor amputations were determined. Limb-specific outcomes after revascularization, including major adverse limb events and amputation-free survival, were compared between initial surgical and endovascular or hybrid revascularization groups using Kaplan-Meier analysis. RESULTS We identified 773 residents who underwent 1906 limb-procedures, including 689 open revascularizations, 685 endovascular or hybrid revascularizations, and 220 major amputations. During the 20-year study period, the incidence of endovascular and hybrid revascularizations increased, whereas the incidence of open surgical revascularizations and major amputations decreased. Incidence of revascularizations for chronic limb-threatening ischemia (CLTI) did not change. Among residents with CLTI undergoing their first revascularization on a limb, endovascular revascularization was associated with more major adverse limb events and major amputations compared with surgical revascularization during the ensuing 15 years. CONCLUSION The rising incidence of endovascular and hybrid revascularizations and the decreasing incidence of open surgical revascularizations for PAD were associated with a decreasing incidence of major amputations in this population between 1990 and 2009, despite a stable incidence of revascularizations for CLTI. With more major adverse limb events and major amputations after endovascular revascularization, these trends suggest that additional emphasis should be placed on improving limb salvage efforts beyond just mode of revascularization.
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Affiliation(s)
| | - Carin Y Smith
- Division of Biomedical Statistics, Mayo Clinic, Rochester, MN. J.J.N. is currently at the Charles George VA Medical Center, Asheville, NC. M.C. is currently at Instituto Vascular, Passo Fundo, Brazil. P.G.R. is currently in the Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Stephen Cha
- Division of Biomedical Statistics, Mayo Clinic, Rochester, MN. J.J.N. is currently at the Charles George VA Medical Center, Asheville, NC. M.C. is currently at Instituto Vascular, Passo Fundo, Brazil. P.G.R. is currently in the Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | | | - Kent R Bailey
- Division of Biomedical Statistics, Mayo Clinic, Rochester, MN. J.J.N. is currently at the Charles George VA Medical Center, Asheville, NC. M.C. is currently at Instituto Vascular, Passo Fundo, Brazil. P.G.R. is currently in the Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery.
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13
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Liu R, Li L, Shao C, Cai H, Wang Z. The Impact of Diabetes on Vascular Disease: Progress from the Perspective of Epidemics and Treatments. J Diabetes Res 2022; 2022:1531289. [PMID: 35434140 PMCID: PMC9012631 DOI: 10.1155/2022/1531289] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/10/2022] [Accepted: 03/23/2022] [Indexed: 12/23/2022] Open
Abstract
At present, the global incidence of diabetes has increased in countries with large populations, and the changes in developing regions are particularly worthy of attention. In the past 40 years or so, the income situation in China, India, and other countries has exploded, leading to changes in the way of life and work as well as an increase in the prevalence of diabetes. Metabolic disorders caused by diabetes can lead to secondary vascular complications, which have long-term malignant effects on the heart, kidneys, brain, and other vital organs of patients. Adequate primary prevention measures are needed to reduce the incidence of diabetic vascular complications, and more attention should be given to treatment after the disease. To this end, it is necessary to determine a standardized drug and physical therapy system and to build a more efficient and low-cost chronic disease management system.
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Affiliation(s)
- Runyang Liu
- Department of Cardiology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Lihua Li
- Department of Pathology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Chen Shao
- Department of Cardiology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Honghua Cai
- Department of Burn Surgery, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Zhongqun Wang
- Department of Cardiology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
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14
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Salisbury AC, Safley DM, Kennedy KF, Bhardwaj B, Aronow HD, Jones WS, Feldman DN, Secemsky E, Tsai TT, Attaran RR, Spertus JA. Development and validation of a predictive model for bleeding after peripheral vascular intervention: A report from the National Cardiovascular Data Registry Peripheral Vascular Interventions Registry. Catheter Cardiovasc Interv 2021; 98:1363-1372. [PMID: 34569709 DOI: 10.1002/ccd.29961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/08/2021] [Accepted: 09/18/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To develop a model to predict risk of in-hospital bleeding following endovascular peripheral vascular intervention. BACKGROUND Peri-procedural bleeding is a common, potentially preventable complication of catheter-based peripheral vascular procedures and is associated with increased mortality. We used the National Cardiovascular Data Registry (NCDR) Peripheral Vascular Interventions (PVI) Registry to develop a novel risk-prediction model to identify patients who may derive the greatest benefit from application of strategies to prevent bleeding. METHODS We examined all patients undergoing lower extremity PVI at 76 NCDR PVI hospitals from 2014 to 2017. Patients with acute limb ischemia (n = 1600) were excluded. Major bleeding was defined as overt bleeding with a hemoglobin (Hb) drop of ≥ 3 g/dl, any Hb decline of ≥ 4 g/dl, or a blood transfusion in patients with pre-procedure Hb ≥ 8 g/dl. Hierarchical multivariable logistic regression was used to develop a risk model to predict major bleeding. Model validation was performed using 1000 bootstrapped replicates of the population after sampling with replacement. RESULTS Among 25,382 eligible patients, 1017 (4.0%) developed major bleeding. Predictors of bleeding included age, female sex, critical limb ischemia, non-femoral access, prior heart failure, and pre-procedure hemoglobin. The model demonstrated good discrimination (optimism corrected c-statistic = 0.67), calibration (corrected slope = 0.98, intercept of -0.04) and range of predicted risk (1%-18%). CONCLUSIONS Post-procedural PVI bleeding risk can be predicted based upon pre- and peri-procedural patient characteristics. Further studies are needed to determine whether this model can be utilized to improve procedural safety through developing and targeting bleeding avoidance strategies.
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Affiliation(s)
- Adam C Salisbury
- University of Missouri-Kansas City, Kansas City, Missouri, USA.,Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
| | - David M Safley
- University of Missouri-Kansas City, Kansas City, Missouri, USA.,Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
| | - Kevin F Kennedy
- Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
| | | | - Herbert D Aronow
- Lifespan Cardiovascular Institute, Brown University, Providence, Rhode, USA
| | - William Schuyler Jones
- Division of Cardiology, Duke Heart Center, Duke University Health System, Durham, North Carolina, USA
| | - Dmitriy N Feldman
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
| | - Eric Secemsky
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Thomas T Tsai
- University of Colorado Institute for Health Research and Kaiser Permanente, Denver, Colorado, USA
| | | | - John A Spertus
- University of Missouri-Kansas City, Kansas City, Missouri, USA.,Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
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15
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Zhang B, Yang M, He T, Li X, Gu J, Zhang X, Dai X, Li X, Lu X, Lang D, Hu H, Chen X, Yang B, Gu H, Zhang X, Zou Y. Twelve-Month Results From the First-in-China Prospective, Multi-Center, Randomized, Controlled Study of the FREEWAY Paclitaxel-Coated Balloon for Femoropopliteal Treatment. Front Cardiovasc Med 2021; 8:686267. [PMID: 34568443 PMCID: PMC8460758 DOI: 10.3389/fcvm.2021.686267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/19/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Several paclitaxel-coated balloons have been proved to provide better efficacy results than uncoated balloons in femoropopliteal lesions. But the efficacy and safety of FREEWAY balloons have not been investigated in Chinese patients. This study aimed to evaluate the efficacy and safety performance of FREEWAY paclitaxel-coated balloons vs. uncoated balloons in Chinese femoropopliteal artery lesions. Methods: In this prospective multi-center randomized controlled FREEWAY-CHINA study, 311 patients with symptomatic lower limb ischemia (Rutherford category 2–5) and femoropopliteal lesions of 14 Chinese centers were randomly assigned in a 1:1 ratio to endovascular treatment with either FREEWAY paclitaxel-coated balloons or uncoated balloons (control). The primary endpoint was the 6-month clinically-driven target lesion revascularization (CD-TLR) rate. Secondary endpoints included the device and technical success rate, the ankle-brachial indexes (ABIs), Rutherford category change, the 6-month primary and secondary patency rates, severe adverse effects, and the 12-month CD-TLR rate. Results: The two groups were comparable in terms of their demographic and lesion characteristics. Patients' mean age was 70 years, and 70% were men. The mean lesion length was 71 mm. The 6-month CD-TLR rate was 2.6% in the FREEWAY group and 11.7% in the control group (P = 0.001). The 12-month CD-TLR rate was 2.7% in the FREEWAY group and 13.2% in the control group (P = 0.0005). Other endpoints, including patency rates, major adverse events, and ABI or Rutherford change, did not differ between the two groups. Conclusion: The FREEWAY balloon resulted in an effective decrease in CD-TLR rates and had similar safety results compared to the uncoated balloon in Chinese femoropopliteal artery patients at the 12-month follow-up appointment.
