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Naiem AA, Kayssi A. Distal Adjuncts for High-Risk Lower Extremity Bypasses. Ann Vasc Surg 2024; 107:140-145. [PMID: 38582219 DOI: 10.1016/j.avsg.2023.12.106] [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: 12/25/2023] [Accepted: 12/27/2023] [Indexed: 04/08/2024]
Abstract
BACKGROUND This review will discuss the use of distal adjuncts for improving graft patency in high-risk lower extremity bypasses. METHODS Factors that contribute to the increased risk of failure in high-risk lower extremity bypasses, such as the use of nonautogenous conduits, the creation of bypasses to very distal arterial targets, and bypasses in patients with significant tibial arterial disease, will be discussed. RESULTS The use of surgical techniques such as creating venous cuffs, venous patches, and arteriovenous fistulas have been shown to improve the patency of high-risk bypasses. CONCLUSIONS Despite the increased risk of failure, the use of surgical adjuncts such as cuffs, patches, and arteriovenous fistulas can improve the patency rates of high-risk lower extremity bypasses.
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Affiliation(s)
- Ahmed A Naiem
- Department of Vascular Surgery, The Royal Hospital, Muscat, Oman
| | - Ahmed Kayssi
- Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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2
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Cleman J, Sierra JG, Romain G, Capuano B, Scierka L, Callegari S, Jacque F, Peri-Okonny P, Nagpal S, Smolderen KG, Mena-Hurtado C. Comparison of mortality and amputation after lower extremity bypass versus peripheral vascular intervention in patients with chronic limb-threatening ischemia and comorbid chronic kidney disease. J Vasc Surg 2024; 80:480-489.e5. [PMID: 38608966 DOI: 10.1016/j.jvs.2024.04.016] [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: 02/21/2024] [Revised: 03/25/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Comorbid chronic kidney disease (CKD) is associated with worse outcomes for patients with chronic limb-threatening ischemia (CLTI). However, comparative effectiveness data are limited for lower extremity bypass (LEB) vs peripheral vascular intervention (PVI) in patients with CLTI and CKD. We aimed to evaluate (1) 30-day all-cause mortality and amputation and (2) 5-year all-cause mortality and amputation for LEB vs PVI in patients with comorbid CKD. METHODS Individuals who underwent LEB and PVI were queried from the Vascular Quality Initiative with Medicare claims-linked outcomes data. Propensity scores were calculated using 13 variables, and a 1:1 matching method was used. The mortality risk at 30 days and 5 years in LEB vs PVI by CKD was assessed using Kaplan-Meier and Cox proportional hazards models, with interaction terms added for CKD. For amputation, cumulative incidence functions and Fine-Gray models were used to account for the competing risk of death, with interaction terms for CKD added. RESULTS Of 4084 patients (2042 per group), the mean age was 71.0 ± 10.8 years, and 69.0% were male. Irrespective of CKD status, 30-day mortality (hazard ratio [HR]: 0.94, 95% confidence interval [CI]: 0.63-1.42, P = .78) was similar for LEB vs PVI, but LEB was associated with a lower risk of 30-day amputation (sub-HR [sHR]: 0.66, 95% CI: 0.44-0.97, P = .04). CKD status, however, did not modify these results. Similarly, LEB vs PVI was associated with a lower risk of 5-year mortality (HR: 0.79, 95% CI: 0.71-0.88, P < .001) but no difference in 5-year amputation (sHR: 1.03, 95% CI: 0.89-1.20, P = .67). CKD status did not modify these results. CONCLUSIONS Regardless of CKD status, patients had a lower risk of 5-year all-cause mortality and 30-day amputation with LEB vs PVI. Results may help inform preference-sensitive treatment decisions on LEB vs PVI for patients with CLTI and CKD, who may commonly be deemed too high risk for surgery.
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Affiliation(s)
- Jacob Cleman
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Juan G Sierra
- Department of Internal Medicine, Division of Cardiology, Naples Healthcare System, Naples Heart Institute, Naples, FL
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Bella Capuano
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Lindsey Scierka
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | | | - Francky Jacque
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | | | - Sameer Nagpal
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT; Department of Internal Medicine, Division of Cardiology, Yale School of Medicine, New Haven, CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT; Department of Internal Medicine, Division of Cardiology, Yale School of Medicine, New Haven, CT.
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Li Q, Birmpili P, Atkins E, Johal AS, Waton S, Williams R, Boyle JR, Harkin DW, Pherwani AD, Cromwell DA. Illness Trajectories After Revascularization in Patients With Peripheral Artery Disease: A Unified Approach to Understanding the Risk of Major Amputation and Death. Circulation 2024; 150:261-271. [PMID: 39038089 DOI: 10.1161/circulationaha.123.067687] [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: 10/20/2023] [Accepted: 05/08/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND The aim of this study was to investigate the illness trajectories of patients with peripheral artery disease (PAD) after revascularization and estimate the independent risks of major amputation and death (from any cause) and their interaction. METHODS Data from Hospital Episode Statistics Admitted Patient Care were used to identify patients (≥50 years of age) who underwent lower limb revascularization for PAD in England from April 2013 to March 2020. A Markov illness-death model was developed to describe patterns of survival after the initial lower limb revascularization, if and when patients experienced major amputation, and survival after amputation. The model was also used to investigate the association between patient characteristics and these illness trajectories. We also analyzed the relative contribution of deaths after amputation to overall mortality and how the risk of mortality after amputation was related to the time from the index revascularization to amputation. RESULTS The study analyzed 94 690 patients undergoing lower limb revascularization for PAD from 2013 to 2020. The majority were men (65.6%), and the median age was 72 years (interquartile range, 64-79). One-third (34.8%) of patients had nonelective revascularization, whereas others had elective procedures. For nonelective patients, the amputation rate was 15.2% (95% CI, 14.4-16.0) and 19.9% (19.0-20.8) at 1 and 5 years after revascularization, respectively. For elective patients, the corresponding amputation rate was 2.7% (95% CI, 2.4-3.1) and 5.3% (4.9-5.8). Overall, the risk of major amputation was higher among patients who were younger, had tissue loss, diabetes, greater frailty, nonelective revascularization, and more distal procedures. The mortality rate at 5 years after revascularization was 64.3% (95% CI, 63.2-65.5) for nonelective patients and 33.0% (32.0-34.1) for elective patients. After major amputation, patients were at an increased risk of mortality if they underwent major amputation within 6 months after the index revascularization. CONCLUSIONS The illness-death model provides an integrated framework to understand patient outcomes after lower limb revascularization for PAD. Although mortality increased with age, the study highlights patients <60 years of age were at increased risk of major amputation, particularly after nonelective revascularization.
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Affiliation(s)
- Qiuju Li
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, United Kingdom (Q.L., D.A.C.)
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (Q.L., P.B., E.A., A.S.J., S.W., D.A.C.)
| | - Panagiota Birmpili
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (Q.L., P.B., E.A., A.S.J., S.W., D.A.C.)
- Hull York Medical School, Heslington, United Kingdom (P.B., E.A.)
| | - Eleanor Atkins
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (Q.L., P.B., E.A., A.S.J., S.W., D.A.C.)
- Hull York Medical School, Heslington, United Kingdom (P.B., E.A.)
| | - Amundeep S Johal
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (Q.L., P.B., E.A., A.S.J., S.W., D.A.C.)
| | - Sam Waton
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (Q.L., P.B., E.A., A.S.J., S.W., D.A.C.)
| | - Robin Williams
- Department of Interventional Radiology, Freeman Hospital, Newcastle-upon-Tyne Hospitals, United Kingdom (R.W.)
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals, National Health Services Foundation Trust and Department of Surgery, University of Cambridge, United Kingdom (J.R.B.)
| | - Denis W Harkin
- Belfast Health and Social Care Trust, United Kingdom (D.W.H.)
- The Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Faculty of Medicine and Health Sciences, Dublin, Ireland (D.W.H.)
| | - Arun D Pherwani
- Keele University School of Medicine and University Hospitals of North Midlands National Health Services Trust, Stoke-On-Trent, United Kingdom (A.D.P.)
| | - David A Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, United Kingdom (Q.L., D.A.C.)
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (Q.L., P.B., E.A., A.S.J., S.W., D.A.C.)
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Toth GG, Brodmann M, Kanoun Schnur SS, Bartus S, Vrsalovic M, Krestianinov O, Kala P, Bil J, Gil R, Kanovsky J, Di Serafino L, Paolucci L, Barbato E, Mangiacapra F, Ruzsa Z. Intentional coronary revascularization versus conservative therapy in patients after peripheral artery revascularization due to critical limb ischemia: the INCORPORATE trial. Clin Res Cardiol 2024:10.1007/s00392-024-02487-2. [PMID: 38990250 DOI: 10.1007/s00392-024-02487-2] [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: 04/08/2024] [Accepted: 06/25/2024] [Indexed: 07/12/2024]
Abstract
OBJECTIVES INCORPORATE trial was designed to evaluate whether default coronary-angiography (CA) and ischemia-targeted revascularization is superior compared to a conservative approach for patients with treated critical limb ischemia (CLI). Registered at clinicaltrials.gov (NCT03712644) on October 19, 2018. BACKGROUND Severe peripheral artery disease is associated with increased cardiovascular risk and poor outcomes. METHODS INCORPORATE was an open-label, prospective 1:1 randomized multicentric trial that recruited patients who had undergone successful CLI treatment. Patients were randomized to either a conservative or invasive approach regarding potential coronary artery disease (CAD). The conservative group received optimal medical therapy alone, while the invasive group had routine CA and fractional flow reserve-guided revascularization. The primary endpoint was myocardial infarction (MI) and 12-month mortality. RESULTS Due to COVID-19 pandemic burdens, recruitment was halted prematurely. One hundred eighty-five patients were enrolled. Baseline cardiac symptoms were scarce with 92% being asymptomatic. Eighty-nine patients were randomized to the invasive approach of whom 73 underwent CA. Thirty-four percent had functional single-vessel disease, 26% had functional multi-vessel disease, and 90% achieved complete revascularization. Conservative and invasive groups had similar incidences of death and MI at 1 year (11% vs 10%; hazard ratio 1.21 [0.49-2.98]). Major adverse cardiac and cerebrovascular events (MACCE) trended for hazard in the Conservative group (20 vs 10%; hazard ratio 1.94 [0.90-4.19]). In the per-protocol analysis, the primary endpoint remained insignificantly different (11% vs 7%; hazard ratio 2.01 [0.72-5.57]), but the conservative approach had a higher MACCE risk (20% vs 7%; hazard ratio 2.88 [1.24-6.68]). CONCLUSION This trial found no significant difference in the primary endpoint but observed a trend of higher MACCE in the conservative arm.
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Affiliation(s)
- Gabor G Toth
- Department of Cardiology, University Heart Center Graz, Medical University Graz, Graz, Austria
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Sadeek S Kanoun Schnur
- Department of Cardiology, University Heart Center Graz, Medical University Graz, Graz, Austria
- Department of Cardiology, Faculty of Medicine, Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
- Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Stanislaw Bartus
- II Dept of Cardiology, Medical College, Jagiellonian University, Krakow, Poland
| | - Mislav Vrsalovic
- Department of Cardiology, University of Zagreb School of Medicine, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Oleg Krestianinov
- E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - Petr Kala
- University Hospital Brno and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Jacek Bil
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Warsaw, Poland
- National Medical Institute of the Internal Affairs and Administration Ministry, Warsaw, Poland
| | - Robert Gil
- National Medical Institute of the Internal Affairs and Administration Ministry, Warsaw, Poland
| | - Jan Kanovsky
- University Hospital Brno and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Luigi Di Serafino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Luca Paolucci
- Department of Medicine and Surgery, Research Unit of Cardiovascular Science, Università Campus Bio-Medico Di Roma and Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Fabio Mangiacapra
- Department of Medicine and Surgery, Research Unit of Cardiovascular Science, Università Campus Bio-Medico Di Roma and Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Zoltan Ruzsa
- Department of Cardiology, Faculty of Medicine, Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary.
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Yamamoto S, Hashimoto T, Sano M, Kimura M, Sato O, Deguchi J. Absolute Lymphocyte Count Predicts Bypass Surgery Outcomes in Patients with Chronic Limb-Threatening Ischemia. Ann Vasc Dis 2024; 17:142-149. [PMID: 38919317 PMCID: PMC11196179 DOI: 10.3400/avd.oa.23-00088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/03/2024] [Indexed: 06/27/2024] Open
Abstract
Objectives: The aim of this study was to evaluate the relationship between absolute lymphocyte count (ALC) and outcomes of infrainguinal bypass surgery for chronic limb-threatening ischemia (CLTI). Methods: From 2004 to 2020, 209 limbs of 189 patients who underwent infrainguinal bypass surgery for CLTI and whose ALCs were available were included. Patients with survival >2 years and limb salvage >2 years were considered discriminant groups, and an ALC cut-off value was calculated. The relationship between preoperative ALC and outcomes was evaluated. Results: Survivorship of the higher ALC group was significantly higher than that of the lower ALC group (cut-off value 1030/μL, p = 0.0009). The limb salvage rate of the higher ALC group was significantly higher than that of the lower ALC group (cut-off value 1260/μL, p = 0.0081). In the dialysis patient group (103 limbs), the limb salvage rate of the higher ALC group was significantly higher than that of the lower ALC group (cut-off value 1170/μL, p = 0.026). ALC was independently associated with limb loss in multivariate analysis. Conclusion: ALC is promising as a predictor of outcomes after bypass surgery in CLTI. In particular, ALC is expected to be useful for limb prognosis in hemodialysis patients.
