Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: Health-related quality of life outcomes, resource utilization, and cost-effectiveness analysis

Quality of Life in Patients With Chronic Limb-Threatening Ischemia Treated With Revascularization

BACKGROUND

In the BEST-CLI trial (Best Endovascular Versus Best Surgical Therapy for Patients With Chronic Limb-Threatening Ischemia), a prespecified secondary objective was to assess the effects of revascularization strategy on health-related quality of life (HRQoL).

METHODS

Patients with chronic limb-threatening ischemia were randomized to surgical bypass (Bypass) or endovascular intervention (Endo) in 2 parallel trials. Cohort 1 included patients with single-segment great saphenous vein; cohort 2 included those lacking suitable single-segment great saphenous vein. HRQoL was assessed over the trial duration using Vascular Quality-of-Life (VascuQoL), European Quality-of-Life-5D (EQ-5D), the Short Form-12 (SF-12) Physical Component Summary (SF-12 PCS), SF-12 Mental Component Summary (SF-12 MCS), Utility Index Score (SF-6D R2), and numeric rating scales of pain. HRQoL was summarized by cohort and compared within and between groups using mixed-model linear regression.

RESULTS

A total of 1193 and 335 patients in cohorts 1 and 2 with a mean follow-up of 2.9 and 2.0 years, respectively, were analyzed. In cohort 1, HRQoL significantly improved from baseline to follow-up for both groups across all measures. For example, mean (SD) VascuQoL scores were 3.0 (1.3) and 3.0 (1.2) for Bypass and Endo at baseline and 4.7 (1.4) and 4.8 (1.5) over follow-up. There were significant group differences favoring Endo when assessed with VascuQoL (difference, -0.14 [95% CI, -0.25 to -0.02]; P=0.02), SF-12 MCS (difference, -1.03 [95% CI, -1.89 to -0.18]; P=0.02), SF-6D R2 (difference, -0.01 [95% CI, -0.02 to -0.001]; P=0.03), numeric rating scale pain at present (difference, 0.26 [95% CI, 0.03 to 0.49]; P=0.03), usual level during previous week (difference, 0.26 [95% CI, 0.04 to 0.48]; P=0.02), and worst level during previous week (difference, 0.29 [95% CI, 0.02 to 0.56]; P=0.04). There was no difference between treatment arms on the basis of EQ-5D (difference, -0.01 [95% CI, -0.03 to 0.004]; P=0.12) or SF-12 PCS (difference, -0.41 [95% CI, -1.2 to 0.37]; P=0.31). In cohort 2, HRQoL also significantly improved from baseline to the end of follow-up for both groups based on all measures, but there were no differences between Bypass and Endo on any measure.

CONCLUSIONS

Among patients with chronic limb-threatening ischemia deemed eligible for either Bypass or Endo, revascularization resulted in significant and clinically meaningful improvements in HRQoL. In patients with an available single-segment great saphenous vein for bypass, but not among those without one, Endo was statistically superior on some HRQoL measures; however, these differences were below the threshold of clinically meaningful difference.

Limb Salvage Surgery for Ponatinib-Induced Bilateral Chronic Limb-Threatening Ischemia in a Patient with Chronic Myeloid Leukemia with T315I Mutation in BCR-ABL: A Case Report

A 72-year-old woman with chronic myeloid leukemia with T315I mutation in breakpoint cluster region-abelson (BCR-ABL) was treated with ponatinib. During the course of her treatment, chronic limb-threatening ischemia developed in both lower extremities, and the left lower extremity was amputated below the knee at a previous hospital. She was referred to our department for salvage of the right lower extremity. We performed a foot bypass and multidisciplinary treatment of the wound, and achieved epithelialization in about 1 month. The rate of vascular occlusive events with ponatinib has been reported to be high, and we believe that careful monitoring is important during use.

Short-term patency of iliofemoral to tibial bypass with vascular allografts in a minority population: A retrospective analysis of a single center acute care facility

OBJECTIVE

The aim of this study was to examine the short-term patency rates and associated factors of open lower limb, iliofemoral to tibial bypass using cryopreserved saphenous vein (CSV) in a minority population at an acute care hospital in New York City.

METHODS

A retrospective analysis of patients undergoing infra-inguinal bypass from iliofemoral vessels to tibial arteries with CSV between March 2020-April 2022 at an acute care facility (Harlem Hospital Center, Harlem, New York) was performed. Data including patient demographics, comorbidities, type of operation, follow-up surveillance, and salvage procedures were collected. Results were presented in patency line graphs and a life table. Target limb revascularization (TLR) and amputation free survival (AFS) were also calculated.

RESULTS

Eleven bypass procedures were included in the analysis. Patients were followed for a mean of 10.8 months. Cumulative primary patency rates at 1, 6, and 12 months were 72.7%, 54.5%, and 40.9%, respectively. TLR was 36.4% and the AFS was 66.67% at the mean 10.8-month follow-up.

CONCLUSIONS

The patency rates of minority patients undergoing bypass with CSV were analyzed with creation of a life table and calculation of patency rates, TLR and AFS. The short-term primary patency rates and post-operative outcomes were found to be comparable to larger studies in non-minority cohorts. These results suggest that larger studies as well as prospective analyses and randomized controlled trials in this patient cohort and demographic are needed, as well as optimal selection of patients to determine true clinical implications.

Disease Specific Health Related Quality of Life in Patients With Chronic Limb Threatening Ischaemia Undergoing Revascularisation of Femoropopliteal Lesions

OBJECTIVE

Patients with chronic limb threatening ischaemia (CLTI) suffer from pain and non-healing ulcers, which impact negatively on both their physical and mental health. While maintaining and improving quality of life is a principal aim with all treatments, little is known about the health related quality of life (HRQoL) of CLTI patients and how revascularisation procedures impact on HRQoL endpoints. The aim of this study was to investigate disease specific HRQoL before and after revascularisation in patients with CLTI undergoing femoropopliteal revascularisation.

METHODS

HRQoL was prospectively analysed in 190 CLTI patients with main atherosclerotic target lesions in the femoropopliteal segment, who were planned for endovascular or open revascularisation. The choice of revascularisation method was made by the vascular team, represented by both open and endovascular expertise. The Vascular Quality of Life (VascuQoL) questionnaire was used to assess disease specific HRQoL before revascularisation and one month, one year, and two years after the procedure. Main endpoints were mean VascuQoL score changes, effect sizes of observed changes and the proportion reaching a minimally important difference (half a standard deviation change from baseline) during two years after revascularisation.

RESULTS

Patient reported VascuQoL scores were low at baseline (mean 2.68, 95% CI 1.18 - 4.17). After revascularisation, the mean VascuQoL score improved statistically significantly over time, with the largest improvement observed after one year (difference from baseline 2.02, 95% CI 1.75 - 2.29; p < .001). No differences in HRQoL change over time were observed between patients treated with endovascular approaches compared with bypass surgery. Approximately half the patients reached the minimally important threshold at one year (53%), which was largely maintained also at two years (41%).

CONCLUSION

While CLTI profoundly affected HRQoL, a large and clinically meaningful HRQoL increase was observed after revascularisation. This confirms the value of CLTI revascularisation on HRQoL and underlines the importance of including patient reported outcomes when evaluating revascularisation procedures in CLTI patients.

Integration of palliative care consultation into the management of patients with chronic limb-threatening ischemia

OBJECTIVE

We assessed the feasibility of integrating palliative care consultation into the routine management of patients with chronic limb-threatening ischemia (CLTI). Additionally, we sought to describe patient-reported outcomes from the palliative care and vascular literature in patients with CLTI receiving a palliative care consultation at our institution.

METHODS

This was a single-institution, prospective, observational study that aimed to assess feasibility of incorporating palliative care consultation into the management of patients admitted to our tertiary academic medical center with CLTI by looking at utilization of palliative care before and after implementation of a protocol-based palliative care referral system. A survey comprised of patient-reported outcomes from the palliative care literature was administered to patients before and after palliative consultation. Length of stay and mortality were compared between our study cohort and a historic cohort of patients admitted with CLTI.

RESULTS

Over a 14-month enrollment period, 44% of patients (n = 39) with CLTI (rest pain, 36%; tissue loss, 64%) admitted to the vascular service received palliative care consultation, compared with 5% of patients (n = 4) who would have met criteria over the preceding 14 months before our protocol was instituted. The mean age was 69 years, 23% were female, 92% were white, and 49% were able to ambulate independently. Revascularization included bypass (46%), peripheral vascular intervention (23%), and femoral endarterectomy (21%). Additional procedures included minor amputation or wound debridement (26%) and major amputation (15%). No patients received medical management alone. After receiving palliative care consultation, patients reported experiencing less emotional distress than before consultation (P = .03). They also reported being less bothered by uncertainty regarding what to expect from the course of their illness (P = .002). Fewer patients reported being unsure of the purpose of their medical care after palliative care consultation (8%) vs before (18%), although this was not statistically significant (P = .10). Median length of stay was longer in the study group compared with the historic cohort (8 vs 7 days; P = .02). There was no difference in 30-day mortality (3% vs 8%; P = .42) between the study group and the historic cohort (n = 77).

CONCLUSIONS

Integrating inpatient palliative care consultation into the routine management of patients with CLTI is feasible and may improve emotional domains of health-related quality of life. This study laid the foundation for future studies on longer term outcomes of patients with CLTI undergoing palliative care consultation as well as the benefit of outpatient palliative care consultation in patients with CLTI.

Relationship between WIfI stage and quality of life at revascularization in the BEST-CLI trial

OBJECTIVE

The WIfI (Wound, Ischemia, foot Infection) stage measures the extent of wounds, ischemia, and foot infection in patients with chronic limb threatening ischemia (CLTI) and has been associated with the risk of major amputation. Patients with CLTI have impaired health-related quality of life (HRQoL), which can be multifactorial. We hypothesized that the severity of the limb threat (WIfI stage) would be associated with poor HRQoL among patients with CLTI presenting for revascularization.