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Affiliation(s)
- Bihui Zhang
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Min Yang
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Tao He
- Department of Vascular Surgery, The Central Hospital of Wuhan, Wuhan, China
| | - Xuan Li
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Jianping Gu
- Department of Interventional Radiology and Vascular Surgery, Nanjing First Hospital, Nanjing, China
| | - Xiaoming Zhang
- Department of Vascular Surgery, Peking University People's Hospital, Beijing, China
| | - Xiangchen Dai
- Department of Vascular Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xuedong Li
- Department of Vascular Surgery, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Dehai Lang
- Department of Vascular Surgery, Ningbo No. 2 Hospital, Ningbo, China
| | - Hongyao Hu
- Department of Vascular Surgery, Renmin Hospital of Wuhan University, Hubei General Hospital, Wuhan, China
| | - Xueming Chen
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Baozhong Yang
- Peripheral Vascular Department, Beijing University of Chinese Medicine Dongfang Hospital, Beijing, China
| | - Hongbin Gu
- Department of Vascular Surgery, People's Liberation Army (PLA) Strategic Support Force Characteristic Medical Center, Beijing, China
| | - Xiwei Zhang
- Department of Vascular Surgery, Jiangsu Province Hospital, Nanjing, China
| | - Yinghua Zou
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
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16
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Brown CS, Smith ME, Kim GY, Sutzko DC, Henke PK, Corriere MA, Siracuse JJ, Goodney PP, Osborne NH. Exploring the rapid expansion of office-based laboratories and peripheral vascular interventions across the United States. J Vasc Surg 2021; 74:997-1005.e1. [PMID: 33617980 PMCID: PMC8373995 DOI: 10.1016/j.jvs.2021.01.061] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 01/06/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To characterize the relationship between office-based laboratory (OBL) use and Medicare payments for peripheral vascular interventions (PVI). METHODS Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use Files from 2014 to 2017, we identified providers who performed percutaneous transluminal angioplasty, stent placement, and atherectomy. Procedures were aggregated at the provider and hospital referral region (HRR) level. RESULTS Between 2014 and 2017, 2641 providers performed 308,247 procedures. The mean payment for OBL stent placement in 2017 was $4383.39, and mean payment for OBL atherectomy was $13,079.63. The change in the mean payment amount varied significantly, from a decrease of $16.97 in HRR 146 to an increase of $43.77 per beneficiary over the study period in HRR 11. The change in the rate of PVI also varied substantially, and moderately correlated with change in payment across HRRs (R2 = 0.40; P < .001). The majority of HRRs experienced an increase in rate of PVI within OBLs, which strongly correlated with changes in payments (R2 = 0.85; P < .001). Furthermore, 85% of the variance in change in payment was explained by increases in OBL atherectomy (P < .001). CONCLUSIONS A rapid shift into the office setting for PVIs occurred within some HRRs, which was highly geographically variable and was strongly correlated with payments. Policymakers should revisit the current payment structure for OBL use and, in particular atherectomy, to better align the policy with its intended goals.
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Affiliation(s)
- Craig S Brown
- Section of General Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
| | - Margaret E Smith
- Section of General Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Gloria Y Kim
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Danielle C Sutzko
- Section of Vascular Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Matthew A Corriere
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston, Mass
| | - Philip P Goodney
- Section of Vascular, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Nicholas H Osborne
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
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Criqui MH, Matsushita K, Aboyans V, Hess CN, Hicks CW, Kwan TW, McDermott MM, Misra S, Ujueta F. Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e171-e191. [PMID: 34315230 PMCID: PMC9847212 DOI: 10.1161/cir.0000000000001005] [Citation(s) in RCA: 225] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Lower extremity peripheral artery disease (PAD) affects >230 million adults worldwide and is associated with increased risk of various adverse clinical outcomes (other cardiovascular diseases such as coronary heart disease and stroke and leg outcomes such as amputation). Despite its prevalence and clinical importance, PAD has been historically underappreciated by health care professionals and patients. This underappreciation seems multifactorial (eg, limited availability of the first-line diagnostic test, the ankle-brachial index, in clinics; incorrect perceptions that a leg vascular disease is not fatal and that the diagnosis of PAD would not necessarily change clinical practice). In the past several years, a body of evidence has indicated that these perceptions are incorrect. Several studies have consistently demonstrated that many patients with PAD are not receiving evidence-based therapies. Thus, this scientific statement provides an update for health care professionals regarding contemporary epidemiology (eg, prevalence, temporal trends, risk factors, and complications) of PAD, the present status of diagnosis (physiological tests and imaging modalities), and the major gaps in the management of PAD (eg, medications, exercise therapy, and revascularization). The statement also lists key gaps in research, clinical practice, and implementation related to PAD. Orchestrated efforts among different parties (eg, health care providers, researchers, expert organizations, and health care organizations) will be needed to increase the awareness and understanding of PAD and improve the diagnostic approaches, management, and prognosis of PAD.
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Wang JN, Kan CD, Lin SH, Chang KC, Tsao S, Wong TW. Potential of Autologous Progenitor Cells and Decellularized Porcine Artery Matrix in Construction of Tissue-engineered Vascular Grafts. Organogenesis 2021; 17:72-84. [PMID: 34405770 DOI: 10.1080/15476278.2021.1963603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
To develop a tissue-engineered vascular graft, we used pericardial effusion-derived progenitor cells (PEPCs) collected from drained fluid after open-heart surgery in children with congenital heart diseases to repopulate a decellularized porcine pulmonary artery. The PEPCs were compared with human fibroblasts (HS68) and human umbilical vein endothelial cells (HUVECs) in cell growth and migration. They were cultured with the matrices via an inner approach (intima), lateral approach (media), and outer approach (adventitia). PEPCs grew and migrated better than the other two cells 14 days after seeding in the decellularized vessel. In immunofluorescence assays, PEPCs expressed CD90 and CD105 indicating a vascular differentiation. PEPCs grew in a decellularized porcine pulmonary artery matrix may have the potential for producing tissue-engineered vascular grafts.
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Affiliation(s)
- Jieh-Neng Wang
- Departments Of Pediatrics, National Cheng Kung University Hospital, College Of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Dann Kan
- Departments Of Surgery, National Cheng Kung University Hospital, College Of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shao-Hsien Lin
- Departments Of Pediatrics, National Cheng Kung University Hospital, College Of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ko-Chi Chang
- Departments Of Pediatrics, National Cheng Kung University Hospital, College Of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Stephanie Tsao
- Department Of Dermatology, National Cheng Kung University Hospital, College Of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tak-Wah Wong
- Department Of Dermatology, National Cheng Kung University Hospital, College Of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department Of Biochemistry And Molecular Biology, College Of Medicine, National Cheng Kung University, Tainan, Taiwan.,Center Of Applied Nanomedicine, National Cheng Kung University, Tainan, Taiwan
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19
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Doyle MD, Hastings G, Dontsi M, Dionisopoulos SB, Kane LA, Pollard JD. The Effects of Endovascular Timing and In-line Flow on the Success of Pedal Amputations. J Foot Ankle Surg 2021; 59:964-968. [PMID: 32414647 DOI: 10.1053/j.jfas.2020.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/21/2020] [Accepted: 03/23/2020] [Indexed: 02/03/2023]
Abstract
There has been a growing trend toward endovascular intervention to improve peripheral flow in patients with peripheral arterial disease. To date, there is no clear consensus regarding timing of lower-extremity amputations after revascularization. The purpose of this study was to evaluate the effects of timing between endovascular intervention and minor lower-extremity amputations and its influence on wound healing and limb loss within 1 year. A secondary purpose was to evaluate the impact of restoring in-line flow on healing rates. A total of 310 patients who underwent endovascular intervention and a minor lower-extremity amputation within 90 days were included in the study. Healing rates were defined as optimal, delayed, or failure. There was a statistically significant difference between patients with optimal healing to delayed healing and amputation ≥30 days after endovascular intervention (p = .037). We found no difference in healing rates in regard to amputation timing when examining patients who ultimately healed versus patients who failed to heal (p = .6717). Absence of in-line flow (p = .0177), male sex (p = .0090) and diabetes mellitus (p = .0076) were statistically significant factors for failing to heal. Presence of infection (p ≤ .0001) and wound dehiscence (p ≤ .001) were also associated with a failure to heal. End-stage renal disease trended toward significance for failing to heal (p = .065). Amputation-free survival at 1 year after endovascular intervention and pedal amputation was 76.8% (n = 238). Our findings suggest that in the absence of infection, performing minor lower-extremity amputations 15 to 60 days after endovascular intervention may allow for improved healing. Absence of in-line flow, male sex, diabetes mellitus, postoperative infection, and wound dehiscence are significant factors for failure.
