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Telianidis S, Aitken SJ. The prevalent causes of death in patients with peripheral artery disease undergoing revascularisation or amputation. Vascular 2024:17085381241236562. [PMID: 38411009 DOI: 10.1177/17085381241236562] [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: 02/28/2024]
Abstract
OBJECTIVE Preventing untimely death in patients with peripheral artery disease (PAD) requires a detailed understanding of the predominant causes of death (COD). This literature review aims to describe how short- and long-term COD are reported in patients who had surgery for PAD. METHODS A literature review was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for articles reporting specific causes of mortality in patients who had surgery for all stages of PAD. Articles were included if they reported COD after open surgical or endovascular revascularisation, or major or minor amputation for PAD. Critical appraisals were conducted according to included study types, using the Joanna Briggs Institute tools. RESULTS Cause of death was reported in 21 publications. Twenty were observational and one was a randomised control trial. Study size ranged from 25 to 10,505 patients. Cardiovascular disease was the most prevalent COD in perioperative periods (42.5% from 13 studies). Long-term follow-up ranged from 1 month and 7 years with 15 studies reporting cardiac related mortality as the most frequent cause of death. However, mortality from neoplasia, respiratory disease (including pneumonia and pulmonary emboli), stroke and sepsis were prevalent. Many studies were low-average quality, with few population-based observational studies. CONCLUSION Whilst cardiovascular COD are the most prevalent reasons for mortality in patients with PAD, the proportion of patients dying from neoplasia and respiratory disease is high. Improved reporting standards for COD in studies examining PAD are needed.
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Affiliation(s)
- Stacey Telianidis
- Master of Surgery Student, Vascular Surgery at The Austin Hospital, University of Sydney, and Unaccredited Vascular Surgery Registrar, The Austin Hospital Melbourne, Melbourne, VIC, Australia
| | - Sarah Joy Aitken
- Vascular Surgery Department, Concord Repatriation General Hospital, Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, and Concord Institute of Academic Surgery, Concord, NSW, Australia
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2
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Manvar-Singh P, Folk A, Genovese EA. A scoping review of female sex-related outcomes after endovascular intervention for lifestyle-limiting claudication and chronic limb-threatening ischemia. Semin Vasc Surg 2023; 36:541-549. [PMID: 38030328 DOI: 10.1053/j.semvascsurg.2023.10.001] [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: 07/31/2023] [Revised: 09/29/2023] [Accepted: 10/01/2023] [Indexed: 12/01/2023]
Abstract
Peripheral arterial disease (PAD) is on the rise, with a growing prevalence in an aging population and increasing rates of diabetes. Chronic limb-threatening ischemia poses a significant risk of limb loss. PAD is common in females, particularly after menopause, with a 35% prevalence rate in females older than 65 years. Studies have suggested that females have inferior outcomes compared with men after endovascular revascularization for PAD. With the rising utilization of endovascular interventions for the treatment of PAD, we sought to perform a review of sex-based outcomes of peripheral endovascular interventions for the treatment of symptomatic PAD. A scoping literature review was conducted to evaluate outcomes in females patients undergoing endovascular peripheral interventions for PAD. Eligibility criteria included studies focusing on adult females with lifestyle-limiting claudication or chronic limb-threatening ischemia who underwent endovascular intervention. Various endovascular procedures were considered and outcomes of interest included mortality, amputations, reinterventions, bleeding complications, and major adverse cardiac events. A systematic search was conducted in PubMed, Embase, Web of Science, and Cochrane Library databases. Sixteen studies were included in the review. Females patients undergoing endovascular interventions were associated with bleeding complications, higher rates of reintervention, and a risk of nonfatal strokes. However, females sex was not linked to higher rates of amputation or conclusively higher mortality rates post intervention. The comprehensive scoping review reveals important sex-related disparities in outcomes after endovascular procedures for symptomatic PAD. Females patients have been reported to experience worse outcomes in terms of reinterventions and bleeding complications. These findings emphasize the need for future trials focusing specifically on females patients to develop sex-inclusive treatment recommendations for advanced PAD.
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Affiliation(s)
- Pallavi Manvar-Singh
- Division of Vascular and Endovascular Surgery at South Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell Health, 250 East Main Street, 1st Floor, Bay Shore, NY, 11706.
| | - Alicia Folk
- Division of Vascular and Endovascular Surgery at South Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell Health, 250 East Main Street, 1st Floor, Bay Shore, NY, 11706
| | - Elizabeth A Genovese
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, PA
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3
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Martelli E, Zamboni M, Sotgiu G, Saderi L, Federici M, Sangiorgi GM, Puci MV, Martelli AR, Messina T, Frigatti P, Borrelli MP, Ruotolo C, Ficarelli I, Rubino P, Pezzo F, Carbonari L, Angelini A, Galeazzi E, Di Pinto LC, Fiore FM, Palmieri A, Ventoruzzo G, Mazzitelli G, Ragni F, Bozzani A, Forliti E, Castagno C, Volpe P, Massara M, Moniaci D, Pagliasso E, Peretti T, Ferrari M, Troisi N, Modugno P, Maiorano M, Bracale UM, Panagrosso M, Monaco M, Giordano G, Natalicchio G, Biello A, Celoria GM, Amico A, Di Bartolo M, Martelli M, Munaó R, Razzano D, Colacchio G, Bussetti F, Lanza G, Cardini A, Di Benedetto B, De Laurentis M, Taurino M, Sirignano P, Cappiello P, Esposito A, Trimarchi S, Romagnoli S, Padricelli A, Giudice G, Crinisio A, Di Nardo G, Battaglia G, Tringale R, De Vivo S, Compagna R, Tolva VS, D’Alessio I, Curci R, Giovannetti S, D’Arrigo G, Basile G, Frigerio D, Veraldi GF, Mezzetto L, Ippoliti A, Oddi FM, Settembrini AM. Sex-Related Differences and Factors Associated with Peri-Procedural and 1 Year Mortality in Chronic Limb-Threatening Ischemia Patients from the CLIMATE Italian Registry. J Pers Med 2023; 13:jpm13020316. [PMID: 36836550 PMCID: PMC9959358 DOI: 10.3390/jpm13020316] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Identifying sex-related differences/variables associated with 30 day/1 year mortality in patients with chronic limb-threatening ischemia (CLTI). METHODS Multicenter/retrospective/observational study. A database was sent to all the Italian vascular surgeries to collect all the patients operated on for CLTI in 2019. Acute lower-limb ischemia and neuropathic-diabetic foot are not included. FOLLOW-UP One year. Data on demographics/comorbidities, treatments/outcomes, and 30 day/1 year mortality were investigated. RESULTS Information on 2399 cases (69.8% men) from 36/143 (25.2%) centers. Median (IQR) age: 73 (66-80) and 79 (71-85) years for men/women, respectively (p < 0.0001). Women were more likely to be over 75 (63.2% vs. 40.1%, p = 0.0001). More men smokers (73.7% vs. 42.2%, p < 0.0001), are on hemodialysis (10.1% vs. 6.7%, p = 0.006), affected by diabetes (61.9% vs. 52.8%, p < 0.0001), dyslipidemia (69.3% vs. 61.3%, p < 0.0001), hypertension (91.8% vs. 88.5%, p = 0.011), coronaropathy (43.9% vs. 29.4%, p < 0.0001), bronchopneumopathy (37.1% vs. 25.6%, p < 0.0001), underwent more open/hybrid surgeries (37.9% vs. 28.8%, p < 0.0001), and minor amputations (22% vs. 13.7%, p < 0.0001). More women underwent endovascular revascularizations (61.6% vs. 55.2%, p = 0.004), major amputations (9.6% vs. 6.9%, p = 0.024), and obtained limb-salvage if with limited gangrene (50.8% vs. 44.9%, p = 0.017). Age > 75 (HR = 3.63, p = 0.003) is associated with 30 day mortality. Age > 75 (HR = 2.14, p < 0.0001), nephropathy (HR = 1.54, p < 0.0001), coronaropathy (HR = 1.26, p = 0.036), and infection/necrosis of the foot (dry, HR = 1.42, p = 0.040; wet, HR = 2.04, p < 0.0001) are associated with 1 year mortality. No sex-linked difference in mortality statistics. CONCLUSION Women exhibit fewer comorbidities but are struck by CLTI when over 75, a factor associated with short- and mid-term mortality, explaining why mortality does not statistically differ between the sexes.