METHODS

The dataset of the BEST-CLI (best endovascular versus best surgical therapy in patients with CLTI) trial, a prospective, randomized trial comparing open and endovascular revascularization strategies, was queried for HRQoL assessments at patient enrollment. The HRQoL assessments included (1) Vascular Quality of Life; (2) 12-item short form survey (SF-12), containing the utility index score (short-form six-dimension R2 utility index, incorporating physical, emotional, and mental well-being) and mental and physical components; and (3) the EQ-5D. Multivariable regression analysis was used to identify the independent associations with the baseline HRQoL assessments.

RESULTS

A total of 1568 patients with complete WIfI data were analyzed, of whom 71.5% were men. The WIfI distribution was 35.5% with stage 4, 29.6% with stage 3, 28.6% with stage 2, and 6.3% with stage 1. Patients presenting with WIfI stage 4, compared with stage 1 to 3, were more often men (74.9% vs 69.6%) and current smokers (25.4% vs. 17.6%), had had end-stage renal disease (13.3% vs 8.5%) and diabetes (83.6% vs 60.2%), were not independently ambulatory (56.8% vs 38.5%), and had had higher median morbidity scores (4 vs 3; P < .05 for all). On multivariable analysis, WIfI stage 4, compared with stage 1 to 3, was associated with lower SF-12 mental component scale scores (estimate, -2.43; 95% confidence interval, -3.73 to -1.13; P < .001) and short-form six-dimension R2 utility index scores (estimate, -0.02; 95% confidence interval, -0.03 to 0.001; P = .04). The WIfI stage was not independently associated with the baseline Vascular Quality of Life, SF-12 physical component scale, or EQ-5D assessments.

CONCLUSIONS

WIfI stage was independently associated with poorer quality of life because of mental, rather than physical, health for patients with CLTI. Clinicians should be aware of the burden of mental stress borne by those with the greatest limb impairment.

Evaluation of the Effects of Extracorporeal Shockwave Therapy in Patients With Peripheral Arterial Disease: A Meta-Analysis of Randomized Control Trials

The aim of this meta-analysis is to assess the efficacy of extracorporeal shockwave therapy (ESWT) in patients with peripheral arterial disease (PAD). This meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search was conducted independently by two authors using PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to January 15, 2023. Primary clinical outcomes assessed in this meta-analysis were changes in maximum waking distance (MWD) and pain-free walking distance (PFWD) from baseline. Other outcomes assessed included change in ankle brachial pressure index (ABI) and degree of arterial stenosis. Four RCTs involving a total of 228 patients were included. Change of PFWD and MWD from baseline was significantly higher in patients randomized in the ESWT group as compared to the control group. No significant differences were reported between the two groups in terms of change in ABI from baseline. In conclusion, this meta-analysis of four randomized controlled trials found evidence that ESWT is an effective treatment for patients with PAD in terms of improving PFWD and MWD and reducing stenosis. However, there was no significant difference in the improvement of the ankle-brachial index between the study groups.

Quality of Life in Chronic Limb Threatening Ischaemia: Systematic Review and Meta-Analysis

OBJECTIVE

To assess the comparative effectiveness and temporal changes in quality of life (QoL) outcomes after revascularisation, major lower extremity amputation (MLEA), and conservative management (CM) in chronic limb threatening ischaemia (CLTI).

DATA SOURCES

MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science.

REVIEW METHODS

A systematic review and meta-analysis were performed on QoL measured by any QoL instrument in adult patients with CLTI after open surgery (OS), endovascular intervention (EVI), MLEA, or CM. Randomised controlled trials and prospective observational studies published in any language between 1 January 1990 and 21 May 2021 were included. There was a pre-specified measurement time point of six months. Random effects meta-analysis was conducted on total scores for each QoL instrument. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach (PROSPERO registration: CRD42021253953).

RESULTS

Fifty-five studies with 8 909 patients were included. There was significant heterogeneity in the methods used to measure QoL, and the study characteristics. In particular, 14 different QoL instruments were used with various combinations of disease specific and generic instruments within each study. A narrative summary is therefore presented. Comparative effectiveness data showed there was reasonable certainty that QoL was similar between OS and EVI at six months. Temporal outcomes suggested small to moderate improvements in QOL six months after OS and EVI compared with baseline. Limited data indicated that QoL can be maintained or slightly improved after MLEA or CM. Treatment effects were overestimated owing to small study effects, selective non-reporting, attrition, and survivorship bias.

CONCLUSION

QoL after OS and EVI appears to be similar. Revascularisation may provide modest QoL benefits, while MLEA or CM can maintain QoL. However, certainty of evidence is generally low or very low, and interpretation is hampered by significant heterogeneity. There is a need for a CLTI specific QoL instrument and methodological standardisation in QoL studies.

Exercise-induced increase in M2 macrophages accelerates wound healing in young mice

Moderate-intensity exercise performed during wound healing has been reported to decrease inflammatory cytokines and chemokines and accelerate wound healing. However, its effect on macrophage phenotype and the mechanism by which exercise accelerates wound healing remain unclear. The purpose of this study was to investigate the effect of exercise on macrophage phenotype during wound healing and to clarify the relationship between angiogenesis and wound healing. 12-week-old male C57BL/6J mice were divided into sedentary (n = 6) and exercise groups (n = 6). The exercise group performed moderate-intensity treadmill running exercise (9.0 m/min, 60 min) for 10 days. Double immunofluorescence analysis was performed using F4/80+ inducible nitric oxide synthase (iNOS)+ for M1 macrophages, F4/80+ transforming growth factor-beta (TGF-β)1+ for M2 macrophages, and CD31+ alpha smooth muscle actin (α-SMA)+ for angiogenesis. The exercise group showed significantly accelerated wound healing compared with the sedentary group. From early wound healing onward, exercise significantly inhibited M1 macrophage infiltration and increased M2 macrophage count. Exercise also significantly increased angiogenesis. Furthermore, the M2 macrophage phenotype was significantly correlated with angiogenesis in the exercise group, indicating that M2 macrophages and angiogenesis are related to accelerated wound healing. These findings suggest that moderate-intensity exercise increases TGF-β1 derived from M2 macrophages, which may be associated with enhanced angiogenesis and wound healing in young mice.

A Systematic Review of Cost-Utility Analyses in Chronic Limb-Threatening Ischemia

BACKGROUND

To review and describe the available literature on cost-utility analysis of revascularization and non-revascularization treatment approaches in chronic limb-threatening ischemia.

METHODS

A systematic review was performed on cost-utility analysis studies evaluating revascularization (open surgery or endovascular), major lower extremity amputation, or conservative management in adult chronic limb-threatening ischemia patients. Six bibliographic databases and online registries were searched for English language articles up to August 2021. The outcome for cost-utility analysis was quality-adjusted in life years. Procedures were compared using incremental cost-effectiveness ratios which were converted to 2021 United States dollars. Study reporting quality was assessed using the 2022 Consolidated Health Economic Evaluation Reporting Standards statement. The study was registered in International Prospective Register of Systematic Reviews (CRD42021273602).

RESULTS

Three trial-based and five model-based studies were included for review. Studies met between 14/28 and 20/28 criteria of the Consolidated Health Economic Evaluation Reporting Standards CHEERS statement. Only one study was written according to standardized reporting guidelines. Most studies evaluated infrainguinal disease, and adopted a health care provider perspective. There was a large variation in the incremental cost-effectiveness ratios presented across studies. Open surgical revascularization (incremental cost-effectiveness ratios: $3,678, $58,828, and $72,937), endovascular revascularization (incremental cost-effectiveness ratios: $52,036, $125,329, and $149,123), and mixed open or endovascular revascularization (incremental cost-effectiveness ratio: $8,094) maybe more cost-effective than conservative management.

CONCLUSIONS

The application of cost-utility analyses in chronic limb-threatening ischemia is in its infancy. Revascularization in infrainguinal disease may be favored over major lower extremity amputation or conservative management. However, data is inadequate to support recommendations for a specific treatment. This review identifies short and long-term considerations to address the current state of evidence. Cost-utility analysis is an important tool in healthcare policy and should be encouraged amongst the vascular surgical community.

Factors Associated with Lower Preoperative Quality of Life in Patients with Chronic Limb Threatening Ischemia in the BEST-CLI Trial

OBJECTIVES

There is limited contemporary data regarding health-related quality of life (HRQOL) measures in patients with chronic limb-threatening ischemia (CLI).

METHODS

The Best Endovascular versus Best Surgical Therapy in Patients with CLI (BEST-CLI) trial is an ongoing, NIH-sponsored, multicenter, randomized controlled trial comparing revascularization strategies in patients with CLI. BEST-CLI baseline HRQOL measures were evaluated for patient-specific variables that were associated with poor HRQOL and then compared with published outcomes. The HRQOL measures VascQOL (Vascular Quality of Life Questionnaire), EQ-5D (EuroHRQOL 5D), and SF-12 Index, physical component (PCS) and mental component (MCS) scores were aggregated from preoperative questionnaires completed by trial subjects at baseline visits. Multivariable linear regression models were fit to determine which baseline characteristics were associated with poor HRQOL.

RESULTS

1830 subjects were randomized into BEST-CLI. The majority (94.9%, 95.8%, and 95.8%) completed the VascQOL, EQ5D, and SF-12 instruments at baseline. In VascQOL, female sex, smoking history, opioid use, and non-independent ambulation predicted lower HRQOL scores. Overall, VascuQOL scores were similar to those of participants in the Bypass versus Angioplasty in Severe Ischemia of the Leg (BASIL) [(3.07(1.2)) vs 2.9(1.1)), P=.07]. In EQ5D, non-independent ambulation predicted lower HRQOL scores. In SF-12, female sex, opioid use, non-independent ambulation and history of smoking predicted lower HRQOL scores. The mean (standard deviation) SF-12 PCS for all patients in the study was 33.0(8.5) and for MCS was 46.4(12.0), significantly lower than the national SF-12 scores for US population over 60 years of age which is PCS of 46.5(11.4) and MCS of 52.9 (8.7).