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Affiliation(s)
- Matthew D Doyle
- Fellow, Silicon Valley Reconstructive Foot and Ankle Fellowship, Palo Alto Medical Foundation, Mountain View, CA.
| | - Geoffrey Hastings
- Attending Physician, Department of Interventional Radiology, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Makdine Dontsi
- Senior Consulting Data Analyst, Division of Research, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Shontal Behan Dionisopoulos
- Resident, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Lewis A Kane
- Resident, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Jason D Pollard
- Attending Staff and Research Director, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Permanente Oakland Medical Center, Oakland, CA
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Chen L, Zhang D, Shi L, Kalbaugh CA. Disparities in Peripheral Artery Disease Hospitalizations Identified Among Understudied Race-Ethnicity Groups. Front Cardiovasc Med 2021; 8:692236. [PMID: 34109228 PMCID: PMC8180581 DOI: 10.3389/fcvm.2021.692236] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/04/2021] [Indexed: 11/30/2022] Open
Abstract
Background: To assess racial/ethnic differences in disease severity, hospital outcomes, length of stay and healthcare costs among hospitalized patients with peripheral artery disease (PAD). Methods: This study used data from the National Inpatient Sample (NIS) to explore the racial/ethnic disparities in PAD-related hospitalizations including presence of PAD with chronic limb threatened ischemia (CLI), amputation, in-hospital mortality, length of hospital stays and estimated medical costs. Race-ethnicity groups included non-Hispanic White, Black, Hispanic, Asian or Pacific Islander, Native American, and others (multiple races). Regression analyses adjusted for age, gender, Charlson Comorbidity Index, primary payer, patient location, bed size of the admission hospital, geographic region of the hospital, and rural/urban location of the hospital. Results: A total of 341,480 PAD hospitalizations were identified. Compared with non-Hispanic Whites, Native Americans had the highest odds of PAD with CLI (OR = 1.77, 95% CI: 1.61, 1.95); Black (OR = 1.71, 95% CI: 1.66, 1.76) and Hispanic (OR = 1.36, 95% CI: 1.31,1.41) patients had higher odds of amputation; Asian or Pacific Islanders had a higher mortality (OR = 1.20, 95% CI: 1.01,1.43), whereas Black (OR = 0.81, 95% CI: 0.76, 0.87) patients has a lower mortality; Asian or Pacific Islanders incurred higher overall inpatient costs (Margin = 30093.01, 95% CI: 28827.55, 31358.48) and most prolonged length of stay (IRR = 0.14, 95% CI: 0.09, 0.18). Conclusions: Our study identified elevated odds of amputation among Hispanic patients hospitalized with PAD as well as higher hospital mortality and medical expenses among Asian or Pacific Islander PAD inpatients. These two demographic groups were previously thought to have a lower risk for PAD and represent important populations for further investigation.
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Affiliation(s)
- LaiTe Chen
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Donglan Zhang
- Department of Health Policy and Management, University of Georgia, Athens, GA, United States
| | - Lu Shi
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Corey A Kalbaugh
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
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21
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Altable García M, Chiriboga Granja JI, Reviriego Eíros M, Zaragozá García JM, Plaza Martinez Á, Martinez Perelló I, Gómez Palonés FJ. Could prior endovascular interventions affect the results of lower extremity below the knee autologous vein bypasses? INT ANGIOL 2021; 40:315-322. [PMID: 33870675 DOI: 10.23736/s0392-9590.21.04542-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Performing a non-selective primary endovascular approach involves risk of performing ineffective procedures and could compromise future treatments. The objective of this research is to determine if previous failed endovascular intervention could affect bypass results. METHODS Retrospective cohort study including 77 below the knee (BTK) bypasses with great saphenous vein (GSV) in patients with critical limb ischemia, carried out between 2008-2018. Primary bypasses (P-BP) were compared with bypasses with history of previous failed endovascular intervention (Secondary bypasses [S-BP]). Primary outcomes included: primary, primary-assisted, and secondary patency, and major amputation-free survival (AFS). The quality of GSV used was evaluated as a potential confounding factor. RESULTS Forty-six procedures were P-BP (59.7%) and 31 S-BP (40.3%). The mean follow-up was 35.4 (SD: 31) and 28 (DS: 30) months respectively. Univariate results showed an increased risk of loss of primary patency (HR=2.7), primary-assisted patency (HR=3.1) and secondary patency (HR=3.26) in S-BP (P<0.05). This group also presented a trend towards an increased risk of major amputation (HR=1.6; P>0.05). Suboptimal GSV was used in 29% of S-BP and 15% of P-BP. This factor was identified as confounding partially, as it decreased the influence assumed by the history of prior endovascular intervention in the analyzed variables. CONCLUSIONS Secondary bypasses show inferior results to primary bypasses in our series. Although the cause could be a prior failed endovascular intervention, the frequent use of suboptimal GSV in this type of patients may also contribute to this effect.
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Affiliation(s)
- Mario Altable García
- Department of Vascular and Endovascular Surgery, Dr. Peset University Hospital, Valencia, Spain -
| | - Jose I Chiriboga Granja
- Department of Vascular and Endovascular Surgery, Dr. Peset University Hospital, Valencia, Spain
| | - Mario Reviriego Eíros
- Department of Biodiversity, Ecology and Evolution, Complutense University of Madrid, Madrid, Spain.,Smart Intelligence Services (SAITS), Madrid, Spain
| | - José M Zaragozá García
- Department of Vascular and Endovascular Surgery, Dr. Peset University Hospital, Valencia, Spain
| | - Ángel Plaza Martinez
- Department of Vascular and Endovascular Surgery, Dr. Peset University Hospital, Valencia, Spain
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22
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Saldana-Ruiz N, Dominguez J, Ham SW, Rowe VL, Magee GA, Weaver FA, Han SM, Ziegler KR. Effect of infrainguinal bypass tunneling technique on patency and amputation in patients with limb ischemia. J Vasc Surg 2021; 74:1242-1250. [PMID: 33845170 DOI: 10.1016/j.jvs.2021.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We investigated the association of tunneling technique on patency and amputation in patients undergoing lower extremity bypass for limb ischemia. METHODS The National Vascular Quality Initiative database infrainguinal bypass module from 2008 to 2017 was queried for analysis. We excluded cases with non-great saphenous vein grafts, grafts using multiple segments, aneurysmal disease indications, bypass locations outside the femoral to below the knee popliteal artery or tibial arteries, and missing data on tunneling type and limb ischemia. The main exposure variable was the tunneling type, subcutaneously vs subfascially. Our primary outcomes were primary patency and amputation. The secondary outcomes included primary-assisted patency and secondary patency. Univariate and multivariate logistic regression models were used. RESULTS A total of 5497 bypass patients (2835 subcutaneous and 2662 subfascial) were included. Age, race, graft orientation (reversed vs not reversed), bypass donor and recipient vessels, harvest type, end-stage renal disease, smoking, coronary artery bypass graft, congestive heart failure, P2Y12 inhibitor at discharge, surgical site infection at discharge, and indication (rest pain vs tissue loss vs acute ischemia) were analyzed for an association with the tunneling technique (P < .05). Multivariate analyses demonstrated that the tunneling type was not associated with primary patency, primary-assisted patency, secondary patency, or major amputation (P > .05). CONCLUSIONS Compared with subfascial tunneling, the superficial tunneling technique was not associated with primary patency or major amputation in limb ischemia patients undergoing infrainguinal bypass with a single-segment great saphenous vein.
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Affiliation(s)
- Nallely Saldana-Ruiz
- Division of Vascular Surgery, Department of Surgery, University of Southern California, Los Angeles, Calif
| | - Josefina Dominguez
- Division of Vascular Surgery, Department of Surgery, University of Southern California, Los Angeles, Calif
| | - Sung Wan Ham
- Division of Vascular Surgery, Department of Surgery, University of Southern California, Los Angeles, Calif
| | - Vincent L Rowe
- Division of Vascular Surgery, Department of Surgery, University of Southern California, Los Angeles, Calif
| | - Gregory A Magee
- Division of Vascular Surgery, Department of Surgery, University of Southern California, Los Angeles, Calif
| | - Fred A Weaver
- Division of Vascular Surgery, Department of Surgery, University of Southern California, Los Angeles, Calif
| | - Sukgu M Han
- Division of Vascular Surgery, Department of Surgery, University of Southern California, Los Angeles, Calif
| | - Kenneth R Ziegler
- Division of Vascular Surgery, Department of Surgery, University of Southern California, Los Angeles, Calif.