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Affiliation(s)
- Eugenio Martelli
- Department of General and Specialist Surgery Paride Stefanini, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 155 viale del Policlinico, 00161 Rome, Italy
- Medicine and Surgery School of Medicine, Saint Camillus International University of Health Sciences, 8 via di Sant’Alessandro, 00131 Rome, Italy
- Division of Vascular Surgery, Department of Cardiovascular Sciences, S. Anna and S. Sebastiano Hospital, via F. Palasciano, 81100 Caserta, Italy
- Correspondence: ; Tel.: +39-3294003220
| | - Matilde Zamboni
- Division of Vascular Surgery, Saint Martin Hospital, 22 viale Europa, 32100 Belluno, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, viale San Pietro, 07100 Sassari, Italy
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, viale San Pietro, 07100 Sassari, Italy
| | - Massimo Federici
- Department of Systems Medicine, University of Rome Tor Vergata, 1 viale Montpellier, 00133 Rome, Italy
| | - Giuseppe M. Sangiorgi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 1 viale Montpellier, 00133 Rome, Italy
| | - Mariangela V. Puci
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, viale San Pietro, 07100 Sassari, Italy
| | - Allegra R. Martelli
- Medicine and Surgery School of Medicine, Campus Bio-Medico University of Rome, 21 via À. del Portillo, 00128 Rome, Italy
| | - Teresa Messina
- Division of Anesthesia and Intensive Care of Organ Transplants, Umberto I Polyclinic University Hospital, 155 viale del Policlinico, 00161 Rome, Italy
| | - Paolo Frigatti
- Divisions of Vascular Surgery, S. Maria Misericordia University Hospital, 15 Piazzale Santa Maria della Misericordia, 33100 Udine, Italy
| | - Maria Pia Borrelli
- Divisions of Vascular Surgery, S. Maria Misericordia University Hospital, 15 Piazzale Santa Maria della Misericordia, 33100 Udine, Italy
| | - Carlo Ruotolo
- Divisions of Vascular Surgery, Cardarelli Hospital, 9 Via A. Cardarelli, 80131 Naples, Italy
| | - Ilaria Ficarelli
- Divisions of Vascular Surgery, Cardarelli Hospital, 9 Via A. Cardarelli, 80131 Naples, Italy
| | - Paolo Rubino
- Divisions of Vascular Surgery, Pugliese Ciaccio Hospital, 83 viale Pio X, 88100 Catanzaro, Italy
| | - Francesco Pezzo
- Divisions of Vascular Surgery, Pugliese Ciaccio Hospital, 83 viale Pio X, 88100 Catanzaro, Italy
| | - Luciano Carbonari
- Divisions of Vascular Surgery, Riuniti University Hospitals, 71 via Conca, Torrette (AN), 60126 Ancona, Italy
| | - Andrea Angelini
- Divisions of Vascular Surgery, Riuniti University Hospitals, 71 via Conca, Torrette (AN), 60126 Ancona, Italy
| | - Edoardo Galeazzi
- Divisions of Vascular Surgery, Treviso Hospital, 1 piazzale del’Ospedale, 31100 Treviso, Italy
| | - Luca Calia Di Pinto
- Divisions of Vascular Surgery, Treviso Hospital, 1 piazzale del’Ospedale, 31100 Treviso, Italy
| | - Franco M. Fiore
- Divisions of Vascular Surgery, SS. Annunziata Hospital, 31 via dei Vestini, 66100 Chieti, Italy
| | - Armando Palmieri
- Divisions of Vascular Surgery, SS. Annunziata Hospital, 31 via dei Vestini, 66100 Chieti, Italy
| | - Giorgio Ventoruzzo
- Divisions of Vascular Surgery, San Donato Hospital, 20 via Pietro Nenni, 52100 Arezzo, Italy
| | - Giulia Mazzitelli
- Divisions of Vascular Surgery, San Donato Hospital, 20 via Pietro Nenni, 52100 Arezzo, Italy
| | - Franco Ragni
- Divisions of Vascular Surgery, San Matteo Polyclinic, 19 viale Camillo Golgi, 27100 Pavia, Italy
| | - Antonio Bozzani
- Divisions of Vascular Surgery, San Matteo Polyclinic, 19 viale Camillo Golgi, 27100 Pavia, Italy
| | - Enzo Forliti
- Divisions of Vascular Surgery, Infermi Hospital, Via dei Ponderanesi 2, 13875 Ponderano, Italy
| | - Claudio Castagno
- Divisions of Vascular Surgery, Infermi Hospital, Via dei Ponderanesi 2, 13875 Ponderano, Italy
| | - Pietro Volpe
- Divisions of Vascular Surgery, Bianchi-Melacrino-Morelli Hospital, 21 via G. Melacrino, 89124 Reggio di Calabria, Italy
| | - Mafalda Massara
- Divisions of Vascular Surgery, Bianchi-Melacrino-Morelli Hospital, 21 via G. Melacrino, 89124 Reggio di Calabria, Italy
| | - Diego Moniaci
- Divisions of Vascular Surgery, San Giovanni Bosco Hospital, 3 piazza del Donatore di Sangue, 10154 Turin, Italy
| | - Elisa Pagliasso
- Divisions of Vascular Surgery, San Giovanni Bosco Hospital, 3 piazza del Donatore di Sangue, 10154 Turin, Italy
| | - Tania Peretti
- Divisions of Vascular Surgery, San Giovanni Bosco Hospital, 3 piazza del Donatore di Sangue, 10154 Turin, Italy
| | - Mauro Ferrari
- Divisions of Vascular Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 2 via Paradisa, 56124 Pisa, Italy
| | - Nicola Troisi
- Divisions of Vascular Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 2 via Paradisa, 56124 Pisa, Italy
| | - Piero Modugno
- Divisions of Vascular Surgery, Gemelli Molise Hospital, 1 largo A. Gemelli, 86100 Campobasso, Italy
| | - Maurizio Maiorano
- Divisions of Vascular Surgery, Gemelli Molise Hospital, 1 largo A. Gemelli, 86100 Campobasso, Italy
| | - Umberto M. Bracale
- Divisions of Vascular Surgery, Federico II Polyclinic, Department of Public Health and Residency Program in Vascular Surgery, University of Naples Federico II, 5 via S. Pansini, 80131 Naples, Italy
| | - Marco Panagrosso
- Divisions of Vascular Surgery, Federico II Polyclinic, Department of Public Health and Residency Program in Vascular Surgery, University of Naples Federico II, 5 via S. Pansini, 80131 Naples, Italy
| | - Mario Monaco
- Divisions of Vascular Surgery, Pineta Grande Hospital, Km. 30 via Domitiana, 81030 Castelvolturno, Italy
- Divisions of Vascular Surgery, Sanatrix Clinic, 31 via S. Domenico, 80127 Naples, Italy
| | - Giovanni Giordano
- Divisions of Vascular Surgery, Sanatrix Clinic, 31 via S. Domenico, 80127 Naples, Italy
| | - Giuseppe Natalicchio
- Divisions of Vascular Surgery, Venere Hospital, 1 via Ospedale di Venere, 70131 Bari, Italy
| | - Antonella Biello
- Divisions of Vascular Surgery, Venere Hospital, 1 via Ospedale di Venere, 70131 Bari, Italy
| | - Giovanni M. Celoria
- Divisions of Vascular Surgery, Sant’Andrea Hospital, 197 via Vittorio Veneto, 19121 La Spezia, Italy
| | - Alessio Amico
- Divisions of Vascular Surgery, Sant’Andrea Hospital, 197 via Vittorio Veneto, 19121 La Spezia, Italy
| | - Mauro Di Bartolo
- Divisions of Vascular Surgery, Sant’Andrea Hospital, 197 via Vittorio Veneto, 19121 La Spezia, Italy
| | - Massimiliano Martelli
- Divisions of Vascular Surgery, MultiMedica Hospital, 300 via Milenese, 20099 Sesto San Giovanni, Italy
| | - Roberta Munaó
- Divisions of Vascular Surgery, MultiMedica Hospital, 300 via Milenese, 20099 Sesto San Giovanni, Italy
| | - Davide Razzano
- Divisions of Vascular Surgery, San Pio Hospital, 1 via dell’angelo, 82100 Benevento, Italy
| | - Giovanni Colacchio
- Divisions of Vascular Surgery, F.Miulli Hospital, Strada Prov. 127 Acquaviva-Santeramo Km. 4, 70021 Acquaviva delle Fonti, Italy
| | - Francesco Bussetti
- Divisions of Vascular Surgery, F.Miulli Hospital, Strada Prov. 127 Acquaviva-Santeramo Km. 4, 70021 Acquaviva delle Fonti, Italy
| | - Gaetano Lanza
- Divisions of Vascular Surgery, Multimedica Hospital, 70 viale Piemonte, 21053 Castellanza, Italy
| | - Antonio Cardini
- Divisions of Vascular Surgery, Multimedica Hospital, 70 viale Piemonte, 21053 Castellanza, Italy
| | | | - Mario De Laurentis
- Divisions of Vascular Surgery, Monaldi Hospital, via L. Bianchi, 84100 Naples, Italy
| | - Maurizio Taurino