CONCLUSIONS

Patients with CLI entering the BEST-CLI trial have very low HRQOL scores comparable to patients suffering from other chronic conditions characterized by physical limitation and chronic pain. A history of smoking, impaired ambulation, opioid use, and female sex predicted lower HRQOL in CLI patients, using multiple HRQOL measurement tools.

Filgrastim, fibrinolysis, and neovascularization

Segmental recanalization of chronically occluded arteries was observed in patients with chronic limb-threatening ischemia (CLTI) treated with Filgrastim, a granulocyte colony stimulating factor, every 72 h for up to a month, and an infra-geniculate programmed compression pump (PCP) for 3 h daily. Molecular evidence for fibrinolysis and neovascularization was sought. CLTI patients were treated with PCP alone (N = 19), or with Filgrastim and PCP (N = 8 and N = 6, at two institutions). Enzyme-Linked Immunosorbent Assay was used to measure the plasma concentration of plasmin and of fibrin degradation products (FDP), and the serum concentration of proteins associated with neovascularization. In the PCP-alone group, blood was sampled on Day 1 (baseline) and after 30 days of daily PCP. In the Filgrastim and PCP group, blood was drawn on Day 1, and 1 day after the 5th and the 10th Filgrastim doses. Each blood draw occurred before and after 2 h of supervised PCP. Significant (p < 0.01) PCP independent increases in the plasma concentration of plasmin (>10-fold) and FDP (>5-fold) were observed 1 day after both the 5th and the 10th Filgrastim doses, compared to Day 1. Significant (p < 0.05) increases in the concentration of pro-angiogenic proteins (e.g., HGF, MMP-9, VEGF A) were also observed. Filgrastim at this novel dosimetry induced fibrinolysis without causing acute hemorrhage, in addition to inducing a pro-angiogenic milieu conducive to NV. Further clinical testing is warranted at this novel dosimetry in CLTI, as well as in other chronically ischemic tissue beds. Trial registration. https://clinicaltrials.gov/ct2/show/NCT02802852.

Defining the relative utility of lumbar spine surgery: A systematic literature review of common surgical procedures and their impact on health states

Degenerative lumbar spondylosis is a common indication for patients undergoing spine surgery. As healthcare costs rise, measuring quality of life (QOL) gains after surgical procedures is critical in assessing value. We set out to: 1) compare baseline and postoperative EuroQol-5D (EQ-5D) scores for lumbar spine surgery and common surgical procedures to obtain post-operative quality-adjusted life year (QALY) gain, and 2) establish the relative utility of lumbar spine surgery as compared to other commonly performed surgical procedures. A systematic literature review was conducted to identify all studies reporting preoperative/baseline and postoperative EQ-5D scores for common surgical procedures. For each study, the number of patients included and baseline/preoperative and follow-up mean EQ-5D scores were recorded, and mean QALY gained for each intervention was calculated. A total of 67 studies comprising 95,014 patients were identified. Patients with lumbar spondylosis had the worst reported QOL at baseline compared to other surgical cohorts. The greatest QALY gain was seen in patients undergoing hip arthroplasty (0.38), knee arthroplasty (0.35) and lumbar spine surgery (0.32), nearly 2.5-fold greater QALY gained than for all other procedures. The low preoperative QOL, coupled with the improvements offered with surgery, highlight the utility and value of lumbar spine surgery compared to other common surgical procedures.

Health Related Quality of Life Over Time After Revascularisation in Patients With Chronic Limb Threatening Ischaemia

OBJECTIVE

Chronic limb threatening ischaemia (CLTI) decreases life expectancy and impairs health related quality of life (HR-QOL). Revascularisation is needed to relieve ischaemia and salvage limbs. Although a major goal of CLTI treatment is maintaining QOL, little information is available about changes of HR-QOL over time after revascularisation. HR-QOL with survival after revascularisation for CLTI was assessed.

METHODS

The clinical database of the Surgical reconstruction versus Peripheral INtervention in pAtients with critical limb isCHemia (SPINACH), a prospective multicentre observational study, was analysed. Outcome measures were disease specific QOL per the Vascular Quality of Life (VascuQOL) questionnaire and the Short Form (SF) 36 evaluated generic QOL, which were assessed at baseline and three, 12, 24, and 36 months. The outcome measure was change of QOL from baseline. The minimally important difference (half a standard deviation from baseline) was used as the cut off point for improved, worsened, and unchanged QOL.

RESULTS

Overall QOL was improved in 61% of patients for the VascuQOL and approximately 40% for the SF-36 component summaries at three months. However, these proportion gradually decreased to 21% - 31% at three years. In contrast, the proportion of deceased patients gradually increased over the three year follow up. Multivariable analysis revealed that pre-operative non-ambulatory status was inversely associated with improved QOL for the three month VascuQOL and SF-36 mental component summary, and surgical reconstruction was positively associated with these measurements. Advanced age and renal failure were inversely associated with improved QOL for the SF-36 mental component summary and VascuQOL at one to three years.

CONCLUSION

Revascularisation improved QOL. However, patients with non-ambulatory status exhibited a negative association with improved QOL at three months, and advanced age and renal failure limited benefits one to three years after revascularisation. Accumulating QOL data will be essential for post-revascularisation QOL estimation. Pre-operative assessment, including estimated QOL, is important in shared decision making for patient oriented outcomes in the treatment of CLTI patients.

Procedural and 12-month in-hospital costs of primary infra-popliteal bypass surgery, infra-popliteal best endovascular treatment, and major lower limb amputation for chronic limb threatening ischemia

OBJECTIVE

Chronic limb-threatening ischemia (CLTI) is a growing global problem due to the widespread use of tobacco and increasing prevalence of diabetes. Although the financial consequences are considerable, few studies have compared the relative cost-effectiveness of different CLTI management strategies. The Bypass vs Angioplasty in Severe Ischaemia of the Leg (BASIL)-2 trial is randomizing patients with CLTI to primary infra-popliteal (IP) vein bypass surgery (BS) or best endovascular treatment (BET) and includes a comprehensive within-trial cost-utility analysis. The aim of this study is to compare over a 12-month time horizon, the costs of primary IP BS, IP best endovascular treatment (BET), and major limb major amputation (MLLA) to inform the BASIL-2 cost-utility analysis.

METHODS

We compared procedural human resource (HR) costs and total in-hospital costs for the index admission, and over the following 12-months, in 60 consecutive patients undergoing primary IP BS (n = 20), IP BET (n = 20), or MLLA (10 transfemoral and 10 transtibial) for CLTI within the BASIL prospective cohort study.

RESULTS

Procedural HR costs were greatest for BS (BS £2551; 95% confidence interval [CI], £1934-£2807 vs MLLA £1130; 95% CI, £1046-£1297 vs BET £329; 95% CI, £242-£390; P < .001, Kruskal-Wallis) due to longer procedure duration and greater staff requirement. With regard to the index admission, MLLA was the most expensive due to longer hospital stay (MLLA £13,320; 95% CI, £8986-£18,616 vs BS £8714; 95% CI, £6097-£11,973 vs BET £4813; 95% CI, £3529-£6097; P < .001, Kruskal-Wallis). The total cost of the index admission and in-hospital care over the following 12 months remained least for BET (MLLA £26,327; 95% CI, £17,653-£30,458 vs BS £20,401; 95% CI, £12,071-£23,926 vs BET £12,298; 95% CI, £6961-£15,439; P < .001, Kruskal-Wallis).

CONCLUSIONS

Over a 12-month time horizon, MLLA and IP BS are more expensive than IP BET in terms of procedural HR costs and total in-hospital costs. These economic data, together with quality of life data from BASIL-2, will inform the calculation of incremental cost-effectiveness ratios for different CLTI management strategies within the BASIL-2 cost-utility analysis.

Retrograde Revascularization of Tibial Arteries in Patients with Critical Limb Ischemia: Plantar-Arch Versus Transpedal Approach

PURPOSE

To compare retrograde plantar-arch and transpedal-access approach for revascularization of below-the-knee (BTK) arteries in patients with critical limb ischemia (CLI) after a failed antegrade approach.

MATERIALS AND METHODS

Retrospectively we identified 811 patients who underwent BTK revascularization between 1/2014 and 1/2020. In 115/811 patients (14.2%), antegrade revascularization of at least 1 tibial artery had failed. In 67/115 (58.3%), patients retrograde access to the target vessel was achieved via the femoral access and the plantar-arch (PLANTAR-group); and in 48/115 patients (41.7%) retrograde revascularization was performed by an additional retrograde puncture (TRANSPEDAL-group). Comorbidities, presence of calcification at pedal-plantar-loop/transpedal-access-site, and tibial-target-lesion was recorded. Endpoints were technical success (PLANTAR-group: crossing the plantar-arch; TRANSPEDAL-group: intravascular placement of the pedal access sheath), procedural success [residual stenosis <30% after plain old balloon angioplasty (POBA)], and procedural complications limb salvage and survival. Correlations between calcification at access site/tibial-target-lesion and technical/procedural-success were tested.