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Affiliation(s)
- Satoshi Yamamoto
- Department of Vascular Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
- Department of Cardiovascular Surgery, Ome Medical Center, Ome, Tokyo, Japan
| | - Takuya Hashimoto
- Department of Vascular Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Masaya Sano
- Department of Vascular Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Masaru Kimura
- Department of Vascular Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Osamu Sato
- Department of Vascular Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Juno Deguchi
- Department of Vascular Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
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Vogel JH, Cheng CP, Murphy EH, Black SA, Desai KR. Fatigue Test Method to Evaluate the 50 Year Durability of Venous Stents. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00541-0. [PMID: 38906369 DOI: 10.1016/j.ejvs.2024.06.024] [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: 11/14/2023] [Revised: 04/23/2024] [Accepted: 06/17/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE Iliofemoral venous obstructive disease can result in significant, potentially debilitating symptoms that can negatively affect quality of life. Unlike arterial disease, patients with deep venous disease have a significantly lower median age, therefore the need for long term stent patency becomes a matter of decades rather than years. Furthermore, iliofemoral lesions frequently require stent placement across the inguinal ligament. Such stents are subject to dynamic stress from leg movement and associated concerns for device fatigue, resulting in stent fracture. The aim of this study was to describe an in vitro 50 year stent fatigue test method designed to assess durability against dynamic stress induced device fracture. METHODS Through literature review, cadaver studies, and computer modelling, the most challenging loading was confirmed to be hip flexion across the inguinal ligament. This occurs when the patient adjusts between a seated and standing position. Sit to stand hip flexion at the inguinal ligament was effectively simulated on the bench in this in vitro experimental study. RESULTS When tested under challenge parameters, hip flexion was reliably found to cause fractures in non-venous nitinol stents. However, a dedicated self expanding nitinol venous stent, engineered for improved durability, underwent up to 50 years of simulated loading on the bench with 15% (3/20) of stents experiencing fractures at 50 years, compared with fractures in 35% (14/40) of non-venous stents tested to 1.4 years; no statistical testing was performed as durations do not match and the objective was to demonstrate the test method. CONCLUSION The presented fatigue test method is a suitable approach for evaluating the durability of stents intended for venous use. Venous stents demonstrated superior fatigue resistance compared with non-venous stents via in vitro hip flexion testing.
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Affiliation(s)
- Jeffrey H Vogel
- Peripheral Vascular Health, Medtronic, Minneapolis, MN, USA.
| | - Christopher P Cheng
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Erin H Murphy
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, NC, USA
| | - Stephen A Black
- School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Kush R Desai
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2497-2604. [PMID: 38752899 DOI: 10.1016/j.jacc.2024.02.013] [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] [Indexed: 05/23/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [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] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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9
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Matthay ZA, Pace WA, Smith EJ, Gutierrez RD, Gasper WJ, Hiramoto JS, Reilly LM, Conte MS, Iannuzzi JC. Predictors of amputation-free survival and wound healing after infrainguinal bypass with alternative conduits. J Vasc Surg 2024; 79:1447-1456.e2. [PMID: 38310981 DOI: 10.1016/j.jvs.2024.01.209] [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: 09/28/2023] [Revised: 01/24/2024] [Accepted: 01/28/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVE Inadequate vein quality or prior harvest precludes use of autologous single segment greater saphenous vein (ssGSV) in many patients with chronic limb-threatening ischemia (CLTI). Predictors of patient outcome after infrainguinal bypass with alternative (non-ssGSV) conduits are not well-understood. We explored whether limb presentation, bypass target, and conduit type were associated with amputation-free survival (AFS) after infrainguinal bypass using alternative conduits. METHODS A single-center retrospective study (2013-2020) was conducted of 139 infrainguinal bypasses performed for CLTI with cryopreserved ssGSV (cryovein) (n = 71), polytetrafluoroethylene (PTFE) (n = 23), or arm/spliced vein grafts (n = 45). Characteristics, Wound, Ischemia, and foot Infection (WIfI) stage, and outcomes were recorded. Multivariable Cox proportional hazards and classification and regression tree analysis modeled predictors of AFS. RESULTS Within 139 cases, the mean age was 71 years, 59% of patients were male, and 51% of cases were nonelective. More patients undergoing bypass with cryovein were WIfI stage 4 (41%) compared with PTFE (13%) or arm/spliced vein (27%) (P = .04). Across groups, AFS at 2 years was 78% for spliced/arm, 79% for PTFE, and 53% for cryovein (adjusted hazard ratio for cryovein, 2.5; P = .02). Among cases using cryovein, classification and regression tree analysis showed that WIfI stage 3 or 4, age >70 years, and prior failed bypass were predictive of the lowest AFS at 2 years of 36% vs AFS of 58% to 76% among subgroups with less than two of these factors. Although secondary patency at 2 years was worse in the cryovein group (26% vs 68% and 89% in arm/spliced and PTFE groups; P < .01), in patients with tissue loss there was no statistically significant difference in wound healing in the cryovein group (72%) compared with other bypass types (72% vs 87%, respectively; P = .12). CONCLUSIONS In patients with CLTI lacking suitable ssGSV, bypass with autogenous arm/spliced vein or PTFE has superior AFS compared with cryovein, although data were limited for PTFE conduits for distal targets. Despite poor patency with cryovein, wound healing is achieved in a majority of cases, although it should be used with caution in older patients with high WIfI stage and prior failed bypass, given the low rates of AFS.
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Affiliation(s)
- Zachary A Matthay
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - William A Pace
- Department of Surgery, University of California, San Francisco, San Francisco, CA.
| | - Eric J Smith
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Richard D Gutierrez
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade S Hiramoto
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Linda M Reilly
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
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Rosen MN, Mor R, Roberts DJ, McIsaac DI. Contraindications to use of neuraxial anesthesia for lower limb revascularization surgery in adults: a cross-sectional study. Can J Anaesth 2024; 71:808-817. [PMID: 37498443 DOI: 10.1007/s12630-023-02546-8] [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: 09/02/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 07/28/2023] Open
Abstract
PURPOSE Nonrandomized and some randomized data suggest neuraxial anesthesia may improve outcomes after lower limb revascularization surgery. Nevertheless, the prevalence of contraindications to neuraxial anesthesia in vascular surgery patients is unknown. We aimed to identify the prevalence of patients with contraindications to neuraxial anesthesia, and to derive and validate a case ascertainment algorithm identifying individuals likely to have contraindications. METHODS We conducted a historical cross-sectional study of open lower limb revascularization surgeries performed between 2019 and 2021 at The Ottawa Hospital. Medical records were reviewed for demographic data, admission, procedural characteristics, and presence of contraindications to neuraxial anesthesia. Case ascertainment algorithms to predict the presence of absolute contraindications to neuraxial anesthesia were derived and internally validated. RESULTS We identified 340 cases. General anesthesia was used in 219 (64.4%) cases, isolated neuraxial (spinal and/or epidural) in 106 (31.2%) cases, and general plus neuraxial in 15 (4.4%) cases. Seventy-eight (22.9%; 95% confidence interval [CI], 18.8 to 27.7) patients had absolute contraindications to neuraxial anesthesia, primarily because of anticoagulation or antiplatelet medication (89.4%); 21 (6.2%; 95% CI, 4.1 to 9.3) had relative contraindications, primarily long anticipated duration of surgery (16/21, 76.2%). We derived and validated three nested case-ascertainment algorithms. Using admission and procedure variables, discrimination was moderate with moderately explained variance, and calibration was inadequate for reliable use. Patient comorbidity and laboratory data did not improve algorithm performance. CONCLUSION Most patients undergoing lower limb revascularization surgery did not have absolute contraindications to neuraxial anesthesia. When present, contraindications typically related to anticoagulation. Admission, procedure, comorbidity, and laboratory data did not provide adequate accuracy to ascertain contraindication status.
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Affiliation(s)
- Michael N Rosen
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Rahul Mor
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Daniel I McIsaac
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Room B311, 1053 Carling Ave., Ottawa, ON, K1Y 4E9, Canada.
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11
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Callegari S, Romain G, Cleman J, Scierka L, Jacque F, Smolderen KG, Mena-Hurtado C. Long-Term Mortality Predictors Using a Machine-Learning Approach in Patients With Chronic Limb-Threatening Ischemia After Peripheral Vascular Intervention. J Am Heart Assoc 2024; 13:e034477. [PMID: 38761075 PMCID: PMC11179837 DOI: 10.1161/jaha.124.034477] [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: 01/16/2024] [Accepted: 04/15/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Patients with chronic limb-threatening ischemia (CLTI) face a high long-term mortality risk. Identifying novel mortality predictors and risk profiles would enable individual health care plan design and improved survival. We aimed to leverage a random survival forest machine-learning algorithm to identify long-term all-cause mortality predictors in patients with CLTI undergoing peripheral vascular intervention. METHODS AND RESULTS Patients with CLTI undergoing peripheral vascular intervention from 2017 to 2018 were derived from the Medicare-linked VQI (Vascular Quality Initiative) registry. We constructed a random survival forest to rank 66 preprocedural variables according to their relative importance and mean minimal depth for 3-year all-cause mortality. A random survival forest of 2000 trees was built using a training sample (80% of the cohort). Accuracy was assessed in a testing sample (20%) using continuous ranked probability score, Harrell C-index, and out-of-bag error rate. A total of 10 114 patients were included (mean±SD age, 72.0±11.0 years; 59% men). The 3-year mortality rate was 39.1%, with a median survival of 1.4 years (interquartile range, 0.7-2.0 years). The most predictive variables were chronic kidney disease, age, congestive heart failure, dementia, arrhythmias, requiring assisted care, living at home, and body mass index. A total of 41 variables spanning all domains of the biopsychosocial model were ranked as mortality predictors. The accuracy of the model was excellent (continuous ranked probability score, 0.172; Harrell C-index, 0.70; out-of-bag error rate, 29.7%). CONCLUSIONS Our random survival forest accurately predicts long-term CLTI mortality, which is driven by demographic, functional, behavioral, and medical comorbidities. Broadening frameworks of risk and refining health care plans to include multidimensional risk factors could improve individualized care for CLTI.
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Affiliation(s)
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program Yale University New Haven CT
| | - Jacob Cleman
- Vascular Medicine Outcomes Program Yale University New Haven CT
| | - Lindsey Scierka
- Vascular Medicine Outcomes Program Yale University New Haven CT
| | - Francky Jacque
- Vascular Medicine Outcomes Program Yale University New Haven CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program Yale University New Haven CT
- Department of Psychiatry Yale School of Medicine New Haven CT
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12
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Zarrintan S, Rahgozar S, Ross EG, Farber A, Menard MT, Conte MS, Malas MB. Endovascular therapy versus bypass for chronic limb-threatening ischemia in a real-world practice. J Vasc Surg 2024:S0741-5214(24)01093-0. [PMID: 38718850 DOI: 10.1016/j.jvs.2024.04.067] [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: 11/09/2023] [Revised: 04/26/2024] [Accepted: 04/29/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE The recent Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) study showed that bypass was superior to endovascular therapy (ET) in patients with chronic limb-threatening ischemia (CLTI) deemed suitable for either approach who had an available single-segment great saphenous vein (GSV). However, the superiority of bypass among those lacking GSV was not established. We aimed to examine comparative treatment outcomes from a real-world CLTI population using the Vascular Quality Initiative-Medicare-linked database. METHODS We queried the Vascular Quality Initiative-Medicare-linked database for patients with CLTI who underwent first-time lower extremity revascularization (2010-2019). We performed two one-to-one propensity score matchings (PSMs): ET vs bypass with GSV (BWGSV) and ET vs bypass with a prosthetic graft (BWPG). The primary outcome was amputation-free survival. Secondary outcomes were freedom from amputation and overall survival (OS). RESULTS Three cohorts were queried: BWGSV (N = 5279, 14.7%), BWPG (N = 2778, 7.7%), and ET (N = 27,977, 77.6%). PSM produced two sets of well-matched cohorts: 4705 pairs of ET vs BWGSV and 2583 pairs of ET vs BWPG. In the matched cohorts of ET vs BWGSV, ET was associated with greater hazards of death (hazard ratio [HR] = 1.34, 95% confidence interval [CI], 1.25-1.43; P < .001), amputation (HR = 1.30, 95% CI, 1.17-1.44; P < .001), and amputation/death (HR = 1.32, 95% CI, 1.24-1.40; P < .001) up to 4 years. In the matched cohorts of ET vs BWPG, ET was associated with greater hazards of death up to 2 years (HR = 1.11, 95% CI, 1.00-1.22; P = .042) but not amputation or amputation/death. CONCLUSIONS In this real-world multi-institutional Medicare-linked PSM analysis, we found that BWGSV is superior to ET in terms of OS, freedom from amputation, and amputation-free survival up to 4 years. Moreover, BWPG was superior to ET in terms of OS up to 2 years. Our study confirms the superiority of BWGSV to ET as observed in the BEST-CLI trial.