- Divisions of Vascular Surgery, Department of Molecular and Clinical Medicine, Sapienza University of Rome, Giorgio Nicola Papanicolau, 00189 Rome, Italy
- Divisions of Vascular Surgery, Sant’Andrea University Hospital, 1035/1039 via di Grottarossa, 00189 Rome, Italy
| | - Pasqualino Sirignano
- Department of General and Specialist Surgery Paride Stefanini, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 155 viale del Policlinico, 00161 Rome, Italy
- Divisions of Vascular Surgery, Sant’Andrea University Hospital, 1035/1039 via di Grottarossa, 00189 Rome, Italy
| | - Pierluigi Cappiello
- Divisions of Vascular Surgery, San Carlo Hospital, via Potito Petrone, 85100 Potenza, Italy
| | - Andrea Esposito
- Divisions of Vascular Surgery, San Carlo Hospital, via Potito Petrone, 85100 Potenza, Italy
| | - Santi Trimarchi
- Divisions of Vascular Surgery, Department of Clinical and Community Sciences, University of Milan, 19 via della Commenda, 20122 Milan, Italy
- Divisions of Vascular Surgery, Maggiore Polyclinic Hospital Ca’ Granda IRCCS and Foundation, 35 via Francesco Sforza, 20122 Milan, Italy
| | - Silvia Romagnoli
- Divisions of Vascular Surgery, Maggiore Polyclinic Hospital Ca’ Granda IRCCS and Foundation, 35 via Francesco Sforza, 20122 Milan, Italy
| | - Andrea Padricelli
- Division of Vascular Surgery, Department of Cardiovascular Sciences, S. Anna and S. Sebastiano Hospital, via F. Palasciano, 81100 Caserta, Italy
| | - Giorgio Giudice
- Division of Vascular Surgery, Department of Cardiovascular Sciences, S. Anna and S. Sebastiano Hospital, via F. Palasciano, 81100 Caserta, Italy
| | - Adolfo Crinisio
- Divisions of Vascular Surgery, Salus Clinic, 4 via F. Confalonieri, 84091 Battipaglia, Italy
| | - Giovanni Di Nardo
- Divisions of Vascular Surgery, Salus Clinic, 4 via F. Confalonieri, 84091 Battipaglia, Italy
| | - Giuseppe Battaglia
- Divisions of Vascular Surgery, San Marco Hospital, viale Carlo Azeglio Ciampi, 95121 Catania, Italy
| | - Rosario Tringale
- Divisions of Vascular Surgery, San Marco Hospital, viale Carlo Azeglio Ciampi, 95121 Catania, Italy
| | - Salvatore De Vivo
- Divisions of Vascular Surgery, Pellegrini Hospital, 41 via Portamedina alla Pignasecca, 80134 Naples, Italy
| | - Rita Compagna
- Divisions of Vascular Surgery, Pellegrini Hospital, 41 via Portamedina alla Pignasecca, 80134 Naples, Italy
| | - Valerio S. Tolva
- Divisions of Vascular Surgery, Niguarda Hospital, Piazza dell’Ospedale Maggiore 3, 20161 Milan, Italy
| | - Ilenia D’Alessio
- Divisions of Vascular Surgery, Niguarda Hospital, Piazza dell’Ospedale Maggiore 3, 20161 Milan, Italy
| | - Ruggiero Curci
- Divisions of Vascular Surgery, Maggiore Hospital, 10 Piazza Ospitale, 26900 Lodi, Italy
| | - Simona Giovannetti
- Divisions of Vascular Surgery, Maggiore Hospital, 10 Piazza Ospitale, 26900 Lodi, Italy
| | - Giuseppe D’Arrigo
- Divisions of Vascular Surgery, Garibaldi-Nesima Hospital, 636 via Palermo, 95122 Catania, Italy
| | - Giusi Basile
- Divisions of Vascular Surgery, Garibaldi-Nesima Hospital, 636 via Palermo, 95122 Catania, Italy
| | - Dalmazio Frigerio
- Divisions of Vascular Surgery, Vimercate Hospital, 10 via Cosma e Damiano, 20871 Vimercate, Italy
| | - Gian Franco Veraldi
- Divisions of Vascular Surgery, University Hospital Pietro Confortini, 1 Piazzale Aristide Stefani, 37126 Verona, Italy
| | - Luca Mezzetto
- Divisions of Vascular Surgery, University Hospital Pietro Confortini, 1 Piazzale Aristide Stefani, 37126 Verona, Italy
| | - Arnaldo Ippoliti
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 1 viale Montpellier, 00133 Rome, Italy
| | - Fabio M. Oddi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 1 viale Montpellier, 00133 Rome, Italy
| | - Alberto M. Settembrini
- Divisions of Vascular Surgery, Maggiore Polyclinic Hospital Ca’ Granda IRCCS and Foundation, 35 via Francesco Sforza, 20122 Milan, Italy
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4
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Kindell DG, Marulanda K, Caruso DM, Duchesneau E, Agala C, Farber M, Marston WA, McGinigle KL. Incidence of venous thromboembolism in patients with peripheral arterial disease after endovascular intervention. J Vasc Surg Venous Lymphat Disord 2023; 11:61-69. [PMID: 36182086 PMCID: PMC10681019 DOI: 10.1016/j.jvsv.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/17/2022] [Accepted: 08/23/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a well-known postoperative complication; however, the incidence of VTE after peripheral vascular intervention (PVI) has not been well described. Despite the minimally invasive nature of these procedures, the patients undergoing PVI have significant risk factors for the development of VTE. In the present study, our objective was to describe the short-term incidence of VTE after PVI, identify differences between sexes, and examine the periprocedural antiplatelet and anticoagulation regimens. METHODS We identified adults (age >66 years) who had undergone PVI from January 1, 2008 to September 30, 2015 from the inpatient Medicare claims data. The patients were followed for 365 days after the procedure. VTE events during follow-up were identified using the International Classification of Diseases, 9th revision, diagnosis codes. The covariate-standardized 30- and 90-day cumulative incidence of VTE events, overall and stratified by sex, were estimated using Aalen-Johansen estimators, accounting for death as a competing risk. Differences in sex between females and males were identified using Gray's test. Any antiplatelet or anticoagulant prescription fill was defined as any fill from 14 days before the endovascular intervention through the date of the VTE event. Persistence with antiplatelet and anticoagulant therapy was assessed by creating daily logs of antiplatelet and anticoagulant coverage using the dispensing dates and days of supply. Over-the-counter medications (ie, aspirin) were not evaluated. RESULTS We identified 31,593 qualifying patients with a mean age of 76.8 ± 7.4 years. Of the 31,593 patients, 46% were male, and 12% had a history of VTE. After the procedure, deep vein thrombosis (DVT) was a commonly diagnosed complication (3.8% and 4.8% at 30 and 90 days, respectively). The cumulative incidence of pulmonary embolism was 0.9% and 1.2% at 30 and 90 days after the procedure, respectively. Throughout the 90-day postoperative period, females had had a slightly increased risk of DVT compared with males (30-day risk difference, 0.007; P < .01; 90-day risk difference, 0.008; P = .02). We found no sex-based differences in the risk of pulmonary embolism. Of the patients who had developed VTE at 90 days, 970 (55%) had had no prescription fill for an antiplatelet or anticoagulant. Assuming all the patients had been taking aspirin, only 15% of the patients who had developed VTE had been taking prescribed dual antiplatelet medication persistently after PVI. In addition, among the patients who had developed VTE at 90 days, females were less likely to have had a prescription fill for an anticoagulant. CONCLUSIONS The findings from our study have demonstrated that the incidence of VTE after PVI is high, with an increased risk of deep vein thrombosis for females. We also found that females were less likely to have been prescribed an anticoagulant after PVI. Future studies are needed to characterize the variables associated with an increased risk of VTE after PVI and to identify strategies to increase dual antiplatelet therapy or anticoagulant prescription adherence to reduce the risk of VTE.