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23
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Arakelian VS. [Amputation as an anticipated consequence of peripheral artery disease and ways to improve the prognosis of limb salvage]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:182-190. [PMID: 33825747 DOI: 10.33529/angio2021101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Peripheral artery disease is a common and acute social burden worldwide. The main method of treatment of PAD consists in open surgical or endovascular revascularization. However, despite steady growth of the number and quality of interventions, the incidence of lower-limb amputation still remains at a high level. Lower-limb amputation is a severe psychological blow for the patient and leads to significant deterioration of his or her quality of life, as well as has an extremely negative prognosis concerning the frequency of subsequent complications and survival. Consequences of amputations include not only severe disability but also an unfavourable prognosis of life, thus determining the necessity of adequate prevention of such events. Reconstructive and endovascular operations, as well as amputations are associated with a significant increase of the probability of the development of major adverse cardiovascular events, the frequency of repeat hospitalizations and, finally, the cost of treatment. Prescribing pathogenetically substantiated antithrombotic therapy is considered to be one of the methods to improve the results of surgical treatment and prognosis for the patient. Presented in the article is a literature review making it possible to assess the risks and consequences of amputations in patients with PAD, as well as to determine therapy capable of improving the prognosis.
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Affiliation(s)
- V S Arakelian
- Department of Surgery for Arterial Pathology, National Medical Research Centre named after A.N. Bakulev under the RF Ministry of Public Health, Moscow, Russia
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24
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Quantifying Step Count and Oxygen Consumption with Portable Technology during the 2-Min Walk Test in People with Lower Limb Amputation. SENSORS 2021; 21:s21062080. [PMID: 33809581 PMCID: PMC7999204 DOI: 10.3390/s21062080] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/03/2021] [Accepted: 03/15/2021] [Indexed: 12/17/2022]
Abstract
Step counts and oxygen consumption have yet to be reported during the 2-min walk test (2MWT) test in persons with lower-limb amputations (LLA). The purpose of this study was to determine step counts and oxygen consumption during the 2MWT in LLA. Thirty-five men and women walked for two minutes as quickly as possible while wearing activity monitors (ActiGraph Link on the wrist (LW) and ankle (LA), Garmin vivofit®3 on the wrist (VW) and ankle (VA), and a modus StepWatch on the ankle (SA), and a portable oxygen analyzer. The StepWatch on the ankle (SA) and the vivofit3 on the wrist (VW) had the least error and best accuracy of the activity monitors studied. While there were no significant differences in distance walked, oxygen consumption (VO2) or heart rate (HR) between sexes or level of amputation (p > 0.05), females took significantly more steps than males (p = 0.034), and those with unilateral transfemoral amputations took significantly fewer steps than those with unilateral transtibial amputations (p = 0.023). The VW and SA provided the most accurate step counts among the activity monitors and were not significantly different than hand counts. Oxygen consumption for all participants during the 2MWT was 8.9 ± 2.9 mL/kg/min, which is lower than moderate-intensity activity. While some may argue that steady-state activity has not yet been reached in the 2MWT, it may also be possible participants are not walking as fast as they can, thereby misclassifying their performance to a lower standard.
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Drug-Coated Balloon versus Bare Nitinol Stent in Femoropopliteal Artery: 12 Months Outcome from a Single Center in China. Ann Vasc Surg 2021; 74:367-381. [PMID: 33556529 DOI: 10.1016/j.avsg.2021.01.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 01/16/2021] [Accepted: 01/17/2021] [Indexed: 11/23/2022]
Abstract
OBJECT The study sought to compare the safety and effectiveness of drug-coated balloon (DCB) with bare nitinol stent in patients with complex femoropopliteal(FP) lesions in real-world practice. METHODS Patients with symptomatic (Rutherford stage 2 to 5) femoropopliteal lesions who underwent DCB or bare nitinol stent implantation at the Department of Cardiovascular Surgery of China-Japan Friendship Hospital from June 2016 to September 2017 were included. Demographics, angiographic and procedural variables were included. Freedom from target lesion revascularization (TLR), primary patency and major adverse events were obtained from follow-up results at 3,6 and12 months. Descriptive analysis was performed on all variables. RESULTS A total of 90 eligible patients were enrolled, which included 51 DCB subjects (mean age, 63.1 ± 13.2 years; 76.5% male) with 55 lesions and 39 nitinol stent subjects (mean age, 66.5 ± 10.5 years; 61.5% male) with 42 lesions. Significant higher primary patency was observed in the DCB group compared with the stent group (74.5% vs. 52.4%; log-rank test P = 0.018; HR 0.335, 95%CI 0.124-0.903, P = 0.031). The rates of freedom from TLR (f-TLR) were 78.2% and 59.5% (log-rank test P = 0.032) for the DCB group and the stent group, respectively, at 12 months. CD-TLR rates were 18.2% vs. 38.1% with a P-value of 0.023. Female sex (HR 6.122, 95%CI 1.880-19.934, P = 0.003), lesion length over 20 cm (HR 5.514, 95%CI 2.312-13.148, P < 0.001) and renal insufficiency (HR 2.609, 95%CI 1.087-6.260, P = 0.032) were suggested as independent risk factors of reducing primary patency. There were no significant differences in major adverse events between the 2 groups. CONCLUSION The result above demonstrates that DCB treatment has higher primary patency and lower TLR at 12 months than nitinol stent. These data confirm the safety and effectiveness of the DCB for patients with complex femoropopliteal lesions.
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Iida O, Takahara M, Soga Y, Kodama A, Terashi H, Azuma N. The Association of Preoperative Characteristics with Reintervention Risk in Patients Undergoing Revascularization for Chronic Limb-Threatening Ischemia. J Atheroscler Thromb 2021. [PMID: 32224557 DOI: 10.5551/jat.54866.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
AIM To investigate the associations between preoperative characteristics and the risk of reintervention in patients undergoing revascularization for chronic limb-threatening ischemia (CLTI) in a contemporary real-world setting. METHODS We retrospectively analyzed data from a clinical database formed by the Surgical Reconstruction Versus Peripheral Intervention in Patients With Critical Limb Ischemia (SPINACH) study, which was a multicenter, prospective, observational study. The study population was composed of 520 CLTI patients with the wound, ischemia, and foot infection (WIfI) classes I-3 with resting pain or classes I-2/3 with ulcers/gangrene. Of the 520 patients, 192 had surgical reconstruction planned, whereas 328 had endovascular therapy (EVT) alone planned at the time of registration. The current analysis was conducted to explore the associations between preoperative characteristics and the risk of reintervention. RESULTS A total of 452 participants (87%) completed the 3-year follow-up regarding reintervention. The competing risk analysis estimated that the three-year cumulative incidence rates for reintervention and reintervention-free deaths were 44.0% and 28.7%, respectively. No preoperative characteristics had a significant interaction effect with EVT versus surgical reconstruction. The risk analysis identified the following independent risk factors for reintervention: 1) EVT instead of bypass reconstruction, 2) renal dysfunction, 3) history of revascularization after CLTI onset (i.e., requirement of redo revascularization for CLTI), and 4) bilateral CLTI. Patients with more than one of these risk factors had an increased risk of reintervention. CONCLUSIONS The current study identified preoperative characteristics associated with an increased risk of reintervention. No preoperative characteristics had any significant interactions with EVT or surgical reconstruction.
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Affiliation(s)
- Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine and Department of Metabolic Medicine, Osaka University Graduate School of Medicine
| | | | - Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University School of Medicine
| | - Hiroto Terashi
- Kobe University Graduate School of Medicine, Department of Plastic Surgery
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
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27
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Guo J, Guo L, Dardik A, Tong Z, Xing Y, Cai Z, Gu Y. Analysis of 17 years of surgical treatment for chronic limb ischemia in a Chinese National Clinical Center for Geriatric Disorders (2002 to 2018). Int J Cardiol 2020; 318:39-42. [DOI: 10.1016/j.ijcard.2020.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 05/04/2020] [Accepted: 06/10/2020] [Indexed: 11/30/2022]
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28
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Aurshina A, Ostrozhynskyy Y, Alsheekh A, Kibrik P, Chait J, Marks N, Hingorani A, Ascher E. Safety of vascular interventions performed in an office-based laboratory in patients with low/moderate procedural risk. J Vasc Surg 2020; 73:1298-1303. [PMID: 33065244 DOI: 10.1016/j.jvs.2020.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE An exponential increase in number of office-based laboratories (OBLs) has occurred in the United States, since the Center for Medicare and Medicaid Services increased reimbursement for outpatient vascular interventions in 2008. This dramatic shift to office-based procedures directed to the objective to assess safety of vascular procedures in OBLs. METHODS A retrospective analysis was performed to include all procedures performed over a 4-year period at an accredited OBL. The procedures were categorized into groups for analysis; group I, venous procedures; group II, arterial; group III, arteriovenous; and group IV, inferior vena cava filter placement procedures. Local anesthesia, analgesics, and conscious sedation were used in all interventions, individualized to the patient and procedure performed. Arterial closures devices were used in all arterial interventions. Patient selection for procedure at OBL was highly selective to include only patients with low/moderate procedural risk. RESULTS Nearly 6201 procedures were performed in 2779 patients from 2011 to 2015. The mean age of the study population was 66.5 ± 13.31 years. There were 1852 females (67%) and 928 males (33%). In group I, 5783 venous procedures were performed (3491 vein ablation, 2292 iliac vein stenting); with group II, 238 arterial procedures (125 femoral/popliteal, 71 infrapopliteal, iliac 42); group III, 129 arteriovenous accesses; and group IV, 51 inferior vena cava filter placements. The majority of procedures belonged to American Society of Anesthesiology class II with venous (61%) and arterial (74%) disease. A total of 5% patients were deemed American Society of Anesthesiology class IV (all on hemodialysis). There was no OBL mortality, major bleed, acute limb ischemia, myocardial infarction, stroke, or hospital transfer within 72 hours. Minor complications occurred in 14 patients (0.5%). Thirty-day mortality, unrelated to the procedure, was noted in 9 patients (0.32%). No statistically significant differences were noted in outcomes between the four groups. CONCLUSIONS Our data suggest that it is safe to use OBL for minimally invasive, noncomplex vascular interventions in patients with a low to moderate cardiovascular procedural risk.