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Affiliation(s)
- Sina Zarrintan
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of California San Diego (UCSD), San Diego, CA
| | - Shima Rahgozar
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of California San Diego (UCSD), San Diego, CA
| | - Elsie G Ross
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of California San Diego (UCSD), San Diego, CA
| | - Alik Farber
- Department of Surgery, Division of Vascular & Endovascular Surgery, Boston University School of Medicine, Boston, MA
| | - Matthew T Menard
- Department of Surgery, Division of Vascular & Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael S Conte
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of California San Francisco (UCSF), San Francisco, CA
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of California San Diego (UCSD), San Diego, CA.
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13
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Korosoglou G, Torsello G, Saratzis A, Isernia G, Kontopodis N, González TM, Jacobs K, Van Herzeele I, Zayed H, Stavroulakis K. Editor's Choice - Endovascular Versus Surgical Treatment for All Comer Patients With Prosthetic Bypass Graft Occlusion: The Multicentre ENSUPRO Study. Eur J Vasc Endovasc Surg 2024; 67:786-796. [PMID: 37543355 DOI: 10.1016/j.ejvs.2023.07.054] [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: 09/03/2022] [Revised: 06/10/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE Bypass surgery plays a key role in complex lower limb lesions. However, there is a lack of evidence regarding the management of symptomatic prosthetic bypass graft (PBG) occlusion. This study aimed to report outcomes following open, hybrid, or endovascular management of patients presenting with symptomatic PBG occlusion. METHODS A multicentre, retrospective cohort study was conducted, including patients presenting with PBG occlusion between January 2014 and December 2021 from 18 centres. It assessed the comparative value of treatment strategies, including (1) recanalisation of native vessels, (2) endovascular treatment of the failed PBG, (3) hybrid treatment, and (4) open surgery. The primary outcome measure was amputation free survival (AFS, time to major amputation and or death), whereas all cause mortality, major amputation, PBG re-occlusion, target lesion revascularisation (TLR), and Rutherford category (RC) improvement during follow up were considered as secondary endpoints. RESULTS Of 260 patients with occluded PBGs, 108 (41.5%) were treated endovascularly (24 [22.2%] by recanalisation of native vessels and 84 [77.7%] by PBG re-opening), 57 (21.9%) underwent hybrid revascularisation, and 58 (22.3%) had surgery. In addition, 27 (10.4%) were treated conservatively and 10 (3.8%) received systemic thrombolysis. With a median follow up of 1.4 (0.6 - 3.0) years, AFS was 95.5%, 76.4%, 45.5%, and 37.1%, respectively in Groups 1 - 4 (p = .007). Older age and non-endovascular treatment (HR 1.05 and 1.70; p < .01 for both) were independent predictors of poor AFS. Endovascular treatment was associated with lower rates of major amputation (p = .04), PBG re-occlusion (p < .001), and TLR (p = .037), and higher RC improvements (p < .001), whereas all cause mortality was comparable between treatment groups (p = .21). CONCLUSION Endovascular treatment is associated with higher rates of AFS and RC improvement and lower rates of PBG re-occlusion and TLR in patients with PBG occlusion.
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Affiliation(s)
| | - Giovanni Torsello
- University Hospital Münster, Institute for Vascular Research, Franziskus Hospital, Münster, Germany
| | - Athanasios Saratzis
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Giacomo Isernia
- Department of Vascular and Endovascular Surgery, University Hospital of Perugia, Perugia, Italy
| | | | | | - Karen Jacobs
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Hany Zayed
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
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14
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Kumar A, Gajanana D, Sharma N, Nanjundappa A, Kalra A. Surgical revascularization versus best endovascular therapy for chronic limb-threatening ischemia with infrapopliteal disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 61:111-112. [PMID: 37951759 DOI: 10.1016/j.carrev.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/01/2023] [Indexed: 11/14/2023]
Affiliation(s)
- Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH, USA
| | - Deepakraj Gajanana
- Department of Cardiology, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH, USA
| | - Navneet Sharma
- Department of Cardiology, Cleveland Clinic Fairview Hospital, Cleveland, OH, USA
| | | | - Ankur Kalra
- Department of Cardiology, Franciscan Health, 3900 St. Francis Way, Suite 200, Lafayette, IN, USA.
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15
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Moras E, Khan MI, Song DD, Syed M, Prabhakaran SY, Gandhi KD, Lavie CJ, Alam M, Sharma R, Krittanawong C. Pharmacotherapy and revascularization strategies of peripheral artery disease. Curr Probl Cardiol 2024; 49:102430. [PMID: 38309544 DOI: 10.1016/j.cpcardiol.2024.102430] [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: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/05/2024]
Abstract
The global epidemiological transition of atherosclerotic vascular diseases is witnessing a rapid redistribution of its burden, shifting from high-income to low- and middle-income countries. With a wide clinical spectrum, spanning from intermittent claudication to more complex critical limb threatening ischemia, nonhealing ulcers, gangrene as well as acute limb ischemia, peripheral artery disease is often faced with the challenges of under-diagnosis and under-treatment despite its high prevalence. The management of peripheral arterial disease in patients with multiple comorbidities presents a formidable challenge and remains a pressing global health concern. In this review, we aim to provide an in-depth overview of the pathophysiology of peripheral artery disease and explore evidence-based management strategies encompassing pharmacological, lifestyle, interventional, and surgical approaches. By addressing these challenges, the review contributes to a better understanding of the evolving landscape of peripheral artery disease, offering insights into effective and holistic management strategies.
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Affiliation(s)
- Errol Moras
- Department of Medicine, Mount Sinai Morningside- West, Mount Sinai Health System, New York, USA
| | - Mohammad Ishrak Khan
- Department of Medicine, Mount Sinai Morningside- West, Mount Sinai Health System, New York, USA
| | - David D Song
- Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, The Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at the Mount Sinai Hospital, Mount Sinai Heart, New York, NY, USA
| | - Moinuddin Syed
- Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, The Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at the Mount Sinai Hospital, Mount Sinai Heart, New York, NY, USA
| | | | - Kruti D Gandhi
- Department of Medicine, Mount Sinai Morningside- West, Mount Sinai Health System, New York, USA
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Mahboob Alam
- The Texas Heart Institute, Baylor College of Medicine, Houston, TX
| | - Raman Sharma
- Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, The Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at the Mount Sinai Hospital, Mount Sinai Heart, New York, NY, USA
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16
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Takei T, Kajiya T, Ohura N, Tomimura N, Kamiyama T, Ninomiya T, Takaoka J, Atsuchi N. Poor short-term outcomes for prognostic high-risk patients with chronic limb-threatening ischemia undergoing endovascular therapy. CVIR Endovasc 2024; 7:31. [PMID: 38502290 PMCID: PMC10951176 DOI: 10.1186/s42155-024-00443-9] [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: 12/10/2023] [Accepted: 03/07/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND The prognosis of chronic limb-threatening ischemia (CLTI) is poor, with an expected life expectancy of 2 or more years, which significantly influences treatment decisions. However, death may occur at the early stages of treatment for wound healing, and aggressive treatment may limit the quality of life of such patients. In patients with CLTI undergoing endovascular therapy (EVT), the Wound, Ischemia, and foot Infection (WIfI) clinical stage, male sex, older age, non-ambulatory status, low body mass index, and dialysis have been reported as predictors of mortality risk. However, most studies have not fully investigated the WIFI clinical stage as a prognostic predictor of CLTI. This study aimed to evaluate short-term prognosis and wound healing rates using the prognostic predictors (PPs) indicated above in risk-stratified patients with CLTI who underwent EVT. METHODS This retrospective single-center observational study included 61 CLTI patients undergoing EVT from April 2020 to October 2022. The patients were divided into a high-risk group (PPs ≥ 4, n = 20) and low-risk group (PPs ≤ 3, n = 41) according to the number of PPs. Survival and wound healing rates within one year were compared between these two groups. RESULTS The mean age of the patients was 74.7 ± 1.6 years, and 42 (68.9%) were male. Among these patients, the high-risk group compared with the low-risk group had a significantly worse survival rate within one year (46.4% vs. 84.7%, log-rank p < 0.001). Fifteen patients died within one year. Of these, seven deaths were cardiovascular deaths and six were deaths from infectious diseases. Cox proportional hazards analysis showed that WIfI clinical stage 4 (p = 0.043, hazard ratio [HR] = 4.85) and the male sex (p = 0.037, HR = 6.34) influenced the prognosis of this population. The high-risk group tended to have a worse wound healing rate within one year than that had by the low-risk group (55.4% vs. 83.0%, log-rank p = 0.086). CONCLUSIONS The assessment of short-term prognosis and wound healing rates using PPs may be useful. Discussing the results of short-term clinical outcome assessments with patients should be considered when determining their individualized treatment plans.
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Affiliation(s)
- Tatsuro Takei
- Department of Cardiology, Tenyoukai Central Hospital, 6-7 Izumi-cho, Kagoshima, 892-0821, Japan.
| | - Takashi Kajiya
- Department of Cardiology, Tenyoukai Central Hospital, 6-7 Izumi-cho, Kagoshima, 892-0821, Japan
| | - Norihiko Ohura
- Department of Plastic and Reconstructive Surgery, Kyorin University School of Medicine, 6-20-2, Shinkawa Mitaka, Tokyo, Japan
| | - Natsuko Tomimura
- Department of Orthopaedic Surgery, Nanpuh Hospital, 14-3 Nagata-cho, Kagoshima, Japan
| | - Takuro Kamiyama
- Department of Radiology, Tenyoukai Central Hospital, 6-7 Izumi-cho, Kagoshima, Japan
| | - Toshiko Ninomiya
- Department of Cardiology, Tenyoukai Central Hospital, 6-7 Izumi-cho, Kagoshima, 892-0821, Japan
| | - Junichiro Takaoka
- Department of Cardiology, Tenyoukai Central Hospital, 6-7 Izumi-cho, Kagoshima, 892-0821, Japan
| | - Nobuhiko Atsuchi
- Department of Cardiology, Tenyoukai Central Hospital, 6-7 Izumi-cho, Kagoshima, 892-0821, Japan
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Zilinyi RS, Alsaloum M, Snyder DJ, Raja A, Mintz AJ, Sethi SS, Bajakian D, Parikh SA. Surgical and Endovascular Therapies for Below-the-Knee Peripheral Arterial Disease: A Contemporary Review. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101268. [PMID: 39131787 PMCID: PMC11308828 DOI: 10.1016/j.jscai.2023.101268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 11/28/2023] [Accepted: 12/14/2023] [Indexed: 08/13/2024]
Abstract
Peripheral arterial disease (PAD) represents one of the most prevalent cardiovascular disease processes and carries a high burden of morbidity and mortality. Patients with chronic limb-threatening ischemia (CLTI), the most severe manifestation of PAD, have the highest rates of cardiovascular morbidity and mortality of the overall PAD population. Patients with below-the-knee (BTK) PAD have an increased propensity toward CLTI due to small-vessel caliber and the frequently comorbid conditions of end-stage renal disease and diabetes mellitus, which tend to affect small artery beds preferentially. For those with BTK PAD with CLTI, the standard of care is revascularization. Early revascularization was performed using surgical bypass. However, endovascular techniques, starting with percutaneous transluminal angioplasty and expanding to the modern armamentarium of adjunctive devices and therapies, have become standard of care for most patients with CLTI due to BTK PAD. In this review, we will discuss the modern surgical and endovascular approaches to revascularization, as well as devices that are currently in development or preapproval study for the treatment of BTK PAD.
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Affiliation(s)
- Robert S. Zilinyi
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Marissa Alsaloum
- Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Daniel J. Snyder
- Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Aishwarya Raja
- Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Ari J. Mintz
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Sanjum S. Sethi
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Danielle Bajakian
- Division of Vascular Surgery, Department of Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
| | - Sahil A. Parikh
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
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18
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Pitoulias AG, Taneva GT, Avranas K, Abu Bakr N, Pitoulias GA, Donas KP. Use of Rotational Atherectomy-Assisted Balloon Angioplasty in the Treatment of Isolated Below-the-Knee Atherosclerotic Lesions in Patients with Chronic Limb-Threatening Ischemia. J Clin Med 2024; 13:1346. [PMID: 38592186 PMCID: PMC10932306 DOI: 10.3390/jcm13051346] [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: 01/25/2024] [Revised: 02/10/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
The aim of the study is to evaluate the safety and effectiveness of rotational atherectomy-assisted balloon angioplasty (BTK-RA) for the treatment of isolated below the knee (BTK) atherosclerotic lesions and to compare the outcomes to plain old balloon angioplasty (POBA). Between January 2020 and September 2023, 96 consecutive patients with chronic limb threatening ischemia (CTLI) and isolated BTK-lesions underwent POBA (group A) or BTK-RA (group B). The primary outcome measures were: periprocedural technical success, primary patency, postoperative increase of the ankle branchial index (ABI), target lesion revascularization (TLR), limb salvage, minor amputation and death. Both techniques had similar technical success, operative time, intraprocedural complications and bailout stent implantations, independently of the operator's experience. Group B had significantly higher primary patency rates (93.5% vs. 72.0%, respectively, p = 0.006), TLR (2.1% vs. 24%, p = 0.057), lower in-hospital stay (2.0-3.0 vs. 4.0-6.0 days, respectively, p < 0.001) and higher postoperative ABI (0.8-0.2 vs. 0.7-0.1, respectively, p = 0.008), compared to group A. Significant differences (POBA n: 20, 40%, BTK-RA n = 3, 6.5%) were found in minor amputation rates between the two groups (p < 0.001), while the respective limb salvage rates were similar in both groups (94.0% vs. 97.8%, p = 0.35). The use of BTK-RA for the treatment of BTK-lesions in patients with CTLI showed significant clinical advantages in comparison to POBA.