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Affiliation(s)
- Daniel G Kindell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Kathleen Marulanda
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Deanna M Caruso
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Emilie Duchesneau
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Chris Agala
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mark Farber
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - William A Marston
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
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5
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Marulanda K, Duchesneau E, Patel S, Browder SE, Caruso DM, Agala CB, Kindell DG, Curcio J, Kibbe MR, McGinigle K. Increased long-term bleeding complications in females undergoing endovascular revascularization for peripheral arterial disease. J Vasc Surg 2022; 76:1021-1029.e3. [PMID: 35700858 PMCID: PMC9923566 DOI: 10.1016/j.jvs.2022.04.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/28/2022] [Accepted: 04/21/2022] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Females with peripheral arterial disease (PAD) treated with endovascular interventions have increased limb-based procedural complications compared with males. Little is known regarding long-term bleeding risk in these patients who often require long-term antiplatelet or anticoagulation therapy. We hypothesize that females have a higher incidence of bleeding events compared with males in the year after endovascular intervention for PAD. METHODS Adults (aged ≥65 years) who underwent endovascular revascularization for PAD between 2008 and 2015 in Medicare claims data were identified. Patients were allocated by prescribed postprocedural antithrombotic therapy, including (1) antiplatelet therapy, (2) anticoagulation therapy, (3) dual antiplatelet and anticoagulation therapy, and (4) no prescription antithrombotic therapy. Bleeding events were classified as gastrointestinal, intracranial, hematoma, airway, or other. Crude and covariate-standardized 30-, 90-, and 365-day cumulative incidence of bleeding events, overall and by sex, were estimated using Aalen-Johansen estimators accounting for death as a competing risk. Sex differences were identified using Gray's test. RESULTS Of 31,593 eligible patients, 54% were females. Females were older (77.9 years vs 75.5 years) and tended to use antiplatelet therapy more often at 30, 90, and 365 days after the intervention. Clopidogrel was the most prescribed antiplatelet, and 32% of patients continued its use at 365 days. Anticoagulants were prescribed to 26.0% of patients at the time of the procedure, and only 8.8% continued anticoagulation at 365 days. Thirty-one percent of patients were diagnosed with a bleeding event within 1 year after the intervention. The cumulative incidence of any bleeding event during the postintervention period was higher in females compared with males with a risk difference of 3% between the sex cohorts (P < .01). Specifically, females had a higher incidence of gastrointestinal bleeding and hematoma (P < .01), but a lower incidence of airway-related bleeding at each time point as compared with males (P < .01). CONCLUSIONS Sex disparities in bleeding complications after endovascular intervention for PAD persist in the long term. Females are more likely to be readmitted with a bleeding complication up to 1 year after the procedure. Antithrombotic therapy disproportionately increases the risk of bleeding in females. Further research is necessary to understand the mechanisms responsible for abnormal coagulopathy in females after endovascular therapy.
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Affiliation(s)
| | - Emilie Duchesneau
- Department of Epidemiology, University of North Carolina, Chapel Hill
| | - Sapna Patel
- Department of Surgery, University of North Carolina, Chapel Hill
| | | | - Deanna M. Caruso
- Department of Epidemiology, University of North Carolina, Chapel Hill
| | - Chris B. Agala
- Department of Epidemiology, University of North Carolina, Chapel Hill
| | | | - Jessica Curcio
- Department of Surgery, University of North Carolina, Chapel Hill
| | - Melina R. Kibbe
- Department of Surgery, University of North Carolina, Chapel Hill
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Ho-Yan Lee M, Li PY, Li B, Shakespeare A, Samarasinghe Y, Feridooni T, Cuen-Ojeda C, Alshabanah L, Kishibe T, Al-Omran M. A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery. J Vasc Surg 2022; 76:581-594.e25. [DOI: 10.1016/j.jvs.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
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7
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Abstract
Peripheral artery disease (PAD) is a prevalent condition that confers substantial morbidity and mortality and remains underdiagnosed as well as undertreated in the overall population. Although PAD prevalence is similar or higher in women compared with men, associations of traditional and nontraditional risk factors with PAD and clinical manifestations of PAD differ by sex and may contribute to delayed or lack of diagnosis in women. Such sex-based differences in the manifestation of PAD may arise from sexual dimorphism in the vascular substrate in health as well as sex variation in the responses to vascular stressors. Despite the availability of proven therapies for improving symptoms and reducing risk of ischemic cardiovascular and limb events among patients with diagnosed PAD, important sex differences in treatment and outcomes have been observed. We provide an overview of current knowledge regarding sex differences in the epidemiology, pathophysiology, clinical presentation, and management of PAD.
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Affiliation(s)
- Maria Pabon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital (M.P.)
| | - Susan Cheng
- Department of Cardiology, Cedars-Sinai Medical Center (S.C.)
| | - S Elissa Altin
- Division of Cardiology, Yale University School of Medicine (S.E.A.)
| | - Sanjum S Sethi
- Columbia Interventional Cardiovascular Care, Division of Cardiology, Columbia University Irving Medical Center (S.S.S.)
| | - Michael D Nelson
- Department of Kinesiology, University of Texas at Arlington (M.D.N.)
| | - Kerrie L Moreau
- Division of Geriatrics, University of Colorado School of Medicine, and Eastern Colorado Geriatric Research Education and Clinical Center (K.L.M.)
| | | | - Connie N Hess
- Division of Cardiology, University of Colorado School of Medicine (C.N.H.)
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8
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Zaghloul MS, Abdul-Malak OM, Cherfan P, Go C, Saadeddin Z, Al-Khoury GE, Chaer RA, Avgerinos ED. Female Gender is a Predictor of Lower Iliac Vein Stenting Patency Rates. Ann Vasc Surg 2021; 78:247-256. [PMID: 34464730 DOI: 10.1016/j.avsg.2021.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/29/2021] [Accepted: 06/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Iliac venous stenting (IVS) for thrombotic and nonthrombotic venous disease is increasingly used as evidence of the safety, efficacy and durability of these interventions increases. Female gender has been implicated as a predictor of failure in arterial endovascular interventions. We hypothesize that female gender could be predictive of patency rates of iliac vein stenting. METHODS Consecutive patients who underwent IVS for thrombotic or nonthrombotic venous disease at our institution from 2007 until 2019 were identified and divided into groups based on gender. Operative notes, venograms, and the electronic health record were then queried to obtain operative details, co-morbid conditions, postoperative outcomes and stent patency. Study outcome was long term patency rate. The data was analyzed using chi-square, logistic regression, and Kaplan-Meier analysis as appropriate. RESULTS A total of 200 consecutive patients (231 limbs) were identified in our retrospective analysis, with a mean age of 48.8 ± 17.3, and BMI of 31.6 ± 8.6. Of those, 119 (59.5%) patients, (131 [56.8%] limbs) were female. Comparisons between the gender groups revealed no difference in age, BMI, or preoperative comorbidities. There was no difference in type of venous disease between male (85% thrombotic, 15% nonthrombotic) and female (84% thrombotic, 16% nonthrombotic), P= 0.830. The male cohort was more likely to present with leg ulceration (17% vs. 4.6%, P = 0.002), and the female cohort was more likely to present with leg edema (98.5% vs. 93.0%, P= 0.03). The male cohort had a higher rate of caval (48% vs. 33.6%, P= 0.027) and infrainguinal stent extension. (11% vs. 6.9%, P= 0.02). Females had a higher rate of left sided stenting (80.9% vs. 66/0%, P= 0.010). There was no difference in the median stent diameter used between the cohorts. Primary patency at 5 years was significantly higher for the male cohort (94.1% vs. 74.4%, P= 0.01) On adjusted multivariable cox regression female gender was a predictor of loss of primary patency within 5 years (HR, 4.04; P= 0.007). CONCLUSIONS In this single center retrospective analysis of IVS, male patients were found to have better primary stent patency compared to female.