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Affiliation(s)
- Afsha Aurshina
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY.
| | - Yuriy Ostrozhynskyy
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY
| | - Ahmad Alsheekh
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY
| | - Pavel Kibrik
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY
| | - Jesse Chait
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY
| | - Natalie Marks
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY
| | - Anil Hingorani
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY
| | - Enrico Ascher
- Division of Vascular Surgery, Department of Surgery, Vascular Institute of New York, Brooklyn, NY
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Kim TI, Mena C, Sumpio BE. The Role of Lower Extremity Amputation in Chronic Limb-Threatening Ischemia. Int J Angiol 2020; 29:149-155. [PMID: 32904807 DOI: 10.1055/s-0040-1710075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Chronic limb-threatening ischemia (CLTI) is a severe form of peripheral artery disease associated with high rates of limb loss. The primary goal of treatment in CLTI is limb salvage via revascularization. Multidisciplinary teams provide improved care for those with CLTI and lead to improved limb salvage rates. Not all patients are candidates for revascularization, and a subset will require major amputation. This article highlights the role of amputations in the management of CLTI, and describes the patients who should be offered primary amputation.
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Affiliation(s)
- Tanner I Kim
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Carlos Mena
- Cardiology Section, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Bauer E Sumpio
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.,Cardiology Section, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
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Bhardwaj B, Spertus JA, Kennedy KF, Jones WS, Safley D, Tsai TT, Aronow HD, Vora AN, Pokharel Y, Kumar A, Attaran RR, Feldman DN, Armstrong E, Prasad A, Gray B, Salisbury AC. Bleeding Complications in Lower-Extremity Peripheral Vascular Interventions: Insights From the NCDR PVI Registry. JACC Cardiovasc Interv 2020; 12:1140-1149. [PMID: 31221303 DOI: 10.1016/j.jcin.2019.03.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study sought to assess periprocedural bleeding complications in lower-extremity peripheral vascular interventions (PVIs). BACKGROUND Few studies have examined the incidence, predictors, or outcomes of periprocedural bleeding after lower-extremity PVI. METHODS The study examined patients undergoing PVI at 76 hospitals in the National Cardiovascular Data Registry PVI registry from 2014 to 2016. Post-PVI major bleeding was defined as any overt bleeding with a hemoglobin (Hb) drop of ≥3 g/dl, any Hb decline of ≥4 g/dl, or blood transfusion in patients with pre-procedure Hb >8 g/dl within 72 h of their procedure. Hierarchical multivariable logistic regression was used to identify factors independently associated with post-PVI bleeding. The study also examined adjusted in-hospital mortality among patients with or without major bleeding complications. RESULTS Among 18,289 PVI procedures, major bleeding occurred in 744 (4.10%). Patient characteristics independently associated with bleeding included age, female sex, heart failure, pre-procedural hemoglobin <12 g/dl, nonelective PVI, and critical limb ischemia on presentation. Procedural characteristics associated with bleeding included nonfemoral vascular access, use of thrombolytic therapy, PVI of the aortoiliac segment, and multilesion interventions, whereas use of closure devices was associated with less bleeding. All-cause in-hospital mortality was higher in patients who experienced bleeding than in those who did not (6.60% vs. 0.30%; p < 0.001; adjusted hazard ratio: 10.9; 95% confidence interval: 6.9 to 17.0). CONCLUSIONS Major bleeding occurred in 4.10% of lower-extremity PVI procedures and was associated with several patient and procedural characteristics, as well as in-hospital mortality. These insights can be incorporated into strategies to reduce periprocedural bleeding after PVI.
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Affiliation(s)
- Bhaskar Bhardwaj
- Division of Cardiovascular Diseases, University of Missouri, Columbia, Missouri; Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - John A Spertus
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri; Division of Cardiovascular Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri
| | - Kevin F Kennedy
- Division of Cardiovascular Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri
| | - W Schuyler Jones
- Division of Cardiology, Duke University Health System, Duke Heart Center, Durham, North Carolina
| | - David Safley
- Division of Cardiovascular Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri
| | - Thomas T Tsai
- Division of Cardiovascular Medicine, University of Colorado and Institute for Health Research, Kaiser Permanente, Denver, Colorado
| | - Herbert D Aronow
- Division of Cardiovascular Medicine, Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - Amit N Vora
- Division of Cardiology, Duke University Health System, Duke Heart Center, Durham, North Carolina
| | - Yashashwi Pokharel
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri; Division of Cardiovascular Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri
| | - Arun Kumar
- Division of Cardiovascular Diseases, University of Missouri, Columbia, Missouri
| | - Robert R Attaran
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Dmitriy N Feldman
- Division of Cardiology, Weill Cornell Medical College, New York, New York
| | - Ehrin Armstrong
- Division of Cardiovascular Medicine, University of Colorado, Denver, Colorado and Denver Veterans Affairs Medical Center, Denver, Colorado
| | - Anand Prasad
- Division of Cardiology, Department of Medicine, UT Health San Antonio, San Antonio, Texas
| | - Bruce Gray
- Department of Surgery at Greenville Health System, Greenville, South Carolina
| | - Adam C Salisbury
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri; Division of Cardiovascular Medicine, Saint Luke's Mid-America Heart Institute, Kansas City, Missouri.
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31
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Martini R. Current opinion on the role of the foot perfusion in limb amputation risk assessment. Clin Hemorheol Microcirc 2020; 76:405-412. [PMID: 32675403 DOI: 10.3233/ch-200901] [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: 01/22/2023]
Abstract
The most important and consulted guidelines dealing with not healing foot ulcers suggest the measurement of the foot perfusion (FP) to exclude the critical limb ischemia (CLI), because of the high risk of limb amputation. But the recommended cut-off values of FP fail to include all the heterogeneity of patients of the real-life with a not healing ulcer. Often these patients are diabetics with a moderate PAD but with a high level of infection. To meet this goal, in 2014, the Society for Vascular Surgery has published the "Lower Extremity Threatened Limb Classification System: Risk stratification based on Wound, Infection, and foot Ischemia (WIfI)." This new classification system has changed the criteria of assessment of limb amputation risk, replacing the single cut-off value role with a combination of a spectrum of perfusion values along with graded infection and dimension levels of skin ulcers. The impact of this new classification system was remarkable so to propose the substitution of the CLI definition, with the new Critical limb-threatening ischemia (CLTI), that seems to define the limb amputation risk more realistically.