RESULTS

Technical success was achieved in 50/67 (75%) patients of the PLANTAR-group and in 39/48 (81%) patients of the TRANSPEDAL-group (p=0.1). Procedural success was obtained in 23/67 (34%) patients of the PLANTAR-group and in 25/48 (52%) patients of the TRANSPEDAL-group (p=0.04). In 14/49 (29%) cases with calcification at the pedal-plantar loop, technical success was not achieved (p=0.04), and in 33/44 (75%) patients with calcification at the tibial-target-lesion, procedural success was not attained (PLANTAR-group) (p=0.026). In the TRANSPEDAL-group, correlations between calcification at access site/tibial-target-lesion and technical/procedural-success were not observed (p=0.2/p=0.4). In the PLANTAR-group, minor complications occurred in 13/67 (19%) and in the TRANSPEDAL-group in 4/48 patients (8%) (p=0.08). Limb salvage at 12 (18) months was 90% (82%) (PLANTAR-group; 95%CI 15.771-18.061) and 84% (76%) (TRANSPEDAL-group; 95%CI 14.475-17.823) (Log-rank p=0.46). Survival at 12 (18) months was 94% (86%) (PLANTAR-group; 95%CI 16.642-18.337) and 85% (77%) (TRANSPEDAL; 95%CI 14.296-17.621) (Log-rank p=0.098).

CONCLUSION

Procedural success was significantly higher using the transpedal-access approach. Calcifications at pedal-plantar loop and target-lesion significantly influenced technical/procedural failure using the plantar-arch approach. No significant difference between both retrograde techniques in terms of feasibility, safety, and limb salvage/survival was found.

Assessing health-related quality of life among patients with peripheral artery disease: A review of the literature and focus on patient-reported outcome measures

Peripheral artery disease (PAD) is a progressive atherosclerotic disease associated with high rates of morbidity and mortality. Symptomatic PAD typically presents with claudication, and symptom severity strongly associates with reduced health-related quality of life (HRQoL). Existing treatment strategies for PAD are aimed at reducing symptom severity and improving functional outcomes. However, there is a need to incorporate patient-reported outcome measures (PROMs) into PAD treatment and research in order to provide more patient-centered care. This review will discuss the impact of PAD on HRQoL, existing PROMs available to assess PAD-related HRQoL, utilization of PROMs in research studies and registries, and challenges and solutions related to the integration of PROMs into research and clinical settings.

Smaller Superficial Femoral Artery is Associated with Worse Outcomes after Percutaneous Transluminal Angioplasty for De Novo Atherosclerotic Disease

BACKGROUND

With the exponential increase in the use of endovascular techniques in the treatment of peripheral artery disease, our understanding of factors that affect intervention failures continues to grow. We sought to assess the outcomes of percutaneous transluminal angioplasty for isolated de novo superficial femoral artery (SFA) disease based on balloon diameter.

METHODS

The Vascular Quality Initiative database was queried for patients undergoing percutaneous balloon angioplasty for isolated de novo atherosclerotic SFA disease. Based on the diameter of the angioplasty balloon as a surrogate measure of arterial diameter, patients were stratified into 2 groups: group 1, balloon diameter <5 mm (354 patients) and group 2, balloon diameter ≥5 mm (1,550 patients). The primary patency and major adverse limb event (MALE) were estimated by the Kaplan-Meier method and compared with the log-rank test, based on vessel diameter. Multivariable Cox regression analysis was used to determine factors associated with the primary patency.

RESULTS

From January 2010 through December 2018, a total of 1,904 patients met criteria for analysis, with a mean follow-up of 13.3 ± 4.5 months. The mean balloon diameters were 3.92 ± 0.26 mm and 5.47 ± 0.55 mm in group 1 and 2, respectively (P < 0.001). The mean length of treatment and distribution of TASC lesions were not statistically different between the groups. Primary patency at 18 months was significantly lower in group 1, compared with group 2 (55% vs. 67%; log-rank P < 0.001). The MALE rate was higher in group 1 than group 2 (33% vs. 26%; log-rank P < 0.001). Among patients with claudication, there was no significant difference in the primary patency (61% vs 68%; log-rank P = 0.073) and MALE (27% vs. 22%; log-rank P = 0.176) at 18 months between groups 1 and 2, respectively. However, in patients with CLTI, group 1 had significantly lower 18-month primary patency (47% vs. 64%; log-rank P < 0.014) and higher MALE rates (41% vs. 35%; log-rank P = 0.012) than group 2. Cox proportional hazard analysis confirmed that balloon diameter < 5 mm was independently associated with increased risks of primary patency loss (HR 1.35; 95% CI, 1.04-1.72; P = 0.021) and MALE (HR 1.29; 95% CI, 1-1.67; P = 0.048) at 18-months.

CONCLUSIONS

In patients undergoing isolated SFA balloon angioplasty for CLTI, smaller SFA (<5 mm) was associated with worse primary patency and MALE. Using balloon size as a surrogate, our findings suggest that patients with a smaller SFA diameter appear to be at increased risk for treatment failure and warrant closer surveillance. Furthermore, these patients may also be considered for alternative approaches, including open revascularization.

Femoral-popliteal peripheral artery disease: From symptom presentation to management and treatment controversies

Peripheral artery disease (PAD) is a common condition with increasing prevalence domestically and worldwide. Patients with PAD have a poor prognosis, as PAD is associated with high rates of myocardial infarction, ischemic stroke, and cardiovascular disease death. The primary symptom of PAD, claudication, significantly reduces quality of life and functional status and is associated with depression. In addition to several advances in medications for PAD over the last decade, endovascular device therapy has seen a significant breakthrough in the form of paclitaxel-coated devices (PCDs), which significantly reduce rates of restenosis relative to non-PCDs, a finding which has been demonstrated in numerous randomized clinical trials. After their introduction to the market in 2012 (paclitaxel-eluting stents) and 2014 (paclitaxel-coated balloons) their use surged as they replaced non-PCDs and were designated the first-line endovascular therapy by society guidelines. This trend was abruptly reversed, however, after a meta-analysis of summary-level data was published in December of 2018 that reported an elevated mortality associated with PCDs compared with non-PCDs 2-5 years after treatment. This meta-analysis has been criticized for considerable methodological flaws. The Food and Drug Administration conducted a review and concluded that insufficient data existed to make a definitive statement regarding the safety of PCDs. They called for restriction of the use of PCDs to the highest-risk patient populations. At the same time, the FDA deemed pursuing new RCTs to better evaluate PCDs unfeasible due to the high numbers of patients and long follow-up time that would be required. In this setting, real-world data emerged as a powerful source of information for the evaluation of PCDs. Real-world data offers advantages over randomized-controlled trials including expeditious access to and analysis of data and the availability of large numbers of patients. Several retrospective observational studies demonstrate no difference in long-term all-cause mortality in patients treated with PCDs relative to those treated with non-PCDs. This paclitaxel controversy has illustrated the critical role that real-world data is assuming in long-term safety monitoring of medical devices.

Change in Domains that Influence Quality of Life after Major Lower Limb Amputation in Patients with Peripheral Arterial Disease

BACKGROUND

Recent guidelines raise the concept of the importance of health-related quality of life (QoL). Change in QoL after amputation in ischemic patients is not well described. We aim to evaluate the change in quality of life after major limb amputation in patients with peripheral arterial disease.

METHODS

We retrospectively identified all patients submitted to above-knee amputation (AKA) and below-knee amputation in our vascular surgery department in a 2-year period. Trauma excluded. A vascular amputee adapted QoL questionnaire was administered comparing the last 2 weeks to the 2 weeks before amputation. It included subjective and objective questions adapted from WHOQoL-BREEF and SF-36 divided into specific domains of QoL (physical health, role physical, pain, social, and psychological health) that were compared to 2 global items (overall QoL and general health). Independent samples tests and linear correlations were calculated.

RESULTS

A total of 106 patients were included, 30-day mortality rate 16.3% and 1-year 39.1%. Patients had an increase in mean total score after amputation of 14.35 out of 100 points, with an improvement of 52.1 points in pain and 11 points in social and psychological health out of 100 (P<0.001). Physical health and role physical scores decreased after amputation. Overall QoL was correlated with total score (P<0.001). Mean QoL total score after amputation was 79.0% ± 12.6. In general, amputees scored higher in the domains social and psychological health. Older people, women, AKA and bilateral amputees had lower physical health scores (P<0.05), prosthesis was correlated with improvement in physical health after amputation (P = 0.026). Elderly and married people had big improvement in overall QoL after amputation (P = 0.008 and P = 0.056, respectively).

CONCLUSIONS

QoL does not seem to diminish in advanced ischemic patients after amputation. Older people value more a decrease in pain and family support over physical health. Therefore, patient oriented treatments should be preferred. Future research should be made to validate a disease-specific questionnaire for this population.

Epidemiology of peripheral artery disease

Peripheral artery disease (PAD) is the clinical manifestation of atherosclerosis that primarily affects peripheral arteries within the lower extremities. In this brief review, we describe the epidemiology and burden of disease of PAD within the United States, particularly among high-risk populations. Although the prevalence of PAD continues to increase and is typically higher among the elderly as well as men, women in lower socioeconomic strata are affected at rates two times that of men. Among racial/ethnic groups, Black and African-American patients both experience higher rates of disease as well as lower rates of access to preventative care. Moreover, despite an overall decrease in amputation rates among all patients with PAD, high-risk populations remain disproportionally affected. Specifically, patients in rural areas, African-American and Native-American patients, and those of low socioeconomic status carry the highest risk of amputation. Efforts to improve care among PAD patients should target these high-risk populations and offer comprehensive, evidence-based preventative care. Wide adoption and integration of these practices into comprehensive care models may help to mitigate amputation in the highest-risk populations. As our treatment pathways continue to evolve, we must place further emphasis on patient input and quality of life as we work toward continual improvement in the care of patients with PAD.

Two-year Outcome of Quality of Life and Health Status for the Elderly with Chronic Limb-threatening Ischemia

Purpose

In elderly patients with chronic limb-threatening ischemia (CLTI), there is little scientific understanding of the long-term changes of quality of life (QoL) and health status (HS) after treatment. The primary goal of this study was to provide long-term QoL and HS results for elderly CLTI patients after therapy. Treatments consisted of endovascular revascularization, surgical revascularization, or conservative treatment. Furthermore, the aim of this study was to identify the distinctive trajectories of QoL and HS.