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Affiliation(s)
- Apostolos G. Pitoulias
- Rhein Main Vascular Center, Department of Vascular and Endovascular Surgery, Asklepios Clinics Langen, Paulinen Wiesbaden, Seligenstadt, 63225 Langen, Germany; (N.A.B.); (K.P.D.)
| | - Gergana T. Taneva
- Research Collaborator at Rhein Main Vascular Center, Department of Vascular and Endovascular Surgery, Asklepios Clinics Langen, Paulinen Wiesbaden, Seligenstadt, 63225 Langen, Germany (K.A.); (G.A.P.)
| | - Konstantinos Avranas
- Research Collaborator at Rhein Main Vascular Center, Department of Vascular and Endovascular Surgery, Asklepios Clinics Langen, Paulinen Wiesbaden, Seligenstadt, 63225 Langen, Germany (K.A.); (G.A.P.)
| | - Nizar Abu Bakr
- Rhein Main Vascular Center, Department of Vascular and Endovascular Surgery, Asklepios Clinics Langen, Paulinen Wiesbaden, Seligenstadt, 63225 Langen, Germany; (N.A.B.); (K.P.D.)
| | - Georgios A. Pitoulias
- Research Collaborator at Rhein Main Vascular Center, Department of Vascular and Endovascular Surgery, Asklepios Clinics Langen, Paulinen Wiesbaden, Seligenstadt, 63225 Langen, Germany (K.A.); (G.A.P.)
| | - Konstantinos P. Donas
- Rhein Main Vascular Center, Department of Vascular and Endovascular Surgery, Asklepios Clinics Langen, Paulinen Wiesbaden, Seligenstadt, 63225 Langen, Germany; (N.A.B.); (K.P.D.)
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19
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Cleman J, Romain G, Smolderen KG, Mena-Hurtado C. Reply. J Vasc Surg 2024; 79:456. [PMID: 38245191 DOI: 10.1016/j.jvs.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/01/2023] [Indexed: 01/22/2024]
Affiliation(s)
- Jacob Cleman
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT
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Kobayashi T, Hamamoto M, Okazaki T, Okusako R, Hasegawa M, Takahashi S. Risk Analysis and Clinical Outcomes in Chronic Limb-threatening Ischemia Patients with Surgical Site Infection after Distal Bypass. Ann Vasc Surg 2024; 99:33-40. [PMID: 37926138 DOI: 10.1016/j.avsg.2023.09.091] [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: 06/30/2023] [Revised: 08/23/2023] [Accepted: 09/18/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND A recent randomized control study showed that long-term outcomes after surgical revascularization were superior to those after endovascular treatment for cases with chronic limb-threatening ischemia (CLTI) with an appropriate single-segment great saphenous vein. However, surgical site infection (SSI) in CLTI cases after infrapoplital bypass also resulted in a prolonged hospital stay and poor outcomes, including graft disruption. The aim of the current study was to analyze risk factors for SSI in CLTI patients after distal bypass and to compare outcomes in patients with and without SSI. METHODS A total of 515 cases that underwent distal bypass at a single center between 2009 and 2022 were analyzed retrospectively. Comparisons were made between patients with and without SSI after distal bypass. The primary end point was limb salvage after distal bypass. RESULTS Of the 515 cases that underwent distal bypass, 79 (15%) had SSI. The risk factors for SSI were preoperative antibacterial drug use (P = 0.001), pedal bypass (P = 0.001), and prolonged operation time (≥150 min) (P = 0.010). The median hospital stay in SSI cases was longer than that in non-SSI cases (P < 0.001). Of 515 distal bypasses, 7 (1.3%) bypass grafts ruptured postoperatively due to SSI, and of these 7 cases, 6 ruptured during the day, 5 cases occurred within 1 month postoperatively, and 2 patients (29%) are alive without amputation. The mean follow-up period was 34 ± 30 months. During follow-up, 62 limbs (SSI cases, 19; non-SSI cases, 43) required major amputation and there were 234 deaths (SSI cases, 46; non-SSI cases, 188). The 1-, 3-, and 5-year limb salvage rates of 82%, 71%, and 62%, respectively, in SSI cases were significantly lower than those in non-SSI cases (P < 0.001). The 5-year survival rate of 29% in SSI cases showed a tendency to be lower than that in non-SSI cases (P = 0.058). CONCLUSIONS The limb salvage rate in SSI cases was lower than in non-SSI cases after distal bypass. Graft rupture due to SSI occurred at a rate of 1.3% and resulted in poor outcomes in most cases. SSIs adversely affect outcomes and further study is needed to identify methods to avoid SSI following distal bypass.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan.
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Ryo Okusako
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Misa Hasegawa
- Department of Reconstructive and Plastic Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Minami-ku, Hiroshima, Japan
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Gallagher KA, Mills JL, Armstrong DG, Conte MS, Kirsner RS, Minc SD, Plutzky J, Southerland KW, Tomic-Canic M. Current Status and Principles for the Treatment and Prevention of Diabetic Foot Ulcers in the Cardiovascular Patient Population: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e232-e253. [PMID: 38095068 PMCID: PMC11067094 DOI: 10.1161/cir.0000000000001192] [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] [Indexed: 01/24/2024]
Abstract
Despite the known higher risk of cardiovascular disease in individuals with type 2 diabetes, the pathophysiology and optimal management of diabetic foot ulcers (DFUs), a leading complication associated with diabetes, is complex and continues to evolve. Complications of type 2 diabetes, such as DFUs, are a major cause of morbidity and mortality and the leading cause of major lower extremity amputation in the United States. There has recently been a strong focus on the prevention and early treatment of DFUs, leading to the development of multidisciplinary diabetic wound and amputation prevention clinics across the country. Mounting evidence has shown that, despite these efforts, amputations associated with DFUs continue to increase. Furthermore, due to increasing patient complexity of management secondary to comorbid conditions, such as cardiovascular disease, the management of peripheral artery disease associated with DFUs has become increasingly difficult, and care delivery is often episodic and fragmented. Although structured, process-specific approaches exist at individual institutions for the management of DFUs in the cardiovascular patient population, there is insufficient awareness of these principles in the general medicine communities. Furthermore, there is growing interest in better understanding the mechanistic underpinnings of DFUs to better define personalized medicine to improve outcomes. The goals of this scientific statement are to provide salient background information on the complex pathogenesis and current management of DFUs in cardiovascular patients, to guide therapeutic and preventive strategies and future research directions, and to inform public policy makers on health disparities and other barriers to improving and advancing care in this expanding patient population.
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Adedokun SD, Sarwar M, Hwang K, Hans A, Baskaran J, Anantha Narayanan M. Outcomes of lower extremity peripheral arterial interventions in patients with and without chronic kidney disease or end-stage renal disease. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:624-633. [PMID: 38078709 DOI: 10.23736/s0021-9509.23.12798-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Peripheral arterial disease (PAD) is a progressive vascular condition characterized by the narrowing or blockage of arteries, primarily attributed to atherosclerosis. PAD's prevalence in the general population is estimated at approximately 5.9%. Notably however, among patients with chronic kidney disease (CKD), PAD's prevalence is substantially higher, ranging from 17% to 48%. This review paper emphasizes the pervasiveness of PAD and its intricate relationship with CKD and end-stage renal disease (ESRD). It demonstrates the importance of early detection, proactive screening, and understanding the formidable challenges associated with treating heavily calcified lesions. EVIDENCE ACQUISITION Comprehensive literature searches encompassed the PubMed/MEDLINE, Cochrane Library, and Embase databases, in order to identify studies involving lower extremity peripheral arterial interventions in patients both with and without CKD or ESRD. The search spanned the timeframe from January 2001 to July 2023. The search strategy included vocabulary terms concerning peripheral artery disease, lower extremities, revascularization, chronic kidney disease, and end-stage renal disease. EVIDENCE SYNTHESIS Initial searches were used to identify articles based on title. Exclusion criteria was then applied, and any redundant articles were removed. The articles abstracts were then reviewed, and relevant articles were selected. Once selected the articles were thoroughly reviewed including the references to find other relevant articles that were missed during the initial search process. In total 28 articles were selected and included for review of clinical data in regard to PAD outcomes in patients with advanced kidney disease. CONCLUSIONS The findings highlight the need for personalized approaches in diagnosing and treating PAD in CKD and ESRD patients. Interdisciplinary collaboration, such as those between nephrologists, vascular surgeons, and interventional radiologists, is vital to optimize outcomes. Further research should focus on innovative, tailored interventions to enhance limb preservation, reduce mortality, prolong patency, and cut healthcare costs.
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Affiliation(s)
| | - Maruf Sarwar
- Section of Internal Medicine, White River Health, Batesville, AR, USA
| | - Keonmin Hwang
- HCA Tristar Skyline Medical Center, Nashville, TN, USA
| | - Aakash Hans
- Section of Internal Medicine, White River Health, Batesville, AR, USA
| | - Janani Baskaran
- Section of Internal Medicine, White River Health, Batesville, AR, USA
| | - Mahesh Anantha Narayanan
- Section of Cardiovascular Diseases, White River Health, Batesville, AR, USA -
- University of Arkansas Medical Sciences, Little Rock, AR, USA
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Qato K, Bahroloomi D, Conway A, Lu E, Pamoukian V, Giangola G, Carroccio A. Contemporary outcomes of initial treatment strategy of endovascular intervention or bypass in patients with critical limb ischemia. Vascular 2023; 31:1117-1123. [PMID: 35698916 DOI: 10.1177/17085381221107749] [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] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The optimal management for revascularization after critical limb ischemia (CLI) is controversial due to limited studies comparing long-term results of endovascular and open techniques. This study compares long-term outcomes after initial management of CLI via lower extremity bypass (LEB) and percutaneous vascular intervention (PVI). METHODS This retrospective cohort study investigates outcomes of patients who underwent endovascular or open surgical management for CLI at a single institution from 2013-2018. All patients with diagnosis of CLI were included and separated based on initial therapy of PVI or LEB. Demographic, procedural, and follow-up data were assessed. Primary endpoints included major adverse limb events (MALE), specifically the need for major amputation and reintervention. Secondary endpoints included mortality at 30 days and one year. A multivariable Cox Proportional Hazard regression model was used to assess the relationship between Surgery group and time to MALE/death while controlling for confounding variables. RESULTS This study identified 338 patients with an initial diagnosis of CLI who underwent either LEB (n = 108, 32%) or PVI (n = 230, 68%). The average age was 71.4, 54.4% were male, 30% were African American, 53.6% were diabetic, and 93.2% had hypertension. Patients who underwent LEB were more predominantly smokers (p = .003) and less predominantly on dialysis at time of surgery (p = .01). Re-intervention rates in the bypass group (11%) were not significantly different than the PVI group (9%; p = .95). In the bypass group, 20 (19%) patients had a major amputation with a median time of 189.5 days compared to 23 (10%) patients at a median time of 113 days in the PVI group; however, this difference was not significant (p = .16). There was no significant difference in 1-year mortality between the LEB (2%) and PVI group (4%; p = .2). The cumulative incidence of MALE/death at 30 days was 4.0% in the bypass group and 3.7% in the PVI group (p = .2). Incidences of MALE/death were 21.1% and 48.5% in the bypass group and 19.7 and 45.9% in the PVI group at one and 2 years, respectively. Intervention type was not found to be significantly associated with MALE/death after controlling for possible confounders (HR = 0.82, p = .43). CONCLUSIONS In the initial management of CLI, there is no significant difference in long-term outcomes in terms of major amputation, need for reintervention, limb-salvage, and 1-year mortality.
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Affiliation(s)
- Khalil Qato
- Division of Vascular Surgery, Northwell Health, Glen Cove, NY, USA
| | - Donna Bahroloomi
- Division of Vascular Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Allan Conway
- Division of Vascular Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Eileen Lu
- Division of Vascular Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Vicken Pamoukian
- Division of Vascular Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Gary Giangola
- Division of Vascular Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Alfio Carroccio
- Division of Vascular Surgery, Lenox Hill Hospital, New York, NY, USA
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Zeller T. Treatment of Complex Femoro-popliteal Lesions: Time to Revise the Guidelines According to Clinical Reality. Cardiovasc Intervent Radiol 2023; 46:1769-1771. [PMID: 37935842 PMCID: PMC10695878 DOI: 10.1007/s00270-023-03589-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/05/2023] [Indexed: 11/09/2023]
Affiliation(s)
- Thomas Zeller
- Department Angiology, Clinic for Cardiology and Angiology, University Heart Center Freiburg-Bad Krozingen, Südring 15, 79189, Bad Krozingen, Germany.