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Affiliation(s)
- Romeo Martini
- Unità Operativa di Angiologia, Azienda Ospedaliera Universitaria di Padova, Padova, Italy
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Guo S, Zhang Z, Wang L, Yuan L, Bao J, Zhou J, Jing Z. Six-month results of stenting of the femoropopliteal artery and predictive value of interleukin-6: Comparison with high-sensitivity C-reactive protein. Vascular 2020; 28:715-721. [PMID: 32408853 DOI: 10.1177/1708538120921005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To determine the association of pre- and postinterventional serum levels of interleukin-6 and high-sensitivity C-reactive protein at the six-month evaluation of restenosis after stenting of the femoropopliteal artery. METHODS Sixty-eight consecutive patients with steno-occlusive femoropopliteal artery disease of Rutherford category III or IV who underwent stent implantation were included. Six-month patency was evaluated with color-coded duplex ultrasound. The association of in-stent restenosis with interleukin-6 and high-sensitivity C-reactive protein levels at baseline, and 24-h postintervention was assessed with a multivariate logistic regression analysis. RESULTS In-stent restenosis was found in 15 patients (22.1%) within six months. Interleukin-6 and high-sensitivity C-reactive protein levels were significantly increased at 24-h postintervention compared to their preintervention values (p < 0.001 and p = 0.002, respectively). Interleukin-6 values at baseline (odds ratio, 1.11; 95% confidence interval: 1.00, 1.23; p = 0.044) and 24-h postintervention (odds ratio, 1.04; 95% confidence interval: 1.02, 1.06; p < 0.001) were independently associated with six-month in-stent restenosis. Twenty-four-hour postinterventional high-sensitivity C-reactive protein levels were also found to be related to restenosis (odds ratio, 1.15; 95% confidence interval: 1.04, 1.26; p = 0.006), but high-sensitivity C-reactive protein levels at baseline did not show an independent association with in-stent restenosis (odds ratio, 0.57; 95% confidence interval: 0.35, 1.80; p = 0.667). Smoking, diabetes mellitus, and cumulative stent length were other parameters associated with an increased risk for in-stent restenosis. CONCLUSIONS Femoropopliteal artery angioplasty with stent placement induces an inflammatory response. Interleukin-6 is a powerful independent predictor of intermediate-term outcomes for stenting of the femoropopliteal artery, suggesting that its predictive value may be superior to that of high-sensitivity C-reactive protein.
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Affiliation(s)
- Songlin Guo
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhang Zhang
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Lei Wang
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Liangxi Yuan
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Junmin Bao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jian Zhou
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zaiping Jing
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
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Kokkinidis DG, Jawaid O, Cantu D, Martinsen BJ, Igyarto Z, Valle JA, Waldo SW, Armstrong EJ. Two-Year Outcomes of Orbital Atherectomy Combined With Drug-Coated Balloon Angioplasty for Treatment of Heavily Calcified Femoropopliteal Lesions. J Endovasc Ther 2020; 27:492-501. [DOI: 10.1177/1526602820915244] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To examine whether the combination of orbital atherectomy (OA) and drug-coated balloons (DCB) can lead to superior procedural and 2-year outcomes compared with DCB only in heavily calcified femoropopliteal (FP) lesions. Materials and Methods: A retrospective chart review was conducted to identify patients treated with DCB only or OA+DCB for de novo FP lesions at a single center over a 4-year period (2014–2017). In the observation period, 113 patients met the inclusion criteria: 63 treated with DCB only (mean age 69.0±8.6 years; 62 men) vs 50 treated with OA+DCB (mean age 70.3±7.1 years; 48 men). The OA+DCB group had higher calcification rates (78% with severe calcification vs 37% in the DCB only group). Propensity score matching (PSM) was used to adjust for baseline differences between the 2 groups. Cox regression analysis was used to compare the follow-up outcomes between lesions treated with OA+DCB vs DCB only. Results: No difference in procedural complications or success was found. After PSM adjustment, the OA+DCB group was associated with lower bailout stenting rates (39.4% vs 66.7% in the DCB only group; p=0.026). The 2 groups had similar long-term outcomes, although the OA+DCB arm had a trend toward reduced TLR rates that did not reach statistical significance. The Kaplan-Meier estimates for 2-year freedom from TLR were 76.1% for the OA+DCB group vs 55.5% for the DCB only group (p=0.109). Conclusion: OA+DCB is a safe and effective combination for the treatment of calcified FP lesions. The combined therapy decreased the bailout stenting rates in the adjusted analysis. Larger cohorts and randomized trials are needed to examine OA efficacy in FP lesions.
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Affiliation(s)
- Damianos G. Kokkinidis
- Division of Cardiology, Rocky Mountain VA Medical Center, University of Colorado, Aurora, CO, USA
| | - Omar Jawaid
- Division of Cardiology, Rocky Mountain VA Medical Center, University of Colorado, Aurora, CO, USA
| | - David Cantu
- Division of Cardiology, Rocky Mountain VA Medical Center, University of Colorado, Aurora, CO, USA
| | - Brad J. Martinsen
- Clinical Scientific Affairs, Cardiovascular Systems, Inc., St Paul, MN, USA
| | - Zsuzsanna Igyarto
- Clinical Scientific Affairs, Cardiovascular Systems, Inc., St Paul, MN, USA
| | - Javier A. Valle
- Division of Cardiology, Rocky Mountain VA Medical Center, University of Colorado, Aurora, CO, USA
| | - Stephen W. Waldo
- Division of Cardiology, Rocky Mountain VA Medical Center, University of Colorado, Aurora, CO, USA
| | - Ehrin J. Armstrong
- Division of Cardiology, Rocky Mountain VA Medical Center, University of Colorado, Aurora, CO, USA
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Schramm KM, DeWitt PE, Dybul S, Rochon PJ, Patel P, Hieb RA, Rogers RK, Ryu RK, Wolhauer M, Hong K, Trivedi PS. Recent Trends in Clinical Setting and Provider Specialty for Endovascular Peripheral Artery Disease Interventions for the Medicare Population. J Vasc Interv Radiol 2020; 31:614-621.e2. [DOI: 10.1016/j.jvir.2019.10.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/14/2019] [Accepted: 10/22/2019] [Indexed: 11/24/2022] Open
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Iida O, Takahara M, Soga Y, Kodama A, Terashi H, Azuma N. The Association of Preoperative Characteristics with Reintervention Risk in Patients Undergoing Revascularization for Chronic Limb-Threatening Ischemia. J Atheroscler Thromb 2020; 28:52-65. [PMID: 32224557 PMCID: PMC7875141 DOI: 10.5551/jat.54866] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
AIM To investigate the associations between preoperative characteristics and the risk of reintervention in patients undergoing revascularization for chronic limb-threatening ischemia (CLTI) in a contemporary real-world setting. METHODS We retrospectively analyzed data from a clinical database formed by the Surgical Reconstruction Versus Peripheral Intervention in Patients With Critical Limb Ischemia (SPINACH) study, which was a multicenter, prospective, observational study. The study population was composed of 520 CLTI patients with the wound, ischemia, and foot infection (WIfI) classes I-3 with resting pain or classes I-2/3 with ulcers/gangrene. Of the 520 patients, 192 had surgical reconstruction planned, whereas 328 had endovascular therapy (EVT) alone planned at the time of registration. The current analysis was conducted to explore the associations between preoperative characteristics and the risk of reintervention. RESULTS A total of 452 participants (87%) completed the 3-year follow-up regarding reintervention. The competing risk analysis estimated that the three-year cumulative incidence rates for reintervention and reintervention-free deaths were 44.0% and 28.7%, respectively. No preoperative characteristics had a significant interaction effect with EVT versus surgical reconstruction. The risk analysis identified the following independent risk factors for reintervention: 1) EVT instead of bypass reconstruction, 2) renal dysfunction, 3) history of revascularization after CLTI onset (i.e., requirement of redo revascularization for CLTI), and 4) bilateral CLTI. Patients with more than one of these risk factors had an increased risk of reintervention. CONCLUSIONS The current study identified preoperative characteristics associated with an increased risk of reintervention. No preoperative characteristics had any significant interactions with EVT or surgical reconstruction.
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Affiliation(s)
- Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine and Department of Metabolic Medicine, Osaka University Graduate School of Medicine
| | | | - Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University School of Medicine
| | - Hiroto Terashi
- Kobe University Graduate School of Medicine, Department of Plastic Surgery
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
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36
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Martini R. Current opinions about the definition of critical limb ischemia: A debate still open after three decades. Clin Hemorheol Microcirc 2020; 73:341-346. [PMID: 30909197 DOI: 10.3233/ch-190576] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Critical limb ischemia (CLI) is the most advanced stage of peripheral arterial disease. It is clinically defined as rest pain with or without skin ulcer or gangrene and carries a very poor prognosis with a high rates of limb amputation and cardiovascular mortality. Despite the first definition of CLI has been published more than 30 years ago, the debate about what it really is, is still open. Over the years the hemodynamic parameters utilised to define the critical level of limb perfusion have changed. This has raised some question about the apparent confusion about the definition of CLI. Moreover, a new term such as "limb threatening ischemia" has replaced the definition of CLI in recent guideline. Therefore, it becomes necessary to understand the evolution of the concept and the definition of CLI, to interpret the future trend.Hence, this work analysing the guideline documents on peripheral arterial disease that have defined the CLI to date, aims to clarify the path that has brought to the current conceptual changes of the definition of CLI.