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Affiliation(s)
- Mohamed S Zaghloul
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Othman M Abdul-Malak
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick Cherfan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Catherine Go
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Zein Saadeddin
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Georges E Al-Khoury
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
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9
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Hicks CW, Ding N, Kwak L, Ballew SH, Kalbaugh CA, Folsom AR, Heiss G, Coresh J, Black JH, Selvin E, Matsushita K. Risk of peripheral artery disease according to race and sex: The Atherosclerosis Risk in Communities (ARIC) study. Atherosclerosis 2021; 324:52-57. [PMID: 33823370 PMCID: PMC8096721 DOI: 10.1016/j.atherosclerosis.2021.03.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/13/2021] [Accepted: 03/24/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND AIMS Previous community-based studies have demonstrated sex and race-based disparities in the risk of cardiovascular disease. We sought to examine the association of sex and race with incident peripheral artery disease (PAD-) and critical limb ischemia (CLI-) related hospitalizations. METHODS In 13,451 Black and White ARIC participants without prevalent PAD at baseline (1987-89), we estimated the cumulative incidence of PAD- and CLI-related hospitalization over a median follow-up of 26 years. We quantified hazard ratios (HRs) using Cox models across four sex- and race-groups. PAD and CLI were defined by hospitalization discharge codes. RESULTS The cumulative incidence of PAD-related hospitalization was higher in males than females in Whites (5.1% vs. 2.7%; p<0.001) but not in Blacks (5.7% vs. 5.0%; p=0.39). The cumulative incidence of CLI-related hospitalization differed significantly by race more than sex, occurring in 3.1% Black males, 3.1% Black females, 1.4% White males, and 0.8% White females (p<0.001). After risk factor adjustment, the risk of incident PAD-related hospitalization was similar for White males vs. White females [HR 1.14, 95%CI 0.90-1.45], and slightly higher for Black males [HR 1.26, 95%CI 0.92-1.72] and Black females [HR 1.39, 95%CI 1.03-1.87] compared to White females. The adjusted risk of incident CLI-related hospitalization was similar for White males vs. White females [HR 1.15, 95%CI 0.75-1.76], and significantly higher for Black males [HR 1.96, 95%CI 1.22-3.16] and Black females [HR 2.06, 95%CI 1.31-3.24] compared to White females. CONCLUSIONS These data suggest that there are both sex- and race-specific patterns of PAD-related hospitalization that lead to differences in clinical disease risk and presentation.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Ning Ding
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lucia Kwak
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Corey A Kalbaugh
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | - Aaron R Folsom
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Gerardo Heiss
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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10
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A Retrospective Comparison Between Hybrid Treatment and Prosthetic Above-the-Knee Femoro-Popliteal Bypass in the Management of the Obstructive Disease of the Superficial Femoral Artery. World J Surg 2021; 44:3555-3563. [PMID: 32468407 DOI: 10.1007/s00268-020-05616-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We assessed early and late outcomes following hybrid intervention (common femoral artery endarterectomy and superficial femoral artery (SFA) stenting) versus above-the-knee (AK) femoro-popliteal bypass performed for peripheral artery occlusive disease (PAOD) in a double-center retrospective comparative cohort study. MATERIALS AND METHODS From January 2006 to December 2017, 82 hybrid revascularizations with femoral endarterectomy and SFA stenting (HY Group) and 98 AK femoro-popliteal bypasses with femoral endarterectomy (BP Group) were performed at two academic vascular centers. The two groups were compared in terms of preoperative and intraoperative details and of perioperative (<30 days) outcomes with χ2 test. Long-term results were compared using Kaplan-Meier curves and log-rank test. RESULTS No differences were found in demographics variables, risk factors, comorbidities and clinical presentation between the two groups. Also perioperative outcomes were similar between the two groups. Median duration of follow-up was 38 months. At five years, the estimated survival rate was 60% in HY Group and 77.5% in BP Group (p = 0.002) Five-year primary patency rates were 46% in HY Group and 64% in BP Group (p = 0.005). Overall, 13 patients in HY Group required conversion to open surgery and 6 patients in BP Group underwent below-knee (n = 4) or distal (n = 2) bypass. The 5-year rate of limb maintenance was 85% in HY Group and 94% in BP Group (p = 0.1) and was not significantly different regardless of presentation, claudication or critical limb ischemia. CONCLUSIONS In patients with PAOD due to complex long lesions of the infrainguinal arteries, open-surgical treatment with AK bypass provided better long-term survival and patency rates compared to a hybrid approach.
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11
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Giannopoulos S, Shammas NW, Cawich I, Staniloae CS, Adams GL, Armstrong EJ. Sex-Related Differences in the Outcomes of Endovascular Interventions for Chronic Limb-Threatening Ischemia: Results from the LIBERTY 360 Study. Vasc Health Risk Manag 2020; 16:271-284. [PMID: 32753875 PMCID: PMC7354949 DOI: 10.2147/vhrm.s246528] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 05/15/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Previous studies have suggested that women with chroniclimb-threatening ischemia (CLTI) may have worse outcomes than men. The aim of this study was to determine whether there are sex-related differences in outcomes of patients with CLTI undergoing endovascular treatment with current endovascular technologies. PATIENTS AND METHODS Data were derived from the LIBERTY 360 study (NCT01855412). Hazard ratios and the respective 95% confidence intervals were synthesized to examine the association between sex and all-cause mortality, target vessel revascularization (TVR), major amputation, major adverse event (MAE) and major amputation/death up to 3 years of follow-up. RESULTS A total of 689 patients with CLTI (female: N=252 vs male: N=437) treated with any FDA approved or cleared device were included. The mean lesion length was 126.9±117.3mm and 127.4±113.3mm for the female and male patients, respectively. Although a slightly higher incidence of in-hospital mortality was observed in the female group (1.2% vs 0.0%, p=0.049), there was no difference in female vs male survival rates during follow-up. However, the risk of major amputation at 18 months was higher for the male group (male vs female: HR: 2.36; 95% CI: 1.09-5.12; p=0.030). No difference between the two groups was detected in terms of TVR or MAE during follow-up. DISCUSSION Data regarding sex-related disparity in outcomes after endovascular therapy of patients with CLTI are conflicting. Gender-related characteristics rather than biological sex characteristics might be the cause of these conflicting findings. Further studies are needed to evaluate the role of sex in revascularization outcomes among this high-risk population.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | | | - Ian Cawich
- Arkansas Heart Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Cezar S Staniloae
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, NY, USA
| | - George L Adams
- Department of Cardiology, North Carolina Heart and Vascular, Rex Hospital, UNC School of Medicine, Raleigh, NC, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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12
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Wu B, Lancaster EM, Ramirez JL, Zarkowsky DS, Reyzelman AM, Gasper WJ, Conte MS, Hiramoto JS. Increased Reintervention After Infrainguinal Revascularization for Chronic Limb-Threatening Ischemia in Women. Ann Vasc Surg 2020; 69:307-316. [PMID: 32561241 DOI: 10.1016/j.avsg.2020.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/15/2020] [Accepted: 06/05/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The objective of this study was to determine if there are gender-based differences in major adverse limb events after revascularization for chronic limb-threatening ischemia (CLTI) and to identify potential associated factors. METHODS This was a single-center retrospective analysis of 151 patients who underwent infrainguinal revascularization for CLTI between April 2013 and December 2015. Only the first revascularized limb was included in patients with bilateral CLTI. Demographic data and clinical outcomes were collected using electronic medical records. RESULTS The mean age was 68.1 ± 12.1 years, and 55 of 151 (36%) were women. Women were less likely to carry a diagnosis of hyperlipidemia (60% vs. 83%; P = 0.003), less likely to be on a statin medication (58% vs. 81%; P = 0.004), and less likely to undergo an infrapopliteal revascularization (60% vs. 77%; P = 0.04) compared with men. There were no differences between genders with regard to the Society for Vascular Surgery Wound Ischemia and Foot Infection stage at presentation or utilization of open versus endovascular intervention. During the median follow-up time of 678 days (interquartile range, 167-1277 days), 48 of 151 patients (32%) underwent reintervention on the threatened limb and 23 of 151 patients (15%) underwent major amputation. Women were more likely than men to need reintervention (P = 0.02). There was no difference between genders for major amputation (P = 0.48) or overall survival (P = 0.65). In a multivariable Cox proportional hazards model for reintervention that included gender, preoperative body mass index, hyperlipidemia, preoperative anticoagulation, and ischemia score ≥2 (all P < 0.20 in univariate analysis), female gender (hazard ratio [HR], 1.96 [1.10-3.54]; P = 0.02) and hyperlipidemia (HR, 2.32 [1.07-5.03]; P = 0.03) were significantly associated with increased rates of reintervention. CONCLUSIONS Women undergoing lower extremity revascularization for CLTI were more likely to require reintervention compared with men but had similar rates of limb preservation. Further study is required to understand potential causative factors to improve treatment outcomes in women.
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Affiliation(s)
- Bian Wu
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Elizabeth M Lancaster
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Joel L Ramirez
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Devin S Zarkowsky
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Alexander M Reyzelman
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Warren J Gasper
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Michael S Conte
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Jade S Hiramoto
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA.