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Koyama Y, Migita S, Shimodai-Yamada S, Suzuki M, Uto K, Okumura Y, Ohura N, Hao H. Pathology of Critical Limb Ischemia; Comparison of Plaque Characteristics Between Anterior and Posterior Tibial Arteries. J Atheroscler Thromb 2023; 30:1893-1904. [PMID: 37331812 DOI: 10.5551/jat.64259] [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] [Indexed: 06/20/2023] Open
Abstract
AIMS Though the number of patients with peripheral arterial disease (PAD) and critical limb ischemia (CLI) is increasing, few histopathological studies of PAD, particularly that involving below-the-knee arteries, has been reported. We analyzed the pathology of anterior tibial artery (ATA) and posterior tibial artery (PTA) specimens obtained from patients who underwent lower extremity amputation due to CLIMethods: Dissected ATAs and PTAs were subjected to ex-vivo soft X-ray radiography, followed by pathological examination using 860 histological sections. This protocol was approved by the Ethics Review Board of Nihon University Itabashi Hospital (RK-190910-01) and Kyorin University Hospital (R02-179). RESULTS The calcified area distribution was significantly larger in PTAs than in ATAs on soft X-ray radiographic images (ATAs, 48.3% ±19.2 versus PTAs, 61.6% ±23.9; p<0.001). Eccentric plaque with necrotic core and macrophage infiltration were more prominent in ATAs than in PTAs (eccentric plaque: ATAs, 63.7% versus PTAs, 49.1%; p<0.0001, macrophage: ATAs, 0.29% [0.095 - 1.1%] versus PTAs, 0.12% [0.029 - 0.36%]; p<0.001), histopathologically. Thromboembolic lesions were more frequently identified in PTAs than in ATAs (ATAs, 11.1% versus PTAs 15.8%; p<0.05). Moreover, post-balloon injury pathology differed between ATAs and PTAs. CONCLUSIONS Histological features differed strikingly between ATAs and PTAs obtained from CLI patients. Clarifying the pathological features of CLI would contribute to establishing therapeutic strategies for PAD, particularly disease involving below-the knee-arteries.
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Affiliation(s)
- Yutaka Koyama
- Division of Human Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Suguru Migita
- Division of Human Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Sayaka Shimodai-Yamada
- Division of Human Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine
| | - Mayumi Suzuki
- Division of Human Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine
| | - Kenta Uto
- Division of Human Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Norihiko Ohura
- Department of Plastic and Reconstructive Surgery, Kyorin University School of Medicine
| | - Hiroyuki Hao
- Division of Human Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine
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Yoshioka N, Tokuda T, Koyama A, Yamada T, Shimamura K, Nishikawa R, Morita Y, Morishima I. Association between High Bleeding Risk and 2-Year Mortality in Patients with Chronic Limb-Threatening Ischemia. J Atheroscler Thromb 2023; 30:1674-1686. [PMID: 36948637 PMCID: PMC10627769 DOI: 10.5551/jat.64157] [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: 01/06/2023] [Accepted: 03/06/2023] [Indexed: 03/24/2023] Open
Abstract
AIM Patients with chronic limb-threatening ischemia (CLTI) have a high bleeding risk (HBR) and mortality rate. The 2-year life expectancy is an important factor in deciding the appropriate treatment strategy. This study aimed to assess the influence of HBR on the prognosis of patients with CLTI. METHODS A total of 259 patients with CLTI who underwent endovascular therapy (EVT) (mean age, 76.2 years; male, 62.9%) between January 2018 and December 2019 were evaluated. The Academic Research Consortium for HBR (ARC-HBR) criteria were applied to each patient, and the ARC-HBR scores were calculated. The cut-off score for predicting all-cause mortality within two years was derived using a survival classification and regression tree (CART) model. Causes of death and the association between ARC-HBR scores and major bleeding events within two years were also investigated. RESULTS Based on the CART model, patients were divided into three groups (low HBR score 0-1.0, 48 patients; moderate HBR score 1.5-3.0, 176 patients; and high HBR score ≥ 3.5, 35 patients). During the study period, 82 patients (39.6%) died due to cardiac (n=23) and non-cardiac causes (n=59). All-cause mortality increased significantly with increasing ARC-HBR scores. Cox multivariate analysis revealed a significant association between high ARC-HBR scores and the risk of all-cause mortality within two years. Major bleeding events increased significantly with increasing ARC-HBR scores. CONCLUSIONS The ARC-HBR score could predict 2-year mortality in patients with CLTI who underwent EVT. Thus, this score can help determine the best revascularization strategy for patients with CLTI.
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Affiliation(s)
- Naoki Yoshioka
- Department of Cardiology, Ogaki Municipal Hospital, Gifu, Japan
| | - Takahiro Tokuda
- Department of Cardiology, Nagoya Heart Center, Nagoya, Japan
| | - Akio Koyama
- Department of Vascular Surgery, Ichinomiya Municipal Hospital, Aichi, Japan
| | - Takehiro Yamada
- Department of Cardiology, Central Japan International Medical Center, Gifu, Japan
| | | | - Ryusuke Nishikawa
- Department of Cardiovascular of Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasuhiro Morita
- Department of Cardiology, Ogaki Municipal Hospital, Gifu, Japan
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Watson NW, Mosarla RC, Secemsky EA. Endovascular Interventions for Peripheral Artery Disease: A Contemporary Review. Curr Cardiol Rep 2023; 25:1611-1622. [PMID: 37804391 DOI: 10.1007/s11886-023-01973-9] [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] [Accepted: 09/26/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE OF REVIEW Peripheral artery disease (PAD) is an increasingly prevalent but frequently underdiagnosed condition that can be associated with high rates of morbidity and mortality. While an initial noninvasive approach is the cornerstone of management, revascularization is often pursued for patients with treatment-refractory claudication or chronic limb-threatening ischemia (CLTI). In this review, we discuss the current state of endovascular interventions for PAD and explore the many new emerging technologies. RECENT FINDINGS The last decade has resulted in numerous advances in PAD interventions including the ongoing evolution of drug-coated devices, novel approaches to complex lesions, and contemporary evidence from large clinical trials for CLTI. Advances in endovascular management have allowed for increasingly complex lesions to be tackled percutaneously. Future directions for the field include the continued evolution in device technology, continued development of state-of-the-art techniques to revascularization of complex lesions, and increased collaboration between a largely multidisciplinary field.
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Affiliation(s)
- Nathan W Watson
- Harvard Medical School, Boston, MA, USA
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ramya C Mosarla
- Division of Cardiology, Department of Medicine, New York University Medical Center, New York, NY, USA
| | - Eric A Secemsky
- Harvard Medical School, Boston, MA, USA.
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Nagy FT, Olajos D, Vattay B, Borzsák S, Boussoussou M, Deák M, Vecsey-Nagy M, Sipos B, Jermendy ÁL, Tóth GG, Nemes B, Merkely B, Szili-Török T, Ruzsa Z, Szilveszter B. Dynamic Perfusion Computed Tomography for the Assessment of Concomitant Coronary Artery Disease in Patients with a History of Percutaneous Transluminal Angioplasty for Chronic Limb-Threatening Ischemia-A Pilot Study. J Cardiovasc Dev Dis 2023; 10:443. [PMID: 37998501 PMCID: PMC10671941 DOI: 10.3390/jcdd10110443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Chronic limb-threatening ischemia (CLTI) is associated with high rates of long-term cardiovascular mortality. Exercise stress testing to detect obstructive coronary artery disease (CAD) can be difficult in this subset of patients due to inability to undergo exercise testing, presence of balanced ischemia and severe coronary artery calcification (CAC). AIM To test the feasibility of regadenoson stress dynamic perfusion computed tomography (DPCT) in CLTI patients. METHODS Between 2018 and 2023, coronary computed tomography angiography (CTA) and, in the case of a calcium score higher than 400, DPCT, were performed in 25 CLTI patients with a history of endovascular revascularization. RESULTS Of the 25 patients, 19 had a calcium score higher than 400, requiring DPCT image acquisition. Obstructive CAD could be ruled out in 10 of the 25 patients. Of the 15 CTA/DPCT+ patients, 13 proceeded to coronary angiography (CAG). Revascularization was necessary in all 13 patients. In these 13 patients, vessel-based sensitivity and specificity of coronary CTA/DPCT as compared to invasive evaluation was 75%, respectively. At follow-up (27 ± 21 months) there was no statistically significant difference in all-cause mortality between CTA/DPCT- positive and -negative patients (p = 0.065). CONCLUSIONS Despite a high prevalence of severe CAC, coronary CTA complemented by DPCT may be a feasible method to detect obstructive and functionally significant CAD in CLTI patients.
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Affiliation(s)
- Ferenc T. Nagy
- Division of Invasive Cardiology, Department of Internal Medicine, University of Szeged, 6725 Szeged, Hungary; (F.T.N.); (D.O.)
| | - Dorottya Olajos
- Division of Invasive Cardiology, Department of Internal Medicine, University of Szeged, 6725 Szeged, Hungary; (F.T.N.); (D.O.)
| | - Borbála Vattay
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Sarolta Borzsák
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Melinda Boussoussou
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Mónika Deák
- Bács-Kiskun County Hospital, 6725 Kecskemét, Hungary
| | - Milán Vecsey-Nagy
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Barbara Sipos
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Ádám L. Jermendy
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Gábor G. Tóth
- Graz University Heart Center Graz, Medical University of Graz, 8036 Graz, Austria
| | - Balázs Nemes
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Tamás Szili-Török
- Division of Invasive Cardiology, Department of Internal Medicine, University of Szeged, 6725 Szeged, Hungary; (F.T.N.); (D.O.)
| | - Zoltán Ruzsa
- Division of Invasive Cardiology, Department of Internal Medicine, University of Szeged, 6725 Szeged, Hungary; (F.T.N.); (D.O.)
| | - Bálint Szilveszter
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
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Levin SR, Farber A, Goodney PP, King EG, Eslami MH, Malas MB, Patel VI, Kiang SC, Siracuse JJ. Five Year Survival in Medicare Patients Undergoing Interventions for Peripheral Arterial Disease: a Retrospective Cohort Analysis of Linked Registry Claims Data. Eur J Vasc Endovasc Surg 2023; 66:541-549. [PMID: 37543356 DOI: 10.1016/j.ejvs.2023.07.055] [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: 09/18/2022] [Revised: 06/19/2023] [Accepted: 07/31/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE To justify the up front risks of offering elective interventions for intermittent claudication (IC), patients should have reasonable life expectancy to derive durable clinical benefits. Open surgery for chronic limb threatening ischaemia (CLTI) is maximally beneficial in patients surviving ≥ 2 years. The aim was to assess long term survival after IC and CLTI interventions. METHODS In a retrospective cohort analysis, the Vascular Quality Initiative (VQI) registry from 1 January 2010 to 31 May 2021 was queried for peripheral vascular intervention (PVI), infra-inguinal bypasses (IIB), and supra-inguinal bypasses (SIB) for IC and CLTI across 286 US centres. VQI linkage to Medicare insurance claims provided five year survival data. Multivariable analysis identified factors associated with five year mortality. RESULTS There were 31 457 PVIs (44.7% IC, 55.3% CLTI), 7 978 IIBs (26.9% IC, 73.1% CLTI), and 2 149 SIBs (50.1% IC, 49.9% CLTI) recorded in the VQI. Among the PVI, IIB, and SIB cohorts, average ages were 75, 73, and 72 years, respectively. Respective five year mortality after PVI for IC and CLTI was 37.2% and 71.1%; after IIB for IC and CLTI it was 37.8% and 60%; and after SIB for IC and CLTI it was 33.8% and 53.8%. On multivariable analysis, across all procedures, end stage renal disease, CLTI, congestive heart failure, anaemia, chronic obstructive pulmonary disease, and prior amputation were independently associated with increased mortality. Pre-admission home living and pre-operative aspirin use were independently associated with decreased mortality. CONCLUSION Long term survival in Medicare patients undergoing interventions in VQI centres for peripheral arterial disease is poor. Two thirds of CLTI patients and over one third of IC patients were not alive at five years. Intervening for IC in patients with high mortality risk should be avoided. For CLTI patients identified with decreased survival likelihood, intervention durability may be less important than invasiveness. Pre-operative medical optimisation should always be undertaken.
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Affiliation(s)
- Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Centre, Boston, MA, USA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Centre, Boston, MA, USA
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Centre, Lebanon, NH, USA
| | - Elizabeth G King
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Centre, Boston, MA, USA
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Virendra I Patel
- Section of Vascular Surgery and Endovascular Interventions, NYP/Columbia University Irving Medical Centre, New York, NY, USA
| | - Sharon C Kiang
- Division of Vascular and Endovascular Surgery, Loma Linda University Medical Centre, Loma Linda, CA, USA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Centre, Boston, MA, USA.