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Affiliation(s)
- Romeo Martini
- Unitá Operativa di Angiologia, Azienda Ospedaliera Universitaria di Padova, Padova, Italy
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37
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Wee I, Tan G, Ng S, Chan ESY, Ng JJ, Samuel M, Choong AMTL. Endovascular versus open surgical endarterectomy for atherosclerotic lesions of the common femoral artery (CFA). Hippokratia 2020. [DOI: 10.1002/14651858.cd013545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ian Wee
- Yong Loo Lin School of Medicine, National University of Singapore; Singapore Singapore
| | - Gerald Tan
- Newcastle University Medicine Malaysia (NUMed Malaysia); Johor Malaysia
| | - Sheryl Ng
- Cardiovascular Research Institute, National University of Singapore; Singapore Singapore
| | | | - Jun Jie Ng
- Cardiovascular Research Institute, National University of Singapore; Singapore Singapore
- SingVaSC, Singapore Vascular Surgical Collaborative; Singapore Singapore
- Yong Loo Lin School of Medicine, National University of Singapore; Department of Surgery; Singapore Singapore
- National University Heart Centre; Division of Vascular Surgery; Singapore Singapore
| | - Miny Samuel
- NUS Yong Loo Lin School of Medicine; Research Support Unit; NUHS Tower Block, Level 11 1E Kent Ridge Road Singapore Singapore 119228
| | - Andrew MTL Choong
- Cardiovascular Research Institute, National University of Singapore; Singapore Singapore
- SingVaSC, Singapore Vascular Surgical Collaborative; Singapore Singapore
- Yong Loo Lin School of Medicine, National University of Singapore; Department of Surgery; Singapore Singapore
- National University Heart Centre; Division of Vascular Surgery; Singapore Singapore
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Hess CN, Wang TY, Weleski Fu J, Gundrum J, Allen LaPointe NM, Rogers RK, Hiatt WR. Long-Term Outcomes and Associations With Major Adverse Limb Events After Peripheral Artery Revascularization. J Am Coll Cardiol 2020; 75:498-508. [DOI: 10.1016/j.jacc.2019.11.050] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 11/04/2019] [Accepted: 11/19/2019] [Indexed: 12/16/2022]
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Eguia E, Baker MS, Bechara C, Shames M, Kuo PC. The Impact of the Affordable Care Act Medicaid Expansion on Vascular Surgery. Ann Vasc Surg 2020; 66:454-461.e1. [PMID: 31923598 DOI: 10.1016/j.avsg.2020.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 12/23/2019] [Accepted: 01/01/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) Medicaid expansion increased Medicaid eligibility such that all adults with an income level up to 138% of the federal poverty threshold in 2014 qualified for Medicaid benefits. Prior studies have shown that the ACA Medicaid expansion was associated with increased access to care. The impact of the ACA Medicaid expansion on patients undergoing complex care for major vascular pathology has not been evaluated. METHODS The Healthcare Cost and Utilization Project State Inpatient Database was used to identify patients undergoing care for major vascular pathology in 6 states from 2010 to 2014. The analysis cohort included adult patients between the ages of 18 and 64 years who underwent a nonemergent surgical procedure for an abdominal aortic aneurysm, thoracic aortic aneurysm, carotid artery stenosis, peripheral vascular disease, or chronic kidney disease. Poisson regression was used to determine the incidence rate ratios (IRRs). RESULTS There were a total of 83,960 patients in the study cohort. Compared with nonexpansion states, inpatient admissions for Medicaid patients with an abdominal or thoracic aneurysm and carotid stenosis diagnosis increased significantly (IRR, 1.20, 1.27, 1.06, respectively; P < 0.05) in states that expanded Medicaid. Vascular-related surgeries increased for carotid endarterectomy, lower extremity revascularization, lower extremity amputation, and arteriovenous fistula in expansion states (IRR, 1.24, 1.10, 1.11, 1.16, respectively; P < 0.05) compared with nonexpansion states. CONCLUSIONS In states that expanded Medicaid coverage under the ACA, the rate of vascular-related surgeries and admissions for Medicaid patients increased. We conclude that expanding insurance coverage results in enhanced access to vascular surgery.
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Affiliation(s)
- Emanuel Eguia
- Department of Surgery, Loyola University Medical Center, Maywood, IL.
| | - Marshall S Baker
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Carlos Bechara
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Murray Shames
- Department of Surgery, University of South Florida, Tampa, FL
| | - Paul C Kuo
- Department of Surgery, University of South Florida, Tampa, FL
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Kreutzburg T, Peters F, Rieß HC, Hischke S, Marschall U, Kriston L, L'Hoest H, Sedrakyan A, Debus ES, Behrendt CA. Editor's Choice – Comorbidity Patterns Among Patients with Peripheral Arterial Occlusive Disease in Germany: A Trend Analysis of Health Insurance Claims Data. Eur J Vasc Endovasc Surg 2020; 59:59-66. [DOI: 10.1016/j.ejvs.2019.08.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/06/2019] [Accepted: 08/11/2019] [Indexed: 02/06/2023]
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41
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Vasilchenko EM. Current Issues of the Rehabilitation of Disabled Elderly and Senile Persons with Limb Loss due to Obliterative Arterial Disease. ADVANCES IN GERONTOLOGY 2019. [DOI: 10.1134/s2079057019040143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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42
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Ramkumar N, Suckow BD, Brown JR, Sedrakyan A, MacKenzie T, Stone DH, Cronenwett JL, Goodney PP. Role of Sex in Determining Treatment Type for Patients Undergoing Endovascular Lower Extremity Revascularization. J Am Heart Assoc 2019; 8:e013088. [PMID: 31475624 PMCID: PMC6755836 DOI: 10.1161/jaha.119.013088] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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 Limited data exist to describe factors that influence the use of different endovascular treatments for peripheral arterial disease. Therefore, we studied sex differences in the utilization of endovascular treatment modalities and their impact on arterial patency. Methods and Results We analyzed procedures from 2010 to 2016 in the Vascular Quality Initiative for arteries treated with percutaneous transluminal angioplasty (PTA) alone, stenting (with/without PTA), and atherectomy (with/without PTA). We explored sex differences in treatment modality by arterial segment (iliac, femoropopliteal, and tibial) with multivariable logistic regression. We used Kaplan-Meier survival analysis and multivariable Cox regression to study sex differences in arterial reintervention and occlusion. In this cohort, patients (n=58 247, mean age 68 years, 41% women,) had 106 073 arteries treated (median=2 arteries, interquartile range=1-3). Half (50%) of these arteries were treated with stents, 39% with PTA alone, and 11% with atherectomy. After risk adjustment, women were less likely to undergo stenting or atherectomy (versus PTA alone) in the femoropopliteal (stent risk ratio=0.78 [0.74-0.82]; atherectomy risk ratio=0.69 [0.58-0.82]) and tibial arteries (stent risk ratio=0.70 [0.55-0.89]; atherectomy risk ratio=0.87 [0.70-1.07]). In the iliac arteries there was no sex difference in stenting, and atherectomy was rarely used (0.2%). Women underwent reintervention in the femoropopliteal arteries (hazard ratio=1.28 [1.17-1.40]) or developed an occlusion in the iliac (hazard ratio=1.42 [1.12-1.81]) and femoropopliteal arteries (hazard ratio=1.19 [1.06-1.34]) more frequently than men. Conclusions Women were less likely to undergo stenting or atherectomy and had higher rates of occlusion and reintervention, especially in the femoropopliteal arteries. Evidence-based guidelines are needed to guide optimal use of endovascular treatments for men and women.