Patients and Methods

CLTI patients aged ≥70 years were included in a prospective observational cohort study with a two-year follow-up. The WHOQOL-BREF was used to asses QoL. The 12-Item Short Form Health Survey was used to measure HS. The QoL and HS scores were compared to the scores in the general elderly Dutch population. Latent class trajectory analysis was used.

Results

A total of 195 patients were included in this study. After two years, in all treatment groups patients showed significantly higher physical QoL score compared to baseline and there was no significant difference with the corresponding values in the elderly Dutch population. In the latent class trajectory analysis, there were no overlapping risk factors for poorer QoL or HS.

Conclusion

This study shows that QoL levels in surviving elderly CLTI patients in the long-term do not differ from the corresponding values for elderly in the general population. There were no disparities in sociodemographic, clinical and treatment characteristics associated with poorer QoL and HS. This study was carried out to encourage further analysis of the influence of biopsychosocial characteristics on QoL and HS in elderly CLTI patients.

Endovascular Interventions to Superficial Femoral Artery Occlusion: Different Approaches, Technique, and Follow-up

Background

Superficial femoral artery lesion is one of the main causes for intermittent claudication or critical limb ischemia. Percutaneous transluminal angioplasty is one of the approved therapies for this medical entity. Anatomical factors should be considered in choosing the right approach and puncture.The purpose of this study is to discuss the anatomical, radiological, and technical factors which determine the preference of various approaches and to determine its safety, efficacy, and mid-term clinical and radiological outcome.

Methods

Retrospectively, data were collected from patients who underwent angioplasty to superficial femoral arteries for total occlusion from January 2015 and June 2018 in our center, we performed angioplasty to 59 occluded superficial femoral artery patients at our center. The ipsilateral femoral artery, ipsilateral popliteal artery, contralateral femoral artery, or upper limb approaches were used depending on the various anatomical factors determined by radiological imaging before the procedure.

Results

Acute success rate was 91.52%. There were no significant periprocedural complications. At the latest clinical follow-up of mean 25.8 months (10-51), a restenosis rate of 16.67% in infrainguinal arteries and 5.88% in suprainguinal arteries were noted.

Conclusions

Percutaneous transluminal angioplasty of superficial femoral artery is a proven, viable, safer, and effective option, with good mid-term clinical results and patency rates. Different approaches to be chosen depends on the anatomical and technical factors to get the best possible outcome.

Self-reported health status and disease-specific quality of life one year after treatment for peripheral arterial disease in clinical practice

BACKGROUND

VascuQoL-6 (VQ-6) is a disease-specific quality of life (QoL) instrument validated for use in clinical practice and vascular registries before and after treatment for peripheral arterial disease (PAD). To improve future interpretation of self-reported outcome, an unselected cohort was followed through one year to provide observational data after both conservative and invasive treatment.

METHODS

Consecutive patients with intermittent claudication (IC) or critical limb ischemia (CLI) were included. All patients completed VQ-6 and Short Form-36 (SF-36), and were evaluated with ankle-brachial index (ABI) measurement pre- and post-exercise, a constant load treadmill test and clinical consultation at baseline and after one year. Change statistics and correlation analysis were used to describe self-reported outcome after conservative and invasive treatment for PAD.

RESULTS

One hundred seventy-one patients with peripheral arterial disease (PAD) were included, 70 (41%) female. 147 (86%) of the patients suffered from IC. 136 (80%) patients had one-year follow up, death, amputation and withdrawal were the major causes of loss to follow-up. Forty-eight patients (35%) evaluated their health to be unchanged compared to one year ago. There was a strong correlation between self-reported general health status based on SF-36 item 2 and VQ-6 summary score (Spearmans rho = - 0.536). Patients admitted to invasive intervention (endovascular or surgery) improved in all domains of SF-36, and in the physical component summary score (SF-36 PCS). Patients admitted to best medical treatment, smoking cessation and walking exercise (conservative group) improved only in the physical domains. There was significant improvement in VQ-6 summary score for both groups, mean 2.20 (95%CI 1.14-3.27) in the conservative group, 4.68 (95%CI 3.67-5.70) in the invasive group. VQ-6 sum score improved more than four points for 56% in the invasive group, 36% in the conservative group.

CONCLUSIONS

Treatment for symptomatic PAD, both invasive and conservative, improves self-reported health status and disease specific QoL after one year. Interpretation of patient-reported outcome measured with VQ-6 after surgery or endovascular treatment must be seen in light of the improvement from conservative treatment alone.

TRIAL REGISTRATION

ISRCTN14846962 (retrospectively registered).

Clinical Effectiveness and Resource Utilization of Surgery versus Endovascular Therapy for Chronic Limb-Threatening Ischemia

BACKGROUND

The clinical effectiveness of surgical versus endovascular therapy for chronic limb-threatening ischemia (CLTI) continues to be debated, and the resources required for each therapy are unclear.

METHODS

Systematic review of randomized controlled trials (RCTs) and observational studies comparing surgery with endovascular therapy for CLTI, which reported clinical effectiveness and resource utilization. Short-term and long-term clinical outcomes were examined.

RESULTS

The search yielded 4,231 titles, of which 17 publications met our inclusion criteria. Five publications were all from 1 RCT, and 12 publications were observational studies. In the RCT, the surgical approach had greater resource use in the first year (total hospital days across all admissions for surgery versus angioplasty: 46.14 ± 53.87 vs. 36.35 ± 51.39; P < 0.001; also true for days in high-dependency and intensive therapy units), but differences were not statistically significant in subsequent years. All-cause mortality presented a nonsignificant difference favoring angioplasty in the first 2 years (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [95% CI], 0.75-2.15), but after 2 years, it favored surgical treatment (aHR, 0.34; 95% CI, 0.17-0.71). The observational studies reported short-term effectiveness and resource utilization favoring endovascular therapy, but most differences were not statistically significant. Long-term outcomes were more mixed; in particular, mortality outcomes generally favored surgery, although concluding that cause and effect is not possible as endovascularly treated patients tended to be older and may have had a shorter life expectancy regardless of therapy.

CONCLUSIONS

The clinical effectiveness and resource utilization of surgery compared with endovascular therapy for CLTI is not known with certainty and will not be known until ongoing trials report results. It is likely that findings will vary by the time horizon, where initial outcomes and utilization tend to favor endovascular interventions, but long-term outcomes favor surgical revascularization.

Current review with evolving management strategies in critical limb ischemia

Critical limb ischemia represents the end stage of peripheral artery disease, which is associated with impaired quality of life and considerable morbidity and mortality. Economical impact of the disease is huge with a substantial burden on patients, healthcare providers, and resources. Varied therapeutic strategies have been employed in the management of these patients. These patients usually have complex multilevel occlusive arteriopathy with significant comorbidities, rendering surgical interventions undesirable in many cases. Recent therapeutic advances with evolving endovascular techniques and gene or cell-based therapies have the potential to dramatically change the therapeutic outlook in these patients.

MicroRNA-125a-3p affects smooth muscle cell function in vascular stenosis

AIMS

Many studies have indicated that microRNAs are closely related to the process of peripheral arterial disease (PAD). Previously, we found that microRNA-125a-3p (miR-125a-3p) in restenotic arteries after interventional therapy of lower extremity vessels was notably decreased compared with that of normal control arteries. However, its role in the development of vascular stenosis is not yet clearly understood. The purpose of this study was to investigate the expression, regulatory mechanism and function of miR-125a-3p in the process of vascular stenosis.

METHODS AND RESULTS

Quantitative reverse-transcription polymerase chain reaction assays indicated that miR-125a-3p in restenotic arteries after interventional therapy was significantly lower than that in normal control arteries. Immunofluorescence and in situ hybridization co-staining assays in arterial sections demonstrated that miR-125a-3p was mainly expressed in the medial smooth muscle layer. Transfection of miR-125a-3p mimics into cultured vascular smooth muscle cells (VSMCs) effectively inhibited cell proliferation and migration. Then, western blot and luciferase activity assays showed that recombinant human mitogen-activated protein kinase 1 (MAPK1) was a functional target of miR-125a-3p and was involved in miR-125a-3p-mediated cell effects. Finally, the lentiviral infection of miR-125a-3p in balloon-injured rat carotid vascular walls showed that miR-125a-3p overexpression significantly reduced the probability of neointimal membrane production.

CONCLUSIONS

miR-125a-3p can effectively inhibit the function of VSMCs and the occurrence of vascular stenosis by targeting MAPK1. This study introduces a new molecular mechanism of PAD. We show that regulation of the miR-125a-3p level has the potential to provide a new treatment for PAD and other proliferative vascular diseases.

The burden of critical limb ischemia: a review of recent literature

Peripheral arterial disease is a chronic vascular disease characterized by impaired circulation to the lower extremities. Its most severe stage, known as critical limb ischemia (CLI), puts patients at an increased risk of cardiovascular events, amputation, and death. The objective of this literature review is to describe the burden of disease across a comprehensive set of domains—epidemiologic, clinical, humanistic, and economic—focusing on key studies published in the last decade. CLI prevalence in the United States is estimated to be approximately 2 million and is likely to rise in the coming years given trends in important risk factors such as age, diabetes, and smoking. Hospitalization for CLI patients is common and up to 60% are readmitted within 6 months. Amputation rates are unacceptably high with a disproportionate risk for certain demographic and socioeconomic groups. In addition to limb loss, CLI patients also have reduced life expectancy with mortality typically exceeding 50% by 5 years. Given the poor clinical prognosis, it is unsurprising that the quality of life burden associated with CLI is significant. Studies assessing quality of life in CLI patients have used a variety of generic and disease-specific measures and all document a substantial impact of the disease on the patient’s physical, social, and emotional health status compared to population norms. Finally, the poor clinical outcomes and increased medical resource use lead to a considerable economic burden for national health care systems. However, published cost studies are not comprehensive and, therefore, likely underestimate the true economic impact of CLI. Our summary documents a sobering assessment of CLI burden—a poor clinical prognosis translating into diminished quality of life and high costs for millions of patients. Continued prevention efforts and improved treatment strategies are the key to ameliorating the substantial morbidity and mortality associated with this disease.