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Cleman J, Romain G, Grubman S, Guzman RJ, Smolderen KG, Mena-Hurtado C. Comparison of lower extremity bypass and peripheral vascular intervention for chronic limb-threatening ischemia in the Medicare-linked Vascular Quality Initiative. J Vasc Surg 2023; 78:745-753.e6. [PMID: 37207790 PMCID: PMC10964324 DOI: 10.1016/j.jvs.2023.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/21/2023]
Abstract
OBJECTIVE There is a relative lack of comparative effectiveness research on revascularization for patients with chronic limb-threatening ischemia (CLTI). We examined the association between lower extremity bypass (LEB) vs peripheral vascular intervention (PVI) for CLTI and 30-day and 5-year all-cause mortality and 30-day and 5-year amputation. METHODS Patients undergoing LEB and PVI of the below-the-knee popliteal and infrapopliteal arteries between 2014 and 2019 were queried from the Vascular Quality Initiative, and outcomes data were obtained from the Medicare claims-linked Vascular Implant Surveillance and Interventional Outcomes Network database. Propensity scores were calculated on 15 variables using a logistic regression model to control for imbalances between treatment groups. A 1:1 matching method was used. Kaplan-Meier survival curves and hierarchical Cox proportional hazards regression with a random intercept for site and operator nested in site to account for clustered data compared 30-day and 5-year all-cause mortality between groups. Thirty-day and 5-year amputation were subsequently compared using competing risk analysis to account for the competing risk of death. RESULTS There was a total of 2075 patients in each group. The overall mean age was 71 ± 11 years, 69% were male, and 76% were white, 18% were black, and 6% were of Hispanic ethnicity. Baseline clinical and demographic characteristics in the matched cohort were balanced between groups. There was no association between all-cause mortality over 30 days and LEB vs PVI (cumulative incidence, 2.3% vs 2.3% by Kaplan Meier; log-rank P-value = .906; hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.62-1.44; P-value = .80). All-cause mortality over 5 years was lower for LEB vs PVI (cumulative incidence, 55.9% vs 60.1% by Kaplan Meier; log-rank P-value < .001; HR, 0.77; 95% CI, 0.70-0.86; P-value < .001). Accounting for competing risk of death, amputation over 30 days was also lower in LEB vs PVI (cumulative incidence function, 1.9% vs 3.0%; Fine and Gray P-value = .025; subHR, 0.63; 95% CI, 0.42-0.95; P-value = .025). There was no association between amputation over 5 years and LEB vs PVI (cumulative incidence function, 22.6% vs 23.4%; Fine and Gray P-value = .184; subHR, 0.91; 95% CI, 0.79-1.05; P-value = .184). CONCLUSIONS In the Vascular Quality Initiative-linked Medicare registry, LEB vs PVI for CLTI was associated with a lower risk of 30-day amputation and 5-year all-cause mortality. These results will serve as a foundation to validate recently published randomized controlled trial data, and to broaden the comparative effectiveness evidence base for CLTI.
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Affiliation(s)
- Jacob Cleman
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Scott Grubman
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT
| | - Raul J Guzman
- Division of Vascular Surgery, Yale School of Medicine, New Haven, CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT
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Kuroki MT, Parikh UM, Chandra V. How I do it: Pedal access and pedal loop revascularization for patients with chronic limb-threatening ischemia. J Vasc Surg Cases Innov Tech 2023; 9:101236. [PMID: 37496650 PMCID: PMC10366544 DOI: 10.1016/j.jvscit.2023.101236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
An increasing proportion of patients with chronic limb-threatening ischemia are older and have multiple comorbidities, including diabetes and renal failure. For those who are not candidates for a surgical bypass, this set of patients presents a challenge to vascular surgeons and interventionalists owing to the complex below-the-knee and increasingly below-the-ankle disease pattern that can fail traditional approaches for endovascular intervention. Two techniques, the retrograde pedal access and the pedal-plantar loop technique, can be useful in these settings and in skilled hands can be used safely, with a high technical success rate. In patients with chronic limb-threatening ischemia who are not candidates for a single-segment saphenous vein bypass, the retrograde pedal access technique can be used not only in the setting of failed antegrade treatment, but also primarily when faced with a difficult groin or as an adjunct during a planned antegrade-retrograde intervention. The pedal plantar loop technique allows for retrograde access to tibial vessels without retrograde vessel puncture and additionally offers the ability to treat the pedal-plantar arch, which may have added benefit in wound healing. We describe the tips and tricks for these two techniques used in our limb salvage practice.
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Affiliation(s)
| | | | - Venita Chandra
- Correspondence: Venita Chandra, MD, Clinical Professor of Surgery, Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, 780 Welch Rd, Ste CJ350H, Palo Alto, CA 94304
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Akingba AG, Chow WB, Rowe VL. Lower Extremity Bypass. Surg Clin North Am 2023; 103:767-778. [PMID: 37455036 DOI: 10.1016/j.suc.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
The original description of the lower extremity bypass (LEB) provided surgeons with a reliable method of limb revascularization. The tenets of the operation have formed the foundation for the advances of surgical care. A careful evaluation of the chronic limb-threatening ischemia patient due to the numerous comorbid conditions is paramount to obtain the best possible outcomes. Use of all adjuncts including judicious target vessels control, completion imaging, and vein harvesting techniques to ensure optimal outcomes because a functioning LEB remains a key to successful limb salvage.
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Affiliation(s)
- Ajibola George Akingba
- DC VAMC, Uniformed Services University of Health Sciences, 50 Irving Street, Washington, DC 20422, USA
| | - Warren Bryan Chow
- Division of Vascular Surgery and Endovascular Therapy, David Geffen School of Medicine at UCLA, 200 Peter Morton Medical Building, Suite 526, Los Angeles, CA 90095, USA
| | - Vincent Lopez Rowe
- Division of Vascular Surgery and Endovascular Therapy, David Geffen School of Medicine at UCLA, 200 Peter Morton Medical Building, Suite 526, Los Angeles, CA 90095, USA.
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Kocaoglu AS, Demirdizen G, Dernek S. The comparison of the short and mid-term results of endovascular interventions and bypass graft surgery in the treatment of patients with intermittent claudication complaints because of isolated femoropopliteal artery disease. Perfusion 2023:2676591231187957. [PMID: 37399504 DOI: 10.1177/02676591231187957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND Intermittent Claudication (IC) is exercise pain seen in lower extremity arterial diseases. If it is left untreated, it may be the initial sign of a process leading to amputation. In the present study, the purpose was to compare the postoperative early and mid-term results of the patients who were treated with endovascular methods and those who underwent bypass graft surgery in the treatment due to IC complaints because of isolated Femoropopliteal Arterial Disease. METHOD Postoperative first-month, sixth-month, and 12th-month follow-up results, procedure requirements, and demographic characteristics of the 153 patients who underwent femoropopliteal bypass because of isolated Femoropopliteal Arterial Disease and 294 patients who underwent endovascular intervention in our hospital between January 2015 and May 2020 were compared in the study. RESULTS It was found in demographic characteristics that endovascular intervention was performed more frequently in smokers and graft bypass surgery was performed more frequently in hyperlipidemic patients, and the results were found to be statistically significant. High amputation rates were detected at statistically significant levels in diabetic and hypertriglycemic patients and 1-year primary patency rates were found to be higher in patients who underwent graft bypass surgery. No differences were detected between the two methods in terms of mortality. CONCLUSION Interventional treatment modalities must be considered for patients with isolated Femoropopliteal Arterial Disease whose symptoms persist despite exercise and the best medical treatment. We think that Bypass Graft Surgery has more positive results than endovascular interventions when short and medium-term amputation, repetitive intervention needs, and changes in quality of life are compared in patients who receive the same medical treatment.
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Affiliation(s)
- Alper Selim Kocaoglu
- Department of Cardiovascular Surgery, Eskisehir City Hospital, Eskisehir, Turkey
| | - Gürkan Demirdizen
- Department of Cardiovascular Surgery, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Sadettin Dernek
- Department of Cardiovascular Surgery, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
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Raja A, Secemsky EA. Late Mortality and Paclitaxel-Coated Devices: Has the Controversy Finally Come to an End? JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100981. [PMID: 39131639 PMCID: PMC11308809 DOI: 10.1016/j.jscai.2023.100981] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 08/13/2024]
Affiliation(s)
- Aishwarya Raja
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Eric A. Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Abstract
The term 'diabetic foot disease' (DFD) often signifies the presence of foot ulceration and infection, but one must also be wary of the rarer occurrence of Charcot foot disease. The worldwide prevalence of DFD is 6.3% (95%CI: 5.4-7.3%). Foot complications present a major challenge to both patients and healthcare systems, with increased rates of hospitalisation and an almost trebled 5-year mortality. The Charcot foot often occurs in patients with long-standing diabetes, presenting as an inflamed or swollen foot or ankle, following unrecognised minor trauma. This review focuses on the prevention and early identification of the 'at-risk' foot. DFD is best managed by a multi-disciplinary foot clinic team consisting of podiatrists and healthcare professionals. This ensures a combination of expertise and provision of a multi-faceted evidence-based treatment plan. Current research using endothelial progenitor cells (EPC) and mesenchymal stem cells (MSC) offers a new dimension in wound management.
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Affiliation(s)
| | | | - David V Coppini
- University Hospitals Dorset NHS Trust, Dorset, UK, and visiting fellow, Bournemouth University, Bournemouth, UK
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36
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Bradbury AW, Moakes CA, Popplewell M, Meecham L, Bate GR, Kelly L, Chetter I, Diamantopoulos A, Ganeshan A, Hall J, Hobbs S, Houlind K, Jarrett H, Lockyer S, Malmstedt J, Patel JV, Patel S, Rashid ST, Saratzis A, Slinn G, Scott DJA, Zayed H, Deeks JJ. A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial. Lancet 2023; 401:1798-1809. [PMID: 37116524 DOI: 10.1016/s0140-6736(23)00462-2] [Citation(s) in RCA: 109] [Impact Index Per Article: 109.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Chronic limb-threatening ischaemia is the severest manifestation of peripheral arterial disease and presents with ischaemic pain at rest or tissue loss (ulceration, gangrene, or both), or both. We compared the effectiveness of a vein bypass first with a best endovascular treatment first revascularisation strategy in terms of preventing major amputation and death in patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal, revascularisation procedure to restore limb perfusion. METHODS Bypass versus Angioplasty for Severe Ischaemia of the Leg (BASIL)-2 was an open-label, pragmatic, multicentre, phase 3, randomised trial done at 41 vascular surgery units in the UK (n=39), Sweden (n=1), and Denmark (n=1). Eligible patients were those who presented to hospital-based vascular surgery units with chronic limb-threatening ischaemia due to atherosclerotic disease and who required an infra-popliteal, with or without an additional more proximal infra-inguinal, revascularisation procedure to restore limb perfusion. Participants were randomly assigned (1:1) to receive either vein bypass (vein bypass group) or best endovascular treatment (best endovascular treatment group) as their first revascularisation procedure through a secure online randomisation system. Participants were excluded if they had ischaemic pain or tissue loss considered not to be primarily due to atherosclerotic peripheral artery disease. Most vein bypasses used the great saphenous vein and originated from the common or superficial femoral arteries. Most endovascular interventions comprised plain balloon angioplasty with selective use of plain or drug eluting stents. Participants were followed up for a minimum of 2 years. Data were collected locally at participating centres. In England, Wales, and Sweden, centralised databases were used to collect information on amputations and deaths. Data were analysed centrally at the Birmingham Clinical Trials Unit. The primary outcome was amputation-free survival defined as time to first major (above the ankle) amputation or death from any cause measured in the intention-to-treat population. Safety was assessed by monitoring serious adverse events up to 30-days after first revascularisation. The trial is registered with the ISRCTN registry, ISRCTN27728689. FINDINGS Between July 22, 2014, and Nov 30, 2020, 345 participants (65 [19%] women and 280 [81%] men; median age 72·5 years [62·7-79·3]) with chronic limb-threatening ischaemia were enrolled in the trial and randomly assigned: 172 (50%) to the vein bypass group and 173 (50%) to the best endovascular treatment group. Major amputation or death occurred in 108 (63%) of 172 patients in the vein bypass group and 92 (53%) of 173 patients in the best endovascular treatment group (adjusted hazard ratio [HR] 1·35 [95% CI 1·02-1·80]; p=0·037). 91 (53%) of 172 patients in the vein bypass group and 77 (45%) of 173 patients in the best endovascular treatment group died (adjusted HR 1·37 [95% CI 1·00-1·87]). In both groups the most common causes of morbidity and death, including that occurring within 30 days of their first revascularisation, were cardiovascular (61 deaths in the vein bypass group and 49 in the best endovascular treatment group) and respiratory events (25 deaths in the vein bypass group and 23 in the best endovascular treatment group; number of cardiovascular and respiratory deaths were not mutually exclusive). INTERPRETATION In the BASIL-2 trial, a best endovascular treatment first revascularisation strategy was associated with a better amputation-free survival, which was largely driven by fewer deaths in the best endovascular treatment group. These data suggest that more patients with chronic limb-threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal, revascularisation procedure to restore limb perfusion should be considered for a best endovascular treatment first revascularisation strategy. FUNDING UK National Institute of Health Research Health Technology Programme.