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13
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Choi KH, Park TK, Kim J, Ko YG, Yu CW, Yoon CH, Lee JH, Min PK, Koh YS, Chae IH, Choi D, Choi SH. Sex Differences in Outcomes Following Endovascular Treatment for Symptomatic Peripheral Artery Disease: An Analysis From the K- VIS ELLA Registry. J Am Heart Assoc 2020; 8:e010849. [PMID: 30663486 PMCID: PMC6497340 DOI: 10.1161/jaha.118.010849] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background With advances in peripheral artery disease (PAD) treatments such as endovascular treatment (EVT), personalized patient assessment is important. Data on sex differences in clinical outcome for PAD patients undergoing EVT have been limited, and studies have produced conflicting results. This study sought to compare midterm clinical outcomes between women and men in a large population of patients with PAD undergoing EVT. Methods and Results The K‐VIS ELLA (Korean Vascular Intervention Society Endovascular Therapy in Lower Limb Artery Disease) registry is a nationwide, multicenter, observational study that includes 3073 PAD patients undergoing EVT. The study population was divided into men (n=2523) and women (n=550). The primary outcome was a composite of death, myocardial infarction, and major amputation; the secondary outcome included major adverse limb events. Women had more comorbidities and more severe and complex target lesions than men. Women showed higher rates of death, myocardial infarction, or major amputation than men (14.8% versus 9.8%, adjusted hazard ratio 1.350, 95% CI 1.017‐1.792, P=0.038), and higher rates of major adverse limb events (19.9% versus 14.5%, adjusted hazard ratio 1.301, 95% CI 1.014‐1.670, P=0.039) and procedural complications (10.2% versus 5.9%, P<0.001) based on multivariable analysis. In patients with claudication, the primary outcome incidence was significantly higher in women (hazard ratio 2.088, 95% CI 1.421‐3.068, P<0.001). In contrast, there was no significant difference in primary outcome for patients with critical limb ischemia between the 2 groups (hazard ratio 1.164, 95% CI 0.800‐1.694, P=0.426). A significant interaction (P=0.035) between patient presentation and outcome was observed. Conclusions In a large population of patients with PAD undergoing EVT, women had higher rates of death, myocardial infarction, or major amputation than men and higher rates of complex lesions, procedural complications, and limb‐specific adverse events.
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Affiliation(s)
- Ki Hong Choi
- 1 Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Taek Kyu Park
- 1 Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Jihoon Kim
- 1 Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Young-Guk Ko
- 2 Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Republic of Korea
| | - Cheol Woong Yu
- 3 Division of Cardiology Department of Internal Medicine Korea University Anam Hospital Seoul Republic of Korea
| | - Chang-Hwan Yoon
- 4 Division of Cardiology Department of Internal Medicine Seoul National University Bundang Hospital Seongnam Gyeonggi-do Republic of Korea
| | - Jae-Hwan Lee
- 5 Division of Cardiology Department of Internal Medicine Chungnam National University Hospital Daejeon Republic of Korea
| | - Pil-Ki Min
- 6 Division of Cardiology Department of Internal Medicine Gangnam Severance Hospital Yonsei University College of Medicine Seoul Republic of Korea
| | - Yoon Seok Koh
- 7 Division of Cardiology Department of Internal Medicine Seoul St. Mary's Hospital College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - In-Ho Chae
- 4 Division of Cardiology Department of Internal Medicine Seoul National University Bundang Hospital Seongnam Gyeonggi-do Republic of Korea
| | - Donghoon Choi
- 2 Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Republic of Korea
| | - Seung-Hyuk Choi
- 1 Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
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Bradaric C, Koppara T, Müller A, Haller B, Ott I, Cassese S, Fusaro M, Kastrati A, Laugwitz KL, Ibrahim T. Incidence and predictors of stent thrombosis after endovascular revascularisation of the superficial femoral artery. EUROINTERVENTION 2019; 15:e1107-e1114. [DOI: 10.4244/eij-d-19-00187] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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15
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Saati A, AlHajri N, Ya'qoub L, Ahmed W, Alasnag M. Peripheral Vascular Disease in Women: Therapeutic Options in 2019. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:68. [PMID: 31728774 DOI: 10.1007/s11936-019-0769-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW In recent years, there have been advances in the prevention, management, and control of peripheral vascular disease (PVD). There is a trend towards aggressive risk factor modification, noninvasive screening, and endovascular revascularization with surgical approaches reserved only for select cases. This article reviews the different management strategies ranging from pharmacotherapy, revascularization, and rehabilitation with an emphasis on the response of women to these therapies. RECENT FINDINGS Overall, the representation of women in the majority of the published data in this arena remains poor. Studies examining medical therapy and endovascular and surgical revascularization were not designed to address sex disparities. Nevertheless, we dissect these therapies and their relevant randomized trials. The paucity of data investigating the response of women to the different management options makes it difficult to make any evidence-based recommendations. This not only applies to the type of intervention, but also the appropriate timing and risks entailed.
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Affiliation(s)
| | - Noora AlHajri
- Division of Cardiovascular Science, National Institute of Health/National Institute of Aging (NIH/NIA), Baltimore, MD, USA
| | | | - Waqar Ahmed
- Cardiac Center, King Fahd Armed Forces Hospital, PO Box 9862, Jeddah, 21159, Saudi Arabia
| | - Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, PO Box 9862, Jeddah, 21159, Saudi Arabia.
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16
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Ramkumar N, Suckow BD, Brown JR, Sedrakyan A, Cronenwett JL, Goodney PP. Sex-Based Assessment of Patient Presentation, Lesion Characteristics, and Treatment Modalities in Patients Undergoing Peripheral Vascular Intervention. Circ Cardiovasc Interv 2019; 11:e005749. [PMID: 29326151 DOI: 10.1161/circinterventions.117.005749] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 11/29/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Limited evidence suggests that women and men might be treated differently for peripheral arterial disease. This analysis evaluated sex-based differences in disease presentation and its effect on treatment modality among patients who underwent endovascular treatment for peripheral arterial disease. METHODS AND RESULTS Using national registry data from the Vascular Quality Initiative between 2010 and 2013, we examined patient, limb, and artery characteristics by sex through descriptive statistics. We studied 26 750 procedures performed in 23 820 patients to treat 30 545 limbs and 44 804 arteries. Women presented at an older age (69 versus 67 years; P<0.001) and were less often current or former smokers (72% versus 85%; P<0.001). Transatlantic Inter-Society Consensus classification was similar among men and women (Transatlantic Inter-Society Consensus C or D: 37% in men versus 37% in women; P=0.81), as was mean occlusion length (4.5 cm in men versus 4.6 cm in women; P=0.04), even after accounting for lesion location. Women more frequently underwent treatment for rest pain (11% in men versus 16% in women; P<0.001) versus claudication (59% in men versus 53% in women; P<0.001) or tissue loss (28% in men versus 27% in women; P=0.75). Treatment modality did not differ by sex but was associated with disease severity (P for trend <0.001) and lesion location (P for trend <0.001). CONCLUSIONS Women undergo peripheral endovascular intervention for peripheral arterial disease at an older age with critical limb ischemia. Treatment modalities do not vary by sex but are determined by disease severity and site. Although there exist sex differences in presentation, these differences do not lead to differential treatment for women with peripheral arterial disease.
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Affiliation(s)
- Niveditta Ramkumar
- From the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (N.R., J.R.B., P.P.G.); Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (B.D.S., J.L.C., P.P.G.); and Weill Cornell Medical College, Cornell University, New York, NY (A.S.).
| | - Bjoern D Suckow
- From the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (N.R., J.R.B., P.P.G.); Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (B.D.S., J.L.C., P.P.G.); and Weill Cornell Medical College, Cornell University, New York, NY (A.S.)
| | - Jeremiah R Brown
- From the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (N.R., J.R.B., P.P.G.); Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (B.D.S., J.L.C., P.P.G.); and Weill Cornell Medical College, Cornell University, New York, NY (A.S.)
| | - Art Sedrakyan
- From the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (N.R., J.R.B., P.P.G.); Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (B.D.S., J.L.C., P.P.G.); and Weill Cornell Medical College, Cornell University, New York, NY (A.S.)
| | - Jack L Cronenwett
- From the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (N.R., J.R.B., P.P.G.); Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (B.D.S., J.L.C., P.P.G.); and Weill Cornell Medical College, Cornell University, New York, NY (A.S.)
| | - Philip P Goodney
- From the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (N.R., J.R.B., P.P.G.); Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (B.D.S., J.L.C., P.P.G.); and Weill Cornell Medical College, Cornell University, New York, NY (A.S.)