Cost-effectiveness of the treatments for critical limb ischemia in the elderly population

OBJECTIVE

The treatment of critical limb ischemia (CLI), with the intention to prevent limb loss, is often an intensive and expensive therapy. The aim of this study was to examine the cost-effectiveness of endovascular and conservative treatment of elderly CLI patients unsuitable for surgery.

METHODS

In this prospective observational cohort study, data were gathered in two Dutch peripheral hospitals. CLI patients aged 70 years or older were included in the outpatient clinic. Exclusion criteria were malignant disease, lack of language skills, and cognitive impairment; 195 patients were included and 192 patients were excluded. After a multidisciplinary vascular conference, patients were divided into three treatment groups (endovascular revascularization, surgical revascularization, or conservative therapy). Subanalyses based on age were made (70-79 years and ≥80 years). The follow-up period was 2 years. Cost-effectiveness of endovascular and conservative treatment was quantified using incremental cost-effectiveness ratios (ICERs) in euros per quality-adjusted life-years (QALYs).

RESULTS

At baseline, patients allocated to surgical revascularization had better health states, but the health states of endovascular revascularization and conservative therapy patients were comparable. With an ICER of €38,247.41/QALY (∼$50,869/QALY), endovascular revascularization was cost-effective compared with conservative therapy. This is favorable compared with the Dutch applicable threshold of €80,000/QALY (∼$106,400/QALY). The subanalyses also established that endovascular revascularization is a cost-effective alternative for conservative treatment both in patients aged 70 to 79 years (ICER €29,898.36/QALY; ∼$39,765/QALY) and in octogenarians (ICER €56,810.14/QALY; ∼$75,557/QALY).

CONCLUSIONS

Our study has shown that endovascular revascularization is cost-effective compared with conservative treatment of CLI patients older than 70 years and also in octogenarians. Given the small absolute differences in costs and effects, physicians should also consider individual circumstances that can alter the outcome of the intervention. Cost-effectiveness remains one of the aspects to take into consideration in making a clinical decision.

Long-Term Limb Salvage and Amputation-Free Survival After Femoropopliteal Bypass and Femoropopliteal PTA for Critical Ischemia in a Clinical Cohort

Objective:

This population-based retrospective cohort study investigates long-term results of femoropopliteal bypass and femoropopliteal endovascular intervention (PTA) in patients with critical ischemia, with focus on limb salvage and amputation-free survival.

Methods:

All patients who underwent femoropopliteal bypass or femoropopliteal PTA for critical ischemia without other simultaneous intervention between 1999 and 2013 were included. Stratification was according to treatment modality and symptoms, rest pain, or ischemic ulcer/gangrene. We assessed technical success, 30-day complications, length of stay, recurrent interventions, limb salvage, survival, and amputation-free survival in all patients.

Results:

We identified 292 operations in 264 patients, 140 bypass and 152 PTA. In 32 PTA cases, the patients were explicitly deemed unfit for bypass surgery. This group had significantly inferior technical success and limb salvage ( P = .00). In other patients, technical success was 96% for bypass and 93% for PTA, while limb salvage after 5 years was 78% for bypass and 81% for PTA. Reoperation for local complications was performed in 16% after bypass and 2% after PTA ( P = .00). Mean length of stay was 8 days after bypass and 1.9 days after PTA ( P = .00).

Conclusions:

Long-term follow-up showed similar technical success and good limb salvage for both PTA and bypass patients in this clinical cohort. Patients who were unfit for bypass surgery had significantly inferior technical success and limb salvage. PTA was associated with shorter hospital stay and fewer reoperations for local complications. The findings support a PTA first strategy in all cases where technical success is likely.

Length and Cost of Hospital Stay in Poor-Risk Patients With Critical Limb Ischemia Undergoing Revascularization

BACKGROUND

The aim of the current study was to identify the distribution of length and cost of hospital stay and their associated risk factors in poor-risk Japanese critical limb ischemia (CLI) patients undergoing revascularization. Methods and Results: We analyzed prospectively collected data from 507 CLI patients who required assistance in their daily lives due to disability in activities of daily living and/or cognitive function impairment and who underwent revascularization. The median length and cost of hospital stay were 23 days (IQR, 9-52 days) and ¥2.25m (IQR, ¥1.33m-3.58m), respectively. Reduced albumin, tissue loss, infection, surgical reconstruction, and bilateral revascularization were associated with prolonged hospital stay (P=0.012, 0.019, <0.001, <0.001, and <0.001, respectively). Doubling the length of the hospital stay was associated with a 44% increase in hospital cost. Regular dialysis, surgical reconstruction, and bilateral revascularization were independently associated with an approximately 20% increase in the cost of hospital stay (all P<0.001).

CONCLUSIONS

Length and cost of hospital stay varied considerably between patients. Low serum albumin, tissue loss, infection, surgical reconstruction, and bilateral revascularization were associated with longer hospital stay. Regular dialysis, surgical reconstruction, and bilateral revascularization were independently associated with an approximately 20% increase in the cost of hospital stay.

A Unique All-Payer Rate-Setting System Controls the Cost but Not the Racial Disparity in Lower Extremity Revascularization Procedures

BACKGROUND

Patients with peripheral arterial disease often have high comorbidity burden that may complicate post-interventional course and drive increased health-care expenditures. Racial disparity had been observed in lower extremity revascularization (LER) patterns and outcomes. In 2014, Maryland adopted an all-payer rate-setting system to limit the rising hospitalization costs. This resulted in an aggregate payment system in which hospital compensation takes place as an overall per capita expenditure for hospital services. We sought to examine racial differences and other patient-level factors that might lead to discrepancies in LER hospital costs in the State of Maryland.

METHODS

We used International Classification of Diseases, Ninth Revision codes to identify patients who underwent infrainguinal open bypass (open) and endovascular repair (endo) in the Maryland Health Services Cost Review Commission database (2009-2015). Multivariable generalized linear model regression analysis was conducted to report cost differences adjusting for patient-specific demographics, comorbidities, and insurance status. Logistic regression analysis was used to assess quality metrics: intensive care unit (ICU) admission, 30-day readmission, protracted length of stay (pLOS) (endo: pLOS >9, open: pLOS > 10 days) and in-hospital mortality.

RESULTS

Among patients undergoing open, costs were higher for nonwhite patients (African-American [AA]: $6,092 [4,682-7,501], other: $3,324 [437-6,212]; both P ≤ 0.024), diabetics ($2,058 [837-3,279]; P < 0.001), and patients with Medicaid had an increased cost over Medicare patients by $4,325 (1,441-7,209). Critical limb ischemia (CLI) was associated with $5,254 (4,014-6,495) risk-adjusted cost increment. In addition, AA patients demonstrated higher risk-adjusted odds of ICU admission (adjusted odds ratio [aOR] [95% confidence interval {CI}]:1.65 [1.46-1.86]; P < 0.001) and pLOS (aOR [95% CI]: 1.56 [1.37-1.79]; P < 0.001) than their white counterparts. For patients undergoing endo, costs were higher for nonwhite patients (AA: $2,642 [1,574-3,711], other: $4,124 [2,091-6,157]; both P < 0.001). Patients with CLI and heart failure had increased costs after endo. AA patients were more likely to be readmitted or stayed longer after endo (1.16 [1.03-1.29], 1.34 [1.21-1.49]; both P < 0.010, respectively). The overall cost trend was rapidly increasing before all-payer rate policy implementation but it dramatically plateaued after 2014.

CONCLUSIONS

This study showed that the all-payer rate-setting system has curbed the LER rising costs, but these costs remained disproportionally higher for disadvantaged populations such as AA and Medicaid communities. This underpins the existing racial disparity in LER. AA patients had higher LER costs, most likely driven by extended hospitalization and ICU admission. Efforts could be directed to evaluate the contributing socioeconomic factors, invest in primary prevention of comorbid conditions that had shown to be associated with prohibitive costs, and identify mechanisms to overcome the existing racial disparity in LER within the promising cost-saving payment system at the State of Maryland.

Cost Analysis of Initial Treatment With Endovascular Revascularization, Open Surgery, or Primary Major Amputation in Patients With Peripheral Artery Disease

Purpose: To compare the total initial treatment costs for open surgery, endovascular revascularization, and primary major amputation within a single-payer healthcare system. Methods: A multicenter, retrospective analysis was undertaken to evaluate 1138 patients with symptomatic peripheral artery disease (PAD) who underwent 1017 endovascular procedures, 86 open surgeries, and 35 major amputations between 2013 and 2016. A cost-mix analysis was performed on individual patient data generated for selected diagnosis-related groups. Mean costs are presented with the 95% confidence interval (CI). Results: There was no intergroup difference in demographics or private health insurance status. However, the amputation group had a higher proportion of emergency procedures (68.6% vs 13.3% vs 27.9%, p<0.001) and critical limb ischemia (88.6% vs 35.9% vs 37.2%, p<0.001) compared with the endovascular therapy and open surgery groups, respectively. The endovascular revascularization group spent less time in hospital and used fewer intensive care unit (ICU) resources compared with the open surgery and major amputation groups (hospital length of stay: 3.4 vs 10.0 vs 20.2 days, p<0.01; ICU: 2.4 vs 22.6 vs 54.6 hours, p<0.01), respectively. While mean prosthetic and device costs were higher in the endovascular group [AUD$2770 vs AUD$1658 (open) and AUD$1219 (amputation), p<0.01], substantial disparities were observed in costs associated with longer operating theater times, length of stay, and ICU utilization, which resulted in significantly higher costs in the open and amputation groups. After adjusting for confounders, the AUD$18,396 (95% CI AUD$16,436 to AUD$20,356) mean cost per admission for the endovascular revascularization group was significantly less (p<0.001) than the open surgery (AUD$31,908, 95% CI AUD$28,285 to AUD$35,530) and major amputation groups (AUD$43,033, 95% CI AUD$37,706 to AUD$48,361). Conclusion: Endovascular revascularization procedures for PAD cost the health payer less compared with open surgery and primary amputation. While devices used to deliver contemporary endovascular therapy are more expensive, the reduction in bed days, ICU utilization, and related hospital resources results in a significantly lower mean total cost per admission for the initial treatment.