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Affiliation(s)
- Andrew W Bradbury
- University Department of Vascular Surgery, Solihull Hospital, University Hospitals Birmingham NHS Foundation Trust, Solihull, UK; Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Catherine A Moakes
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Matthew Popplewell
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Lewis Meecham
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Gareth R Bate
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Lisa Kelly
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Chetter
- Hull York Medical School, University of Hull and University of York, York, UK
| | - Athanasios Diamantopoulos
- Department of Interventional Radiology, Guy's and St Thoma's NHS Foundation Trust, London, UK; School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Arul Ganeshan
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jack Hall
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Simon Hobbs
- Department of Vascular Surgery, Dudley Group NHS Foundation Trust, Dudley, UK
| | - Kim Houlind
- Lillebaelt Hospital, University of Southern Denmark, Odense, Denmark
| | - Hugh Jarrett
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Suzanne Lockyer
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jonas Malmstedt
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Division of Vascular Surgery, Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Jai V Patel
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Smitaa Patel
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - S Tawqeer Rashid
- Department of Vascular Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Athanasios Saratzis
- National Institute for Health and Care Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Gemma Slinn
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - D Julian A Scott
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Hany Zayed
- Department of Vascular Surgery, Guy's and St Thoma's NHS Foundation Trust, London, UK
| | - Jonathan J Deeks
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Kalra A, Kumar A. Endovascular reperfusion strategy for infra-popliteal chronic limb threatening ischaemia. Lancet 2023; 401:1749-1750. [PMID: 37116525 DOI: 10.1016/s0140-6736(23)00632-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 03/23/2023] [Indexed: 04/30/2023]
Affiliation(s)
- Ankur Kalra
- Department of Cardiology, Franciscan Health, Lafayette, IN 47905, USA.
| | - Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
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Yii E, Tiong J, Farah S, Al-Talib H, Clarke J, Yii MK. Should Long-Term Survival in Elderly Patients Presenting with Diabetic Foot Complications Impact Treatment Decision Making? INT J LOW EXTR WOUND 2023:15347346231170663. [PMID: 37081800 DOI: 10.1177/15347346231170663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Patients presenting with diabetic foot ulceration (DFU) and associated complications often require revascularisation. Although current evidence advocates for an open bypass first strategy if patients are expected to live more than two years, this may not be appropriate in octogenarians. We sought to investigate the survival of patients aged over 70 years presenting with complicated DFU and chronic limb threatening ischaemia (CLTI) to clarify its prognosis and guide subsequent management. A database of patients admitted into a large tertiary service over the age of 70 years with DFU and CLTI between 2014 and 2017 were included. Survival data was obtained from medical records and public obituaries through to 2020. Patients were divided into three age groups: seventies (70-79 years), eighties (80-89 years) and nineties (≥90 years). Survival was evaluated using a stratified log-rank test and Kaplan-Meier methods. A total of 323 patients were included for analysis. Survival information was available for 225 patients (69%). Mean duration of follow-up was 19 months. There were 113 deaths recorded (35%). Mean survival for patients in their seventies, eighties and nineties was 63 months (95% CI 48.8-65.5), 37 months (95% CI 27.4-44.9) and 6 months (95% CI 2.3-19.2), respectively. In patients over 70 years of age presenting with DFU and CLTI, long-term survival decreases rapidly with increasing age, especially in the octogenarians. With recent technological advances and reduced morbidity, an endovascular approach may sufficiently treat acute presentations in octogenarians while reserving an open first strategy for younger patients with better long-term survival and adequate autologous conduit.
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Affiliation(s)
- Erwin Yii
- Department of Vascular Surgery, Eastern Health, Box Hill, Australia
| | - Jonathan Tiong
- Department of Vascular Surgery, Monash Health, Clayton, Australia
| | - Sam Farah
- Department of Vascular Surgery, Austin Health, Heidelberg, Australia
- Department of Vascular Surgery, Alfred Health, Melbourne, Australia
| | - Husein Al-Talib
- Department of Vascular Surgery, Monash Health, Clayton, Australia
| | - Jonathan Clarke
- Department of Vascular Surgery, Monash Health, Clayton, Australia
| | - Ming Kon Yii
- Department of Vascular Surgery, Monash Health, Clayton, Australia
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Australia
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Ramachandran M, Sen I, Tallarita T, Beckermann J, Ramakrishna H. Outcomes in the Management of Chronic Limb-Threatening Ischemia -- Analysis of the BEST-CLI Trial. J Cardiothorac Vasc Anesth 2023; 37:632-636. [PMID: 36707379 DOI: 10.1053/j.jvca.2022.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023]
Affiliation(s)
- Mokhshan Ramachandran
- Division of Vascular and Endovascular Surgery, Mayo Clinic Health System, Eau Claire, WI
| | - Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic Health System, Eau Claire, WI
| | - Tiziano Tallarita
- Division of Vascular and Endovascular Surgery, Mayo Clinic Health System, Eau Claire, WI
| | - Jason Beckermann
- Department of Surgery, Mayo Clinic Health System, Eau Claire, WI
| | - Harish Ramakrishna
- Division of Vascular and Endovascular Surgery, Mayo Clinic Health System, Eau Claire, WI.
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40
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Liu IH, El Khoury R, Wu B, Gasper WJ, Schneider PA, Hiramoto JS, Vartanian SM, Conte MS. Presenting limb severity is associated with long-term outcomes after infrainguinal revascularization for chronic limb-threatening ischemia. J Vasc Surg 2023; 77:1137-1146.e3. [PMID: 36584906 DOI: 10.1016/j.jvs.2022.12.036] [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: 10/06/2022] [Revised: 12/19/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The SVS Wound, Ischemia, foot Infection (WIfI) limb staging system was established to estimate risk of major amputation in chronic limb-threatening ischemia (CLTI) and better stratify outcomes comparisons. There is little data on treatment outcomes beyond 1 year based on presenting WIfI stage. METHODS This is a single-institution retrospective study of 413 patients who underwent infrainguinal revascularization for CLTI (2011-2021) with data available for WIfI staging. Patient characteristics and outcomes were gathered from the electronic medical record. Data were analyzed based on presenting WIfI stage and initial treatment received at our center. RESULTS Presenting WIfI stages were 1 to 2 (23%), 3 (27%), and 4 (50%). Index revascularization approach was endoluminal (59%), autogenous vein bypass (29%), or non-autogenous bypass (13%). Operative mortality within 30 days was 2.9% and was not associated with WIfI stage or revascularization approach. Median limb follow-up time was 502 days (interquartile range [IQR], 112-1256 days), and median survival follow-up time was 932 days (IQR, 343-1770 days). Major amputation or death occurred in 19% and 46% of patients at median times of 119 days (IQR, 28-314 days) and 739 days (IQR, 204-1475 days), respectively. WIfI stage was independently associated with major amputation (P = .001), as was initial revascularization approach (P = .01). In a Cox proportional hazards model, factors independently associated with major amputation were male sex (hazard ratio [HR], 1.4; 95% confidence interval [CI], 1.04-2.0; P = .03), diabetes (HR, 1.8; 95% CI, 1.3-2.5; P = .001), WIfI stage 4 (HR, 2.3; 95% CI, 1.5-3.5; P < .001), and non-autogenous bypass (HR, 2.9; 95% CI, 2.1-4.2; P < .001). In a Cox proportional hazards model for mortality, independently associated factors were age (HR, 1.04; 95% CI, 1.02-1.05; P < .001), end-stage renal disease (HR, 2.8; 95% CI, 1.9-4.0; P < .001), congestive heart failure (HR, 1.9; 95% CI, 1.4-2.5; P < .001), chronic obstructive pulmonary disease (HR, 1.5; 95% CI, 1.1-2.1; P = .02), and WIfI stage 4 (HR, 1.6; 95% CI, 1.04-2.2; P = .03). Among those presenting with WIfI stage 4 limbs, Kaplan-Meier estimated rates of freedom from major amputation or death at 2 years were 71% ± 3.7% and 68% ± 3.5%, respectively. In an inverse propensity weighted Cox proportional hazards model, non-white race (HR, 1.5; 95% CI, 1.01-2.2; P = .047), diabetes (HR, 2.0; 95% CI, 1.2-3.3; P = .008), Global Anatomic Staging System infrapopliteal grade (HR, 1.2; 95% CI, 1.05-1.3; P = .005), non-autogenous bypass (HR, 3.2; 95% CI, 1.9-5.3; P < .001), and endoluminal revascularization (HR, 2.6; 95% CI, 1.6-4.3; P < .001) were independently associated with major amputation in the WIfI stage 4 subgroup. CONCLUSIONS Presenting WIfI stage is strongly associated with long-term risks of major amputation and death following infrainguinal revascularization for CLTI and should be used to stratify outcomes comparisons. Effective revascularization is critical in WIfI stage 4 disease, and autogenous vein bypass provides durable long-term limb preservation.
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Affiliation(s)
- Iris H Liu
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Rym El Khoury
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Bian Wu
- Kaiser Permanente San Francisco, San Francisco, CA
| | - Warren J Gasper
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Peter A Schneider
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Jade S Hiramoto
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Shant M Vartanian
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Michael S Conte
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA.
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41
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Cormican DS, Healy DA, Chess BA. Surgical Revascularization Versus Endovascular Therapy to Treat Chronic Limb-Threatening Ischemia: Perhaps Less Invasive Is Not Always Better. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00195-7. [PMID: 37080845 DOI: 10.1053/j.jvca.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/17/2023] [Indexed: 04/22/2023]
Affiliation(s)
- Daniel S Cormican
- Division of Cardiothoracic Anesthesiology, Anesthesiology Institute, Allegheny Health Network, Pittsburgh, PA; Division of Surgical Critical Care, Anesthesiology Institute, Allegheny Health Network, Pittsburgh, PA.
| | - Dean A Healy
- Division of Vascular Surgery, Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA; Division of Surgical Critical Care, Surgery Institute, Allegheny Health Network, Pittsburgh, PA
| | - Bart A Chess
- Division of Vascular Surgery, Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA
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Kobayashi T, Hamamoto M, Okazaki T, Tomota M, Fujiwara T, Hasegawa M, Takahashi S. Effectiveness of the Vascular Quality Initiative Chronic Limb-Threatening Ischemia Mortality Prediction Model in Patents with Distal Bypass. Ann Vasc Surg 2023; 90:188-196. [PMID: 36442707 DOI: 10.1016/j.avsg.2022.10.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/12/2022] [Accepted: 10/27/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The purpose of this study is to evaluate the effectiveness of mortality prediction using the Vascular Quality Initiative (VQI) chronic limb-threatening ischemia (CLTI) model in patients with distal bypass. METHODS Patients who underwent distal bypass for CLTI from 2009 to 2020 at a single center were retrospectively reviewed. Distal bypass was defined as any bypass with a distal anastomosis to the posterior tibial, anterior tibial, dorsalis pedis, plantar, or peroneal artery. Baseline characteristics, operative details, hospital outcomes, and medium-term outcomes were compared among patients with a low-, medium-, and high-risk of mortality based on a VQI CLTI calculation. The primary endpoints were survival and limb salvage. RESULTS A total of 287 distal bypasses were performed in 230 patients (153 males; median age, 74 years; diabetes mellitus, 70%; end-stage renal disease [ESRD] with hemodialysis, 38%). These patients were stratified into 153 (66%) low-, 35 (15%) medium-, and 42 (18%) high-risk cases based on the VQI CLTI model. There were two hospital deaths (1%) within 30 days. During a mean follow-up period of 33 ± 29 months, 105 patients died and 26 limbs (9%) required major amputation. The 2-year survival rate of 81% in the low-risk group was significantly higher than those of 41% in the medium-risk group and 46% in the high-risk group (both P < 0.001). The 2-year survival rates did not differ significantly between the medium- and high-risk groups (P = 0.81). The 2-year limb salvage rate of 93% in the low-risk group was significantly higher than those of 81% in the medium-risk (P = 0.023) and those of 87% in the high-risk (P = 0.039) groups. There were no significant differences in graft patency and wound healing among the three groups. CONCLUSIONS These results suggest that distal bypass is optimal treatment for patients with a low VQI-predicted risk of mortality. However, the lower limb salvage and higher mortality rates at 2 years suggest that the decision-making for VQI medium- and high-risk patients may be carefully considered.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan.
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mayu Tomota
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Takashi Fujiwara
- Department of Cardiology, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Misa Hasegawa
- Department of Reconstructive and Plastic Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University, Hiroshima, Japan
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Haque MZ, Reesha S, Khan S, Rafique R, Saleem A, Ilyas O, Abdullah L, Hussain A, Husain M. Peripheral Arterial Diseases and Diabetes Mellitus: Associations With Quality of Health Measures in Patients Undergoing Percutaneous Vascular Interventions. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 48:34-38. [PMID: 36379829 DOI: 10.1016/j.carrev.2022.11.003] [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: 10/03/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Peripheral arterial disease (PAD) is more prevalent and severe in patients with diabetes mellitus (DM) compared with those without DM. Peripheral vascular intervention (PVI) is often used in patients failing conservative management. The association of PVI with health status in diabetic patients has yet to be determined. METHODS We analyzed the clinical response to PVI in DM (n = 203, 52 %) compared with non-DM patients (n = 183, 48 %), using the Peripheral Arterial Questionnaire (PAQ) for patients during baseline and a maximum 6 months after PVI. We used the PAQ summary score, which summarized the patients' level of physical and social function, patient symptoms, and overall quality of life. This represented the PAD-related Quality of Health (QOH). Our score range is between 0 (lowest health quality) and 100 (highest health quality). RESULTS Compared with non-DM patients, those with DM were more likely to have a history of prior PVI, an increased prevalence of PAD risk factors, and significantly lower QOH scores at baseline (32.7 ± 20 vs 37.5 ± 20.6, p = 0.02). After adjustment for baseline confounding, neither the baseline, the change, nor the final summary scores were significantly different between groups, suggesting similar symptomatic and functional improvement in non-DM and DM patients post-PVI. CONCLUSIONS Following PVI, PAD-specific health status showed a similar improvement in patients with and without DM, illustrating that use of this strategy among patients with multiple comorbidities or diffuse PAD as useful.