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Affiliation(s)
- Ellen K Brinza
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
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Schaumeier MJ, Hawkins AT, Hevelone ND, Sethi RKV, Nguyen LL. Association of Treatment for Critical Limb Ischemia with Gender and Hospital Volume. Am Surg 2018. [DOI: 10.1177/000313481808400668] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Critical limb ischemia (CLI) is a frequent and major vascular problem and can lead to amputation and death despite surgical revascularization. Women have been shown to have 3 to 4 per cent lower revascularization rates for CLI compared with men as well as inferior outcomes. We hypothesize that this difference is a result of women being more likely admitted to low-volume hospitals, which in turn perform fewer revascularizations. Prospective cohort study. Data from the Nationwide Inpatient Sample 2007 to 2010 were used to identify admissions with primary International Classification of Diseases-9 codes for CLI (International Classification of Diseases-9 codes: 440.22, 440.23, 440.24, 707.1, 707.10–707.15, or 707.19). Hospitals were grouped in quintiles by annual revascularization procedures. Bivariate analyses were performed and multivariable logistic regression was used to analyze the odds of revascularization, amputation, and mortality while controlling for patient and hospital-level factors. Of 113,631 admissions, 54,370 (47.8%) were women, who were more likely admitted to low-volume hospitals (very low: 49.6% vs very high: 47.1%; P < 0.001). Revascularization rates were lower in women (31.6% vs 35.1%, P < 0.001) across all volume quintiles, whereas the difference was greatest in the use of open surgical revascularization (12.5% vs 16.0%, P < 0.001). In multivariable analysis, female gender [odds ratio (OR) 0.87, 95% confidence interval (CI) 0.83–0.92, P < 0.001] and very-low hospital volume (OR 0.21, 95% CI 0.17–0.26, P < 0.001) were both significantly associated with lower rates of revascularization. Women had lower odds of major amputation compared with men (OR 0.75, 95% CI 0.69–0.82, P < 0.001), whereas treatment in a very high-volume hospital was associated with increased odds for amputation (OR 1.37, 95% CI 1.09–1.73, P = 0.008). Neither gender nor hospital volume were independently associated with in-hospital mortality in the multivariable regression model. Women are more likely to be admitted to low-volume hospitals for treatment of CLI. Because of this, they are less likely to undergo revascularization, although they also had lower rates of major amputation.
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Affiliation(s)
- Maria J. Schaumeier
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Surgery, University Hospital Basel, Basel, Switzerland
| | - Alexander T. Hawkins
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nathanael D. Hevelone
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Louis L. Nguyen
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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19
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Abstract
In the past 20 years, peripheral artery disease (PAD) has been increasingly recognized as a significant cause of morbidity and mortality in the United States. PAD has traditionally been identified as a male-dominant disease; however, recent population trends and studies in PAD suggest that women are affected at least as often as men. Women comprise a larger population of the elderly than men, as well as an increasing proportion of patients with PAD. Much of the existing research on PAD has focused on whole populations, and gender-specific data on PAD is sparse. This review focuses on gender-specific differences in presentation, management, and outcomes of PAD intervention that are important considerations for the interventional radiologist.
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Affiliation(s)
- Kristofer Schramm
- Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Paul J Rochon
- Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado
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20
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Wang J, He Y, Shu C, Zhao J, Dubois L. The effect of gender on outcomes after lower extremity revascularization. J Vasc Surg 2017; 65:889-906.e4. [DOI: 10.1016/j.jvs.2016.11.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 11/10/2016] [Indexed: 01/24/2023]
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21
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Campesi I, Franconi F, Seghieri G, Meloni M. Sex-gender-related therapeutic approaches for cardiovascular complications associated with diabetes. Pharmacol Res 2017; 119:195-207. [PMID: 28189784 DOI: 10.1016/j.phrs.2017.01.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 12/14/2016] [Accepted: 01/23/2017] [Indexed: 12/14/2022]
Abstract
Diabetes is a chronic disease associated with micro- and macrovascular complications and is a well-established risk factor for cardiovascular disease. Cardiovascular complications associated with diabetes are among the most important causes of death in diabetic patients. Interestingly, several sex-gender differences have been reported to significantly impact in the pathophysiology of diabetes. In particular, sex-gender differences have been reported to affect diabetes epidemiology, risk factors, as well as cardiovascular complications associated with diabetes. This suggests that different therapeutic approaches are needed for managing diabetes-associated cardiovascular complications in men and women. In this review, we will discuss about the sex-gender differences that are known to impact on diabetes, mainly focusing on the cardiovascular complications associated with the disease. We will then discuss the therapeutic approaches for managing diabetes-associated cardiovascular complications and how differences in sex-gender can influence the existing therapeutic approaches.
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Affiliation(s)
- Ilaria Campesi
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy.
| | - Flavia Franconi
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy; Dipartimento Politiche della Persona, Regione Basilicata, Italy.
| | | | - Marco Meloni
- BHF Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, UK.
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Yu JS, Park KM, Jeon YS, Cho SG, Hong KC, Shin WY, Choe YM, Shin SH, Kim KR. Midterm Outcome of Femoral Artery Stenting and Factors Affecting Patency. Vasc Specialist Int 2015; 31:115-9. [PMID: 26719837 PMCID: PMC4694182 DOI: 10.5758/vsi.2015.31.4.115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/05/2015] [Accepted: 11/03/2015] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The purpose of this study was to evaluate the early and midterm results of superficial femoral artery (SFA) stenting with self-expanding nitinol stents and to identify the factors affecting patency. MATERIALS AND METHODS SFA stenting was performed in 165 limbs of 117 patients from January 2009 to December 2013. Patients were followed-up for the first occurrence of occlusion or stenosis based on computed tomography and duplex scan results and a decrease in ankle brachial index of >15%. RESULTS During the follow-up period (mean, 15.3±3.2 months), no early thrombotic reocclusions occurred within 30 days, but in-stent restenosis developed in 78 limbs. The primary patency rates at 6, 12, 18, and 24 months were 78%, 66%, 42%, and 22%, respectively, and the secondary patency rates were 85%, 72%, 58%, and 58%, respectively. TASC II C or D lesions, stent length >8 cm, number of patent tibial arteries and diabetes were significantly associated with reintervention. CONCLUSION The midterm results of stenting for SFA occlusive disease were disappointing because the primary and secondary patency rates at two years were 22% and 58%, respectively. Reintervention after SFA stenting remains a major problem, particularly in patients with diabetes mellitus or long TASC II C or D lesions.
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Affiliation(s)
- Jae Seoung Yu
- Department of Surgery and, Inha University College of Medicine, Incheon, Korea
| | - Keun-Myoung Park
- Department of Surgery and, Inha University College of Medicine, Incheon, Korea
| | - Yong Sun Jeon
- Department of Radiology, Inha University College of Medicine, Incheon, Korea
| | - Soon Gu Cho
- Department of Radiology, Inha University College of Medicine, Incheon, Korea
| | - Kee Chun Hong
- Department of Surgery and, Inha University College of Medicine, Incheon, Korea
| | - Woo Young Shin
- Department of Surgery and, Inha University College of Medicine, Incheon, Korea
| | - Yun-Mee Choe
- Department of Surgery and, Inha University College of Medicine, Incheon, Korea
| | - Seok-Hwan Shin
- Department of Surgery and, Inha University College of Medicine, Incheon, Korea
| | - Kyung Rae Kim
- Department of Surgery and, Inha University College of Medicine, Incheon, Korea
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23
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Intermediate Outcomes of Femoropopliteal Stenting in Women: 3-Year Results of the DURABILITY II Trial. Ann Vasc Surg 2015; 30:110-7. [PMID: 26585648 DOI: 10.1016/j.avsg.2015.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/16/2015] [Accepted: 10/27/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND This study investigated the effects of gender on the 3-year outcomes of the StuDy for EvalUating EndovasculaR TreAtments of Lesions in the Superficial Femoral Artery and Proximal Popliteal By usIng the Protege EverfLex NitInol STent System II (DURABILITY II) trial. METHODS A total of 287 patients enrolled in the DURABILITY II trial (prospective and nonrandomized trial) were stratified by gender and evaluated for primary, primary assisted, and secondary patency at 3 years. Clinical scores including changes in ankle-brachial index (ABI) and walking impairment questionnaire (WIQ) scores were evaluated. RESULTS Overall 190 male and 97 female patients were included for analysis. The 3-year primary, assisted primary, and secondary patency rates for women versus men were 62.5% vs. 58.8%, 68.5% vs. 64.9%, and 72.1% vs. 67.2%, respectively (P < 0.05). Although ABIs at presentation were similar between women versus men (0.64 vs. 0.65, P < 0.05), women had lower ABI scores at 3 years compared with men (0.85 vs. 0.92, P = 0.03). Women versus men had inferior walking distance scores at presentation (13.6 vs. 25.7, P < 0.001), scores were equalized by 2 years (51.6 vs. 60.8, P < 0.05); however, 3-year follow-up demonstrated less durable results for women versus men (37.3 vs. 58.8, P < 0.05). In addition, women had worse WIQ scores for pain, walking speed, and stair climbing. However, the relative change in scores between men and women were comparable, with both groups seeing similar improvements from baseline for these parameters. CONCLUSIONS Women continue to see clinical improvement after intervention, achieving comparable ABIs and walking distance to men at 2 years. These benefits are diminished at 3-year follow-up with women achieving lower absolute ABI and WIQ parameters compared with men, but improved overall compared with scores at presentation.