Below-the-Knee Retrograde Access for Peripheral Interventions: A Systematic Review

PURPOSE

To investigate the hypothesis that interventions involving retrograde below-the-knee (BTK) vessel punctures have an acceptably low complication rate and high procedural success.

METHODS

A systematic review was performed of the MEDLINE and Scopus databases for articles describing the results of BTK retrograde access for peripheral interventions. Outcome measures were access success, procedure success, and complications. A predefined subgroup analysis was performed of prospective studies to reduce the influence of possible reporting bias on outcomes.

RESULTS

Nineteen articles, including 3 prospective studies, were selected, including a total of 1905 interventions in 1395 patients (mean age 69.5 years; 918 men). The BTK vessels were punctured in 1168 (61.3%) of these interventions. Access was successful in 94.0% of BTK attempts, 86.0% of all lesions were successfully crossed using a retrograde access, and 84.0% of interventions achieved technical success. Forty-eight (4.1%) distal access site complications were reported. Vessel perforations were seen in 13 (1.1%) interventions, vasospasm in 5 (0.4%), and acute distal occlusions in 5 (0.4%). Predefined subgroup analysis of prospective studies showed similar results (p=0.24).

CONCLUSION

A retrograde approach to facilitate peripheral endovascular interventions is a safe and successful technique and should be considered when an antegrade approach is not possible or fails to cross the lesion. Because of missing data on long-term outcomes and methodological shortcomings, real world data of retrograde access in nonexpert centers remains necessary before this technique can be advised to all interventionists dealing with peripheral artery disease.

Regional variation in the cost of infrainguinal lower extremity bypass surgery in the United States

BACKGROUND

Lower extremity bypass (LEB) remains the gold standard revascularization procedure in patients with peripheral arterial disease. The cost of LEB substantially varies based on patient's characteristics and comorbidities. The aim of this study was to assess regional variation in infrainguinal LEB cost and to identify the specific health care expenditures per service that are associated with the highest cost in each region.

METHODS

We identified adult patients who underwent infrainguinal LEB in the Premier database between June 2009 and March 2015. Generalized linear regression models were used to report differences between regions in total in-hospital cost and service-specific cost adjusting for patient's demographics, clinical characteristics, and hospital factors.

RESULTS

A total of 50,131 patients were identified. The median in-hospital cost was $13,259 (interquartile range, $9308-$19,590). The cost of LEB was significantly higher in West and Northeast regions with a median cost of nearly $16,000. The high cost in the Northeast region was driven by the fixed (indirect) cost, whereas the driver of the high cost in the West region was the variable (direct) cost. The adjusted total in-hospital cost was significantly higher in all regions compared with the South (mean difference, West, $3752 [95% confidence interval (CI), 3477-4027]; Northeast, $2959 [95% CI, 2703-3216]; Midwest, 1586 [95% CI, 1364-1808]).

CONCLUSIONS

In this study, we show the marked regional variability in LEB costs. This disparity was independent from patient clinical condition and hospital factors. Cost inequality across the US represents a financial burden on both the patient and the health system.

Validity and test retest reliability of the vascular quality of life Questionnaire-6: a short form of a disease-specific health-related quality of life instrument for patients with peripheral arterial disease

BACKGROUND

Many existing patient-reported outcome measures are extensive regarding both patient burden and administration, and in terms of analysing and reporting results. The VascuQoL-6 (VQ6) - a short version of the original Vascular Quality of Life Questionnaire (VascuQoL), a disease-specific instrument for peripheral arterial disease - was recently developed. However, the VQ6 has not yet been empirical tested with regard to content validity, construct validity and test retest reliability. Our aim was, therefore, to explore both the validity and the reliability of the VQ-6 in a target population with established peripheral arterial disease.

METHODS

Two hundred patients treated at two vascular centres were consecutively recruited for the survey. Administered questionnaires included VQ6 and the Short Form Health Survey-36 (SF-36). Out of the 200 patients, 150 also received a second VQ6 questionnaire for a test-retest assessment. Further, a purposive sample of 22 patients consented to participate in cognitive interviews. All included patients suffer from peripheral arterial disease. The questionnaire data was tested by both Rasch analysis and traditional psychometric methods, while the cognitive interviews were analysed descriptively.

RESULTS

The validity and reliability of the VQ6, as tested in a target population without the surrounding 19 items from the original VascuQoL, was high, in general, and a good fit to the Rasch model was observed. Further, an excellent internal consistency and significant correlations between comparable dimensions in SF-36 were demonstrated. In the test-retest analysis, the percentage agreement was somewhat poor (<70%) in the six items. However, no systematic disagreements between the two assessments were seen in any of the six items, and the test-retest assessment for the VQ6 sum score showed an acceptable intraclass correlation coefficient (0.86). Finally, all items in the VQ6 were considered as both understandable and relevant by the interviewed patients.

CONCLUSIONS

The VQ6 has acceptable to good psychometric properties with regard to data quality, scale assumptions, targeting, validity and reliability. Further, VQ6 seems to be easy to use and comprehend within the target population of patients with PAD.

Validation of the Vascular quality of life questionnaire - 6 for clinical use in patients with lower limb peripheral arterial disease

Background

The VascuQoL-6 (VQ-6) health-related quality of life questionnaire, a short version of the disease-specific VascuQoL-25, was developed for clinical practice and use in vascular registries. The study purpose was to evaluate the validity and reliability of VQ-6.

Methods

VQ-6 was translated to Norwegian with linguistic validation and face value evaluation, and consecutive patients with intermittent claudication (IC) or critical limb ischemia (CLI) were included. All patients completed VQ-6 and Short Form-36 (SF-36), and were evaluated with ankle-brachial index (ABI) measurement pre- and post-exercise, a constant load treadmill test and clinical consultation at baseline and after 4 weeks. Correlation analysis, change statistics and receiver operator characteristics (ROC) curves were used to evaluate reliability, validity and responsiveness to change.

Results

One hundred seventy-one patients with peripheral arterial disease (PAD) were included, 70 (41%) female. 147 (86%) of the patients suffered from IC. The reliability of VQ-6 was good, Cronbachs-α 0.82. The ability of VQ-6 to differentiate between IC and CLI was good, area under the curve (AUC) 0.754. There was good correlation between SF-36 physical domains and component scores and VQ-6 score (r = 0.55–0.62) and excellent responsiveness to change after treatment, standard response mean (SRM) 1.12. The clinical anchors of ABI at rest, treadmill walking performance and Fontaine class improvement were less responsive to change than VQ-6, SF-36 and the vascular surgeon’s evaluation.

Conclusions

VQ-6 is reliable and valid, and can be used to evaluate PAD treatment in clinical practice and in vascular registries. Further research is necessary to determine the clinically important change over time.

Trial registration

ISRCTN14846962 (retrospectively registered).

Decision-Making in Critical Limb Ischemia: A Markov Simulation

BACKGROUND

Critical limb ischemia (CLI) is a feared complication of peripheral vascular disease that often requires surgical management and may require amputation of the affected limb. We developed a decision model to inform clinical management for a 63-year-old woman with CLI and multiple medical comorbidities, including advanced heart failure and diabetes.

METHODS

We developed a Markov decision model to evaluate 4 strategies: amputation, surgical bypass, endovascular therapy (e.g. stent or revascularization), and medical management. We measured the impact of parameter uncertainty using 1-way, 2-way, and multiway sensitivity analyses.

RESULTS

In the base case, endovascular therapy yielded similar discounted quality-adjusted life months (26.50 QALMs) compared with surgical bypass (26.34 QALMs). Both endovascular and surgical therapies were superior to amputation (18.83 QALMs) and medical management (11.08 QALMs). This finding was robust to a wide range of periprocedural mortality weights and was most sensitive to long-term mortality associated with endovascular and surgical therapies. Utility weights were not stratified by patient comorbidities; nonetheless, our conclusion was robust to a range of utility weight values.

CONCLUSIONS

For a patient with CLI, endovascular therapy and surgical bypass provided comparable clinical outcomes. However, this finding was sensitive to long-term mortality rates associated with each procedure. Both endovascular and surgical therapies were superior to amputation or medical management in a range of scenarios.

Cost-utility analysis comparing laparoscopic vs open aortobifemoral bypass surgery

OBJECTIVES

Laparoscopic aortobifemoral bypass has become an established treatment option for symptomatic aortoiliac obstructive disease at dedicated centers. Minimally invasive surgical techniques like laparoscopic surgery have often been shown to reduce expenses and increase patients' health-related quality of life. The main objective of our study was to measure quality-adjusted life years (QALYs) and costs after totally laparoscopic and open aortobifemoral bypass.

PATIENTS AND METHODS

This was a within trial analysis in a larger ongoing randomized controlled prospective multicenter trial, Norwegian Laparoscopic Aortic Surgery Trial. Fifty consecutive patients suffering from symptomatic aortoiliac occlusive disease suitable for aortobifemoral bypass surgery were randomized to either totally laparoscopic (n=25) or open surgical procedure (n=25). One patient dropped out of the study before surgery. We measured health-related quality of life using the EuroQol (EQ-5D-5L) questionnaire at 4 different time points, before surgery and for 6 months during follow-up. We calculated the QALYs gained by using the area under the curve for both groups. Costs were calculated based on prices for surgical equipment, vascular prosthesis and hospital stay.