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Affiliation(s)
- Mahfujul Z Haque
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Syeda Reesha
- Downriver Heart and Vascular Specialists, Southgate, MI, USA
| | - Shahrin Khan
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Rumyah Rafique
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Abdulmalik Saleem
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Omar Ilyas
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
| | | | - Arif Hussain
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Mashkur Husain
- Downriver Heart and Vascular Specialists, Southgate, MI, USA
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Nasr B, Gouailler F, Marret O, Guillou M, Chaillou P, Guyomarc'h B, Maurel B, Gouëffic Y. Treatment of Long Femoropopliteal Lesions With Self-Expanding Interwoven Nitinol Stent: 24 Month Outcomes of the STELLA-SUPERA Trial. J Endovasc Ther 2023; 30:98-105. [PMID: 35114841 DOI: 10.1177/15266028221075227] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE The performance of self-expanding interwoven nitinol stent (Supera) in femoropopliteal interventions has been proven through trials with short lesions and with relatively low proportion of occlusions. There is limited evidence of Supera stent in long lesions. The aim of this study was to assess the clinical safety and efficiency of the Supera stent in the treatment of long femoropopliteal lesions (Trans-Atlantic Inter-Society Consensus [TASC] C/D) in patients with symptomatic peripheral arterial disease (PAD). METHODS The STELLA SUPERA (STEnting Long de L'Artère fémorale superficielle par le stent métallique Supera) is a prospective, 2-center, single-arm study. Patients with symptomatic (Rutherford stages 2-6) de novo and TASC C/D lesions of the femoropopliteal segment were treated with Supera stent. The primary endpoint was the primary sustained clinical improvement at 12 months. Follow-up included clinical examination, duplex scan, and biplane X-ray up to 24 months. RESULTS Between December 2016 and October 2018, 48 symptomatic patients with 49 femoropopliteal lesions (TASC D = 32, 65%) were treated. The mean lesion length was 234 ± 123 mm, and 78% were total occlusion. The mean stented lesion length was 273 ± 127 mm. At 12 and 24 months, the primary sustained clinical improvement rate was 87.2% and 79.7%, respectively. The Rutherford category assessment was significantly improved at 24 months compared with baseline (p=0.02). At 24 months, the primary patency and freedom from target lesion revascularization (TLR) rates were 77.9% and 86.9%, respectively. The ankle-brachial pressure index increased from 0.62 ± 0.15 at baseline to 0.93 ± 0.15 at 24 months (p<0.0001). There were no stent fractures at 24 months. CONCLUSION The use of Supera stent in long lesions (TASC C/D) is a safe and effective endovascular alternative. These results reinforce the need for randomized clinical trials to assess the value of interwoven stents for long femoropopliteal lesions.
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Affiliation(s)
- Bahaa Nasr
- Service de Chirurgie Vasculaire, l'institut du Thorax, CHU Nantes, Nantes, France
| | - Flora Gouailler
- Service de Chirurgie Vasculaire, Clinique Océane, Vannes, France
| | - Olivier Marret
- Service de Chirurgie Vasculaire, CH de la Roche sur Yon, La Roche-sur-Yon, France
| | - Marie Guillou
- Service de Chirurgie Vasculaire, l'institut du Thorax, CHU Nantes, Nantes, France
| | - Philippe Chaillou
- Service de Chirurgie Vasculaire, l'institut du Thorax, CHU Nantes, Nantes, France
| | - Béatrice Guyomarc'h
- Service de Chirurgie Vasculaire, l'institut du Thorax, CHU Nantes, Nantes, France
| | - Blandine Maurel
- Service de Chirurgie Vasculaire, l'institut du Thorax, CHU Nantes, Nantes, France.,Laboratoire de Physiopathologie de la Résorption Osseuse, Inserm-UN UMR-957, Nantes, France
| | - Yann Gouëffic
- Laboratoire de Physiopathologie de la Résorption Osseuse, Inserm-UN UMR-957, Nantes, France.,Service de Chirurgie Vasculaire et Endovasculaire, Groupe Hospitalier Paris St Joseph, Paris, France
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45
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Kobayashi T, Hamamoto M, Okazaki T, Tomota M, Fujiwara T, Yoshitomi Y, Hasegawa M, Takahashi S. Outcomes of a bypass-first strategy in chronic limb-threatening ischemia based on the Global Vascular Guidelines. J Vasc Surg 2023; 77:201-207. [PMID: 35934216 DOI: 10.1016/j.jvs.2022.06.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 06/20/2022] [Accepted: 06/28/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The Global Vascular Guidelines (GVGs) recommend initial revascularization (bypass or endovascular therapy) for chronic limb-threatening ischemia (CLTI) based on anatomical complexity and limb severity. This decision is made based on a prediction of the outcomes after endovascular intervention. This study was performed to evaluate outcomes after distal bypass in cases recommended for GVG bypass. METHODS A total of 239 distal bypasses for CLTI were evaluated in 195 patients with a GVG bypass recommendation treated between 2009 and 2020 at a single center in Japan. Comparisons were made between crural and pedal bypass cases. RESULTS The 195 patients (median age, 77 years; 67% male) underwent 133 crural bypasses (106 patients; 54%) and 106 pedal bypasses (89 patients; 46%). Hemodialysis was more common in pedal cases than in crural cases (P = .03). Hospital deaths occurred in two cases (1%) within 30 days. The whole cohort has a follow-up rate of 96% over a mean of 28 ± 26 months, with 3-year limb salvage rates of 87% and 3-year primary, assisted primary, and secondary patency rates of 40%, 65%, and 67%, all without significant differences between crural and pedal cases. The 1-year wound healing rate was 88% and tended to be higher in crural cases than in pedal cases (P = .068). The 3-year survival rate was 52% in the cohort and did not differ significantly between crural and pedal cases. CONCLUSIONS Patients with CLTI with a GVG bypass recommendation had acceptable limb salvage, graft patency, wound healing, and survival after distal bypass, regardless of the bypass method. These findings indicate that a GVG bypass recommendation as an initial revascularization method is valid in the real world.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan.
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mayu Tomota
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Takashi Fujiwara
- Department of Cardiology, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Yuki Yoshitomi
- Department of Cardiology, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Misa Hasegawa
- Department of Reconstructive and Plastic Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University, Hiroshima, Japan
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Ji S, Hou X, Zhang X, Wu Z, Lin J, Lin Y, Wu J, Guo P, Cai F, Dai Y, Zhang J. The Relationship Between the Global Limb Anatomic Staging System Inframalleolar Modifier and the Outcomes of Diabetic Foot Ulcer with Peripheral Artery Disease. Ann Vasc Surg 2022; 92:256-263. [PMID: 36549472 DOI: 10.1016/j.avsg.2022.12.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/04/2022] [Accepted: 12/04/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND We aimed to investigate the relationship between the condition of the inframalleolar (IM) arteries, as assessed by the Global Limb Anatomic Staging System Inframalleolar (GLASS IM) modifier, and the outcomes of patients with diabetic foot ulcers. METHODS The data of 215 patients, who underwent endovascular therapy from January 2016 to May 2020 at our center, were retrospectively reviewed. Patients were divided into the P0, P1, and P2 groups according to the angiography results. The rates of ulcer healing, limb salvage, survival, and amputation-free survival were compared during the 2-year period after discharge. RESULTS Of the 216 affected limbs, 35 (16%) were classed as P0, 122 (57%) as P1, and 59 (27%) as P2. Compared with the P2 group, the P0 + P1 group had a higher ulcer healing rate (P = 0.001), a shorter ulcer healing time (P = 0.004), and a higher survival rate (P = 0.044). GLASS IM Modifier classification P2 was an independent predictor of nonhealing ulcers. No significant difference was observed between the P0 versus P1 groups. CONCLUSIONS GLASS IM modifier classification P2 is an independent risk factor for a poor outcome. GLASS IM modifier classification P0 versus P1 demonstrates similar outcomes to each other.
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Affiliation(s)
- Shiping Ji
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xinhuang Hou
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xunliang Zhang
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zhiye Wu
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jie Lin
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yichen Lin
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jie Wu
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Pingfan Guo
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Fanggang Cai
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yiquan Dai
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jinchi Zhang
- Departments of Vascular and Endovascular Surgery, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China.
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Jenkins P, MacCormick A, Harborne K, Liu W, Mahay U, Zhong J, Haslam P. Barriers to research in interventional radiology within the UK. Clin Radiol 2022; 77:e821-e825. [DOI: 10.1016/j.crad.2022.08.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/24/2022] [Accepted: 08/27/2022] [Indexed: 11/03/2022]
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Gray WA, Cardenas J, Teigen CL. Evaluation of safety and efficacy of the S.M.A.R.T.® Flex Vascular Stent System (OPEN study). Catheter Cardiovasc Interv 2022; 100:1078-1087. [PMID: 36177491 DOI: 10.1002/ccd.30414] [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: 03/02/2022] [Revised: 06/23/2022] [Accepted: 09/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The OPEN study evaluated the safety and efficacy of the S.M.A.R.T.® Flex Vascular Stent System in patients with femoropopliteal arterial disease. BACKGROUND Long-term data on endovascular treatments of femoropopliteal arterial disease are required to establish the repair durability. METHODS The OPEN study was a multicenter, single-arm, prospective study comparing primary safety and efficacy outcomes to performance goals (PG) developed for bare nitinol stents. Patients with symptoms due to a single, ≤180 mm length, de novo femoropopliteal arterial lesion with >70% stenosis were enrolled were enrolled and followed for 36 months. Subjects with lesions ≤150 mm served as the initial comparison cohort for the PG (other cohorts were analyzed if the PG was met). RESULTS 257 subjects with lesions ≤180 mm were enrolled. The mean lesion length was 71 ± 46, and 52.5% had severe claudication. The primary safety endpoint (freedom from all-cause death, index limb amputation, and target lesion revascularization [TLR] through 30 days) was met in 98.8% (96.5%, 99.6%) of subjects in the comparison cohort, meeting the PG (88.0%). The primary efficacy endpoint (comparison cohort vessel patency at 12 months) was 68.4% (61.1%, 74.8%), where the lower limit of the 95% confidence interval did not meet the 66.0% PG. Freedom from TLR in the per-protocol cohort at 12-, 24-, 36-month was 84.7%, 74.6%, and 72.8%, respectively. The 24-month stent fracture rate was 4.3%, with no new fractures identified at 36 months. CONCLUSION The results show promising long-term safety and effectiveness for the S.M.A.R.T.® Flex Vascular Stent System in patients with femoropopliteal arterial disease.
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Affiliation(s)
- William A Gray
- Main Line Health, Lankenau Heart Institute, Wynnewood, Pennsylvania, USA
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Higashita R, Miyazaki M, Oi M, Ishikawa N. First-in-human results of an in-body tissue architecture-induced tissue-engineered vascular graft “Biotube” for application in distal bypass for chronic limb-threatening ischemia. J Vasc Surg Cases Innov Tech 2022; 8:488-493. [PMID: 36052213 PMCID: PMC9424347 DOI: 10.1016/j.jvscit.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/08/2022] [Indexed: 11/24/2022] Open
Abstract
Small-diameter vascular substitutes remain necessary, especially in the absence of an available autologous vein. Using a completely autologous approach termed “in-body tissue architecture,” a small-diameter, long, tissue-engineered vascular graft, a “Biotube,” was developed. A below-the-knee distal bypass using the Biotube as a composite with expanded polytetrafluoroethylene grafts was performed to treat a patient with chronic limb-threatening ischemia without a venous graft available. The wound on the foot had completely healed 3 months after the bypass surgery, and limb salvage and walking without claudication were achieved. At the 1-year postoperative follow-up examination, duplex ultrasound scans demonstrated graft patency without thrombus or stenosis.
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50
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Salamaga S, Stępak H, Krasiński Z. Supera stent implantation for the treatment of isolated popliteal artery disease systematic review and evaluation of current endovascular strategies. POLISH JOURNAL OF SURGERY 2022; 95:1-7. [PMID: 36807095 DOI: 10.5604/01.3001.0015.9578] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
<b>Introduction:</b> The anatomical location of the popliteal artery is one of the greatest challenges for percutaneous interventions. The biomechanical attributes of the vessel lead to higher rates of restenosis, stent fracture, and occlusion. Some surgeons consider the popliteal artery as a no stenting zone. Many specialists favor percutaneous transluminal angioplasty to be the first line of endovascular treatment in the popliteal artery with bail-out stent implantation if the results are suboptimal. The Supera peripheral stent system is a novel stent that has been manufactured with a high degree of flexibility and supposedly might be appropriate for implantation in the popliteal artery. </br></br> <b>Aim:</b> Evaluation of the performance of Supera stent in isolated popliteal artery disease in comparison to other methods of treatment. </br></br> <b>Methods:</b> As many as 92 articles were found in the databases and after full-text review, 4 studies matched the inclusion criteria and were evaluated. </br></br> <b>Results:</b> Primary patency rates of Supera implantation in an isolated popliteal artery at 12 months ranged from 68% to 90%. In all four studies, no stent fractures were observed. Only one study provided longer follow-up than 12 months and evaluated the performance of the Supera stent 36 months after implantation. </br></br> <b>Conclusion:</b> In conclusion, mentioned studies show promising and superior to other stent patency rates of the Supera stent regarding popliteal artery lesions. What is more, no stent fracture is promising regarding longer follow-up. However, more studies with longer follow-ups and direct comparison to other methods are required to fully evaluate Supera's performance in the popliteal artery.
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Affiliation(s)
- Szymon Salamaga
- Department of General and Vascular Surgery, Medical University of Karol Marcinkowski in Poznan, Poland
| | - Hubert Stępak
- Department of General and Vascular Surgery, Medical University of Karol Marcinkowski in Poznan, Poland
| | - Zbigniew Krasiński
- Department of General and Vascular Surgery, Medical University of Karol Marcinkowski in Poznan, Poland
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