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Affiliation(s)
- Niveditta Ramkumar
- The Dartmouth Institute for Health Policy and Clinical Practice Lebanon NH
| | - Bjoern D Suckow
- Section of Vascular Surgery Department of Surgery Dartmouth-Hitchcock Medical Center Lebanon NH
| | - Jeremiah R Brown
- The Dartmouth Institute for Health Policy and Clinical Practice Lebanon NH
| | - Art Sedrakyan
- Weill Cornell Medical College Cornell University New York NY
| | - Todd MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice Lebanon NH
| | - David H Stone
- Section of Vascular Surgery Department of Surgery Dartmouth-Hitchcock Medical Center Lebanon NH
| | - Jack L Cronenwett
- Section of Vascular Surgery Department of Surgery Dartmouth-Hitchcock Medical Center Lebanon NH
| | - Philip P Goodney
- The Dartmouth Institute for Health Policy and Clinical Practice Lebanon NH.,Section of Vascular Surgery Department of Surgery Dartmouth-Hitchcock Medical Center Lebanon NH
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Impact of Plaque Calcification and Stent Oversizing on Clinical Outcomes of Atherosclerotic Femoropopliteal Arterial Occlusive Disease Following Stent Angioplasty. Eur J Vasc Endovasc Surg 2019; 58:215-222. [DOI: 10.1016/j.ejvs.2019.01.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 01/22/2019] [Indexed: 11/21/2022]
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Miller SM, Sumpio BJ, Miller MS, Erben Y, Cordova AC, Sumpio BE. Higher Inpatient Mortality for Women after Intervention for Lifestyle Limiting Claudication. Ann Vasc Surg 2019; 58:54-62. [DOI: 10.1016/j.avsg.2019.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 10/23/2018] [Accepted: 01/13/2019] [Indexed: 10/27/2022]
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45
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Smith ME, Sutzko DC, Beck AW, Osborne NH. Provider Trends in Atherectomy Volume between Office-Based Laboratories and Traditional Facilities. Ann Vasc Surg 2019; 58:83-90. [DOI: 10.1016/j.avsg.2018.12.059] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 11/21/2018] [Accepted: 12/06/2018] [Indexed: 12/19/2022]
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Trends in mortality, readmissions, and complications after endovascular and open infrainguinal revascularization. Surgery 2019; 165:1222-1227. [DOI: 10.1016/j.surg.2019.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/12/2019] [Accepted: 03/14/2019] [Indexed: 11/17/2022]
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Holscher CM, Canner JK, Garonzik Wang JM, Abularrage CJ, Black JH, Hicks CW. Temporal trends and hospital costs associated with an endovascular-first approach for acute limb ischemia. J Vasc Surg 2019; 70:1506-1513.e1. [PMID: 31068269 DOI: 10.1016/j.jvs.2019.01.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 01/20/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Recent studies suggest similar perioperative outcomes for endovascular and open surgical management of acute limb ischemia (ALI). We sought to describe temporal trends, patient factors, and hospital costs associated with contemporary ALI management. METHODS We used the weighted National Inpatient Sample to estimate primary ALI cases requiring open or endovascular intervention (2005-2014). We used multivariable regression models to examine temporal trends, patient factors, and hospital costs associated with endovascular-first vs open-first management. RESULTS Of 116,451 admissions for ALI during the study period, 35.2% were treated by an endovascular-first approach. The percentage of admissions managed with an endovascular-first approach increased over time (P < .001). Independent predictors of endovascular-first management included younger age, male sex, renal insufficiency, and more recent calendar year of admission (P ≤ .02), whereas patients who underwent fasciotomy, those with Medicaid, and those admitted on a weekend were more likely to undergo open-first management (P ≤ .02). Endovascular-first management had higher mean hospital costs than open-first management ($29,719 vs $26,193; P < .001). After adjustment for patient, hospital, and admission characteristics, there was an increase of $981 in treatment costs per year in the endovascular-first group (95% confidence interval [CI], $571-$1392; P < .001), whereas the costs associated with an open-first approach remained relatively stable over time ($10 per year; 95% CI, -$295 to $315; P = .95; P < .001 for interaction). The risk-adjusted odds of in-hospital major amputation was similar in both groups (adjusted odds ratio, 0.99; 95% CI, 0.85-1.15; P = .88). CONCLUSIONS Use of an endovascular-first approach for the treatment of ALI has significantly increased over time. Although major amputation rates are similar for both approaches, the costs associated with an endovascular-first approach are increasing over time, whereas the costs of open surgery have remained stable. The cost-effectiveness of modern ALI management warrants further investigation.
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Affiliation(s)
- Courtenay M Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Joseph K Canner
- Johns Hopkins Surgery Center for Outcomes Research (JSCOR), Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md.
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Shanmugasundaram M, Murugapandian S, Truong HT, Lotun K, Banerjee S. Drug-coated balloon in peripheral artery disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:338-343. [DOI: 10.1016/j.carrev.2018.04.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/26/2018] [Accepted: 04/17/2018] [Indexed: 12/24/2022]
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Mufti Alsadiqi AI, Subki AH, Abushanab RH, Ocheltree MR, Bajahmom HA, Alsadiqi YIM, Alhejily WA. Peripheral artery disease risk factors in Jeddah, Saudi Arabia: a retrospective study. Int J Gen Med 2019; 12:49-54. [PMID: 30662279 PMCID: PMC6329343 DOI: 10.2147/ijgm.s176451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background Peripheral artery disease (PAD) is a major health problem in Saudi Arabia with considerable implications for morbidity and mortality. Many risk factors have been established for developing PAD, but the prevalence of these risk factors is variable from one country to another. Aim To identify the risk factors for PAD and study their prevalence in Jeddah, Saudi Arabia. Methods A retrospective chart review study was conducted in a tertiary center in Jeddah from July 2012 to September 2015. All patients with PAD were recruited into this study, and their data were analyzed using IBM SPSS. Correlation between PAD and various risk factors was studied using Spearman's coefficient. Results A total of 261 patients were recruited, of which 55% were males. Hypertension, diabetes type 2, and obesity were found among 34.2%, 33.3%, and 29.2% of the patients, respectively. About 45% had a history of previous vascular surgery, and amputation was performed in 6.9% particularly in legs. Hypertension and metabolic syndrome were the only risk factors that showed a significant correlation with PAD (P=0.039 and 0.040, respectively). Conclusion The most prevalent risk factors for PAD in Jeddah were hypertension, diabetes, obesity, and smoking. Hypertension and metabolic syndrome were the only risk factors significantly associated with PAD. Males were often more affected by PAD than females. The most commonly affected site was the lower limbs.
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Affiliation(s)
| | - Ahmed Hussein Subki
- Department of Internal Medicine, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia,
| | - Rami Hussam Abushanab
- Department of Internal Medicine, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia,
| | - Mohammed Rashid Ocheltree
- Department of Internal Medicine, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia,
| | - Hattan Ahmed Bajahmom
- Department of Internal Medicine, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia,
| | | | - Wesam Awad Alhejily
- Department of Internal Medicine, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia,
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Ye M, Ni Q, Qi H, Qian X, Chen J, Guo X, Li M, Zhao Y, Xue G, Deng H, Zhang L. Exosomes Derived from Human Induced Pluripotent Stem Cells-Endothelia Cells Promotes Postnatal Angiogenesis in Mice Bearing Ischemic Limbs. Int J Biol Sci 2019; 15:158-168. [PMID: 30662356 PMCID: PMC6329927 DOI: 10.7150/ijbs.28392] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 09/26/2018] [Indexed: 12/27/2022] Open
Abstract
Induced pluripotent stem cell (iPSC) derived endothelial cells (ECs) is a novel therapeutic option for ischemic diseases. Although the detailed mechanism of this novel therapy remains unknown, emerging evidence has demonstrated that exosomes derived from hiPSC-ECs play a critical role in this approach. In this study, we first isolated and characterized the exosomes from iPSCs-ECs (hiPSC-EC-Exo) and determined the functional roles of hiPSC-EC-Exo in neovascularization and the underlying mechanism. Further, we evaluated the effect of exosomes derived from hiPS-ECs on promoting angiogenesis in a mouse model bearing ischemic limbs. Our results showed that miR-199b-5p, an miRNA highly associated with angiogenesis, is significantly upregulated during the differentiation of hiPSC-ECs. Mechanically, our studies found that hiPSC-ECs expressing miR-199b-5p significantly promote cell migration, proliferation and tube formation through Jagged-1-dependent upregulation of VEGFR2 in HUVECs. Similarly, coculture of hiPSC-ECs-Exo with HUVECs also resulted in a significant improvement in HUVEC migration, proliferation, and tube formation, suggesting that exosome-mediated cell-cell communication in a paracrine manner may serve as a fundamental mechanism for iPSC-EC-based treatment. Consequently, we found that the transfer of hiPSC-ECs enriched with miR-199b-5p significantly enhanced micro-vessel density and blood perfusion in ischemic limbs in vivo. Taken together, our studies were the first to demonstrate that transfer of hiPSC-ECs-Exo is a promising approach to treat ischemic injury via the mechanism of promoting neovascularization.
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Affiliation(s)
- Meng Ye
- Department of Vascular Surgery, RenJi Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qihong Ni
- Department of Vascular Surgery, RenJi Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Haozhe Qi
- Department of Vascular Surgery, RenJi Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xin Qian
- Department of Vascular Surgery, RenJi Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jiaquan Chen
- Department of Vascular Surgery, RenJi Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiangjiang Guo
- Department of Vascular Surgery, RenJi Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Maoran Li
- Department of Vascular Surgery, RenJi Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yiping Zhao
- Department of Vascular Surgery, RenJi Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Guanhua Xue
- Department of Vascular Surgery, RenJi Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Haoyu Deng
- Department of Vascular Surgery, RenJi Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lan Zhang
- Department of Vascular Surgery, RenJi Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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