RESULTS

We found a significantly higher increase in QALYs after laparoscopic vs open aortobifemoral bypass surgery, with a difference of 0.07 QALYs, (p=0.001) in favor of laparoscopic aortobifemoral bypass. The total cost of surgery, equipment and hospital stay after laparoscopic surgery (9,953 €) was less than open surgery (17,260 €), (p=0.001).

CONCLUSION

Laparoscopic aortobifemoral bypass seems to be cost-effective compared with open surgery, due to an increase in QALYs and lower procedure-related costs.

Patient-perceived health-related quality of life before and after laparoscopic aortobifemoral bypass

Background

In patients operated with laparoscopic aortobifemoral bypass (LABFB) for atherosclerotic obstruction in aortoiliac segment, the main focus of the reports published during the last two decades has been morbidity and mortality. The primary objective of this study was to examine the health-related quality of life (HRQL) in these patients before and after LABFB.

Patients and methods

Fifty consecutive patients (27 females) with Trans-Atlantic Inter-Society Consensus II, type D lesions were prospectively included. Short-Form 36 (SF-36) questionnaire was used to get information about the HRQL before LABFB and at 1, 3 and 6 months after the operation. Main indication for LABFB was intermittent claudication. Linear mixed-effect models were used to assess changes in HRQL over time. Age, gender, smoking, blood loss, operation time, concomitant operation, the American Society of Anesthesiologists category, length of hospital stay, previous vascular procedures and aorta cross-clamping were used as fixed factors and their impact on the physical components of the SF-36, as well as the summary scores were determined with univariate analysis. Variables with P<0.2 were included in the multivariate regression analysis. P<0.05 was considered statistically significant.

Results

Statistically significant improvement was found in all SF-36 domains as well as in the summary scores after LABFB compared to the preoperative scores. The improvement in scores was substantial already at 1 month and the effect was maintained at 3 and 6 months survey time points. Concomitant operations had a statistically significant negative impact on the physical components of SF-36. Data completeness of item questionnaires was 93% in the whole material. Reliability scale and homogeneity estimates for the eight domains had high internal consistency.

Conclusion

Patients operated with LABFB for Trans-Atlantic Inter-Society Consensus II, type D lesions have reduced HRQL. LABFB leads to substantial and statistically significant improvement in the patients’ HRQL, when examined with SF-36. These results need to be replicated by a randomized clinical trial.

Infrainguinal open reconstruction: a review of surgical considerations and expected outcomes

Infrainguinal arterial occlusive disease can lead to potentially disabling and limb-threatening conditions. Revascularization may be indicated for claudication, rest pain, or tissue loss. Although endovascular interventions are becoming more prevalent, open surgeries such as endarterectomy and bypass are still needed and performed regularly. Open reconstruction has been associated with postoperative morbidity, both at the local and at the systemic levels. Local complications include surgical site infections (SSIs 0-5.3%), graft failure (12-60%), and amputation (5.7-27%), and more systemic issues include cardiac (2.6-18.4%), respiratory (2.5%), renal (4%), neurovascular (1.5%), and thromboembolic (0.2-1%) complications. While such outcomes present an additional challenge to the postoperative management of surgical patients, it may be possible to minimize their occurrence through careful risk stratification and preoperative assessment. Therefore, individualized selection of candidates for open repair requires weighing the need for intervention against the likelihood of adverse outcomes based on preoperative risk factors. This review provides an overview of open reconstruction, focusing on identifying the clinical indications for surgery and perioperative morbidity and mortality.

Bypass surgery for chronic lower limb ischaemia

BACKGROUND

Bypass surgery is one of the mainstay treatments for patients with critical lower limb ischaemia (CLI). This is the second update of the review first published in 2000.

OBJECTIVES

To assess the effects of bypass surgery in patients with chronic lower limb ischaemia.

SEARCH METHODS

For this update, the Cochrane Vascular Group searched its trials register (last searched October 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (last searched Issue 9, 2016).

SELECTION CRITERIA

We selected randomised controlled trials of bypass surgery versus control or any other treatment. The primary outcome parameters were defined as early postoperative non-thrombotic complications, procedural mortality, clinical improvement, amputation, primary patency, and mortality within follow-up.

DATA COLLECTION AND ANALYSIS

For the update, two review authors extracted data and assessed trial quality. We analysed data using odds ratio (OR) and 95% confidence intervals (CIs). We applied fixed-effect or random-effects models.

MAIN RESULTS

We selected 11 trials reporting a total of 1486 participants. Six trials compared bypass surgery with percutaneous transluminal angioplasty (PTA), and one each with remote endarterectomy, thromboendarterectomy, thrombolysis, exercise, and spinal cord stimulation. The quality of the evidence for the most important outcomes of bypass surgery versus PTA was high except for clinical improvement and primary patency. We judged the quality of evidence for clinical improvement to be low, due to heterogeneity between the studies and the fact that this was a subjective outcome assessment and, therefore, at risk of detection bias. We judged the quality of evidence for primary patency to be moderate due heterogeneity between the studies. For the remaining comparisons, the evidence was limited. For several outcomes, the CIs were wide.Comparing bypass surgery with PTA revealed a possible increase in early postinterventional non-thrombotic complications (OR 1.29, 95% CI 0.96 to 1.73; six studies; 1015 participants) with bypass surgery, but bypass surgery was associated with higher technical success rates (OR 2.26, 95% CI 1.49 to 3.44; five studies; 913 participants). Analyses by different clinical severity of disease (intermittent claudication (IC) or CLI) revealed that peri-interventional complications occurred more frequently in participants with CLI undergoing bypass surgery than PTA (OR 1.57, 95% CI 1.09 to 2.24). No differences in periprocedural mortality were identified (OR 1.67, 95% CI 0.66 to 4.19; five studies; 913 participants). The primary patency rate at one year was higher after bypass surgery than after PTA (OR 1.94, 95% CI 1.20 to 3.14; four studies; 300 participants), but this difference was not shown at four years (OR 1.15, 95% CI 0.74 to 1.78; two studies; 363 participants). No differences in clinical improvement (OR 0.65, 95% CI 0.03 to 14.52; two studies; 154 participants), amputation rates (OR 1.24, 95% CI 0.82 to 1.87; five studies; 752 participants), reintervention rates (OR 0.76, 95% CI 0.42 to 1.37; three studies; 256 participants), or mortality within the follow-up period (OR 0.94, 95% CI 0.71 to 1.25; five studies; 961 participants) between surgical and endovascular treatment were identified. No differences in subjective outcome parameters, indicated by quality of life and physical and psychosocial well-being, were reported. The hospital stay for the index procedure was reported to be longer in participants undergoing bypass surgery than in those treated with PTA.In the single study (116 participants) comparing bypass surgery with remote endarterectomy of the superficial femoral artery, the frequency of early postinterventional non-thrombotic complications was similar in the treatment groups (OR 1.11, 95% CI 0.53 to 2.34). No mortality within 30 days of the index treatment or during stay in hospital in either group was recorded. No differences were identified in patency (OR 1.66, 95% CI 0.79 to 3.46), amputation (OR 1.70, 95% CI 0.27 to 10.58), and mortality rates within the follow-up period (OR 1.66, 95% CI 0.61 to 4.48). Information regarding clinical improvement was unavailable.No differences in major complications (OR 0.66, 95% CI 0.34 to 1.31) or mortality (OR 2.09, 95% CI 0.67 to 6.44) within 30 days of treatment between surgery and thrombolysis (one study, 237 participants) for chronic lower limb ischaemia were identified. The amputation rate was lower after bypass surgery (OR 0.10, 95% CI 0.01 to 0.80). No differences in late mortality were found (OR 1.56, 95% CI 0.71 to 3.44). No data regarding patency rates and clinical improvement were reported.Technical success resulting in blood flow restoration was higher after bypass surgery than thromboendarterectomy for aorto-iliac occlusive disease (one study, 43 participants) (OR 0.01, 95% CI 0 to 0.17). The periprocedural mortality (OR 0.33, 95% CI 0.01 to 8.65), follow-up mortality (OR 3.29, 95% CI 0.13 to 85.44), and amputation rates (OR 0.47, 95% CI 0.08 to 2.91) did not differ between treatments. Clinical improvement and patency rates were not reported.Comparing surgery and exercise (one study, 75 participants) did not identify differences in early postinterventional complications (OR 7.45, 95% CI 0.40 to 137.76) and mortality (OR 1.55, 95% CI 0.06 to 39.31). The remaining primary outcomes were not reported. There was no difference in maximal walking time between exercise and surgery (1.66 min, 95% CI -1.23 to 4.55).Regarding comparisons of bypass surgery with spinal cord stimulation for CLI, there was no difference in amputation rates after 12 months of follow-up (OR 4.00, 95% CI 0.25 to 63.95; one study, 12 participants). The remaining primary outcome parameters were not reported.

AUTHORS' CONCLUSIONS

There is limited high quality evidence for the effectiveness of bypass surgery compared with other treatments; no studies compared bypass to optimal medical treatment. Our analysis has shown that PTA is associated with decreased peri-interventional complications in participants treated for CLI and shorter hospital stay compared with bypass surgery. Surgical treatment seems to confer improved patency rates up to one year. Endovascular treatment may be advisable in patients with significant comorbidity, rendering them high risk surgical candidates. No solid conclusions can be drawn regarding comparisons of bypass surgery with other treatments because of the paucity of available evidence. Further large trials evaluating the impact of anatomical location and extent of disease and clinical severity are required.