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24
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Hernández Mateo MM, Martínez López I, Revuelta Suero S, Marqués de Marino P, Cernuda Artero I, Cabrero Fernández M, Serrano Hernando FJ. Clinical Outcomes after Endovascular Treatment Failure in Patients with Femoropopliteal Occlusive Disease. Ann Vasc Surg 2015; 30:299-304. [PMID: 26541966 DOI: 10.1016/j.avsg.2015.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 07/24/2015] [Accepted: 07/31/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND To analyze the clinical impact derived from endovascular treatment failure on patients with femoropopliteal occlusive disease (FPOD) regarding their preoperative clinical stage. METHODS Retrospective review for primary endovascular procedures for FPOD from 2008 to 2013. Primary end point included clinical deterioration defined as acute limb ischemia (ALI) or clinical worsening by, at least, one Rutherford's classification category, related to procedure's failure (restenosis >70% or occlusion). RESULTS Ninety procedures were analyzed in 85 patients, 87.8% operated due to critical limb ischemia. The lesion treated was classified as Trans-Atlantic Inter-Society Consensus (TASC)-A/B in 76.7%, with a mean length of 98.5 ± 54 mm. Covered stent graft (SG) was used in 31.1% of the cases. Median follow-up was 14.5 months and treatment failure occurred in 33.3% of cases (n = 30, 9 restenosis and 21 occlusions). Clinical worsening was assessed in 40% of treatment failures and 6 of 21 (28.6%) presented as ALI. Twenty-two major adverse limb events (MALEs) were recorded and 8 major amputations. Regarding the type of stent, more occlusions were recorded on patients treated with SG compared with bare metal stent (39.3% vs. 16%; P = 0.02). However, no differences were found between groups regarding clinical worsening attributable to treatment failure (HR, 1.33; CI 95%, 0.5-3.5; P = 0.5). On multivariate analysis, TASC-C/D lesions (HR, 5.5; CI 95%, 2.3-13.3; P < 0.001) and female sex (HR, 4.9; CI 95%, 1.9-12.5; P = 0.001) behaved as significant predictors for failure and dual-antiplatelet therapy as a protective factor (HR, 0.3; CI 95%, 0.3-0.13; P = 0.03). No predictors were obtained regarding clinical worsening and occurrence of MALEs in our series. CONCLUSIONS Patients with failure of endovascular procedures on FPOD appeared with clinical worsening in a no negligible number of cases in our sample regarding their preoperative clinical situation. Thus, we believe that endovascular treatment should be carefully deliberated.
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Affiliation(s)
| | - Isaac Martínez López
- Department of Angiology and Vascular Surgery, Hospital Clínico San Carlos, Madrid, Spain
| | - Sergio Revuelta Suero
- Department of Angiology and Vascular Surgery, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Iñaki Cernuda Artero
- Department of Angiology and Vascular Surgery, Hospital Clínico San Carlos, Madrid, Spain
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25
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Ferranti KM, Osler TM, Duffy RP, Stanley AC, Bertges DJ. Association between gender and outcomes of lower extremity peripheral vascular interventions. J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.03.066] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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26
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Age does not predict need for reintervention in patients with critical limb ischemia. J Vasc Surg 2015; 61:413-8. [DOI: 10.1016/j.jvs.2014.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 08/01/2014] [Indexed: 11/22/2022]
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27
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Stavroulakis K, Donas KP, Torsello G, Osada N, Schönefeld E. Gender-Related Long-term Outcome of Primary Femoropopliteal Stent Placement for Peripheral Artery Disease. J Endovasc Ther 2015; 22:31-7. [DOI: 10.1177/1526602814564382] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To evaluate gender-related long-term outcomes in patients undergoing stent treatment of femoropopliteal peripheral artery disease. Methods: Between September 2006 and August 2010, all 517 patients (333 men and 184 women; mean age 70.6 years) undergoing primary stent placement in femoropopliteal atherosclerotic lesions at 2 European vascular centers were prospectively enrolled in the study. The main study outcome was primary stent patency. Secondary outcomes included secondary patency, limb salvage, and all-cause mortality. Results: Women had a higher incidence of critical limb ischemia (32.1% vs. 16.9%, p<0.001). Lesion characteristics according to the TransAtlantic Inter-Society Consensus (TASC) classification were comparable in both genders (p=0.52), although total occlusions and popliteal involvement were observed more frequently in female patients (p=0.043 and p=0.001, respectively). Both genders showed similar 5-year primary patency rates (64.3% men vs. 58.1% women, p=0.11). A statistically significant difference was observed concerning the secondary patency rates in favor of men (71.9% vs. 66.8% at 5 years, p=0.005). Limb salvage rates did not vary between the groups (p=0.83). Survival rates were comparable at 5 years (83.3% and 82.6% for men and women, respectively; p=0.63), although female patients were older at their presentation (68.5 vs. 74.3 years, p<0.001). Female gender was an independent risk factor for restenosis for TASC C/D lesions (primary patency rate 39.8% in women vs. 62.0% in men; p=0.002). Finally, critical limb ischemia was an independent risk factor for restenosis in women (odds ratio 1.5). Conclusion: Female gender was associated with a higher prevalence of critical limb ischemia, poorer secondary patency, and more frequent restenosis in TASC C/D lesions. Endovascular treatment of femoropopliteal lesions provides equal results between genders in terms of primary stent patency in the long term.
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Affiliation(s)
- Konstantinos Stavroulakis
- Department of Vascular and Endovascular Surgery, University of Münster, and Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany
| | - Konstantinos P. Donas
- Department of Vascular and Endovascular Surgery, University of Münster, and Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany
| | - Giovanni Torsello
- Department of Vascular and Endovascular Surgery, University of Münster, and Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany
| | - Nani Osada
- Department of Vascular and Endovascular Surgery, University of Münster, and Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany
| | - Eva Schönefeld
- Department of Vascular and Endovascular Surgery, University of Münster, and Department of Vascular Surgery, St. Franziskus Hospital, Münster, Germany
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28
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Armstrong EJ. Commentary: Does Gender Influence Outcomes After Femoropopliteal Stenting? J Endovasc Ther 2015; 22:38-40. [DOI: 10.1177/1526602814565774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Ehrin J. Armstrong
- Section of Cardiology, Denver VA Medical Center, and University of Colorado School of Medicine, Denver, CO, USA
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29
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Duffy RP, Adams JE, Callas PW, Schanzer A, Goodney PP, Ricci MA, Cronenwett JL, Bertges DJ. The influence of gender on functional outcomes of lower extremity bypass. J Vasc Surg 2014; 60:1282-1290.e1. [PMID: 25242270 DOI: 10.1016/j.jvs.2014.05.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 05/08/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Our aim was to evaluate the effect of gender on early and late procedural and functional outcomes of lower extremity bypass (LEB). METHODS We reviewed the records of 2576 patients (828 women; 32%) who underwent LEB for claudication or critical limb ischemia (CLI) in the Vascular Study Group of New England from 2003 to 2010. Logistic regression and proportional hazards models were used to adjust for potential confounding differences between genders. Morbidity, mortality, graft patency, freedom from major amputation, ambulation, and living status were analyzed postoperatively and over 1 year. RESULTS Women were older (70 vs 68 years; P < .001), had more hypertension (89% vs 85%; P = .006), less coronary artery disease (35% vs 39%; P = .03), smoking (73% vs 88%; P < .001), and preoperative statin use (60% vs 64%; P = .04). Women were more likely to have CLI (76% vs 71%; P = .003), and ambulate with assistance at presentation (19% vs 16%; P = .02). Morbidity was similar except women had higher rates of reoperation for thrombosis (4% vs 2%; P < .001) without differences in major amputation (2% vs 1%; P = .13) or in-hospital mortality (1.7% vs 1.7%; P = .96). Women and men with claudication had similar 1-year graft patency rates. Women with CLI had lower rates of primary (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.03-1.48; P = .02), assisted primary (HR, 1.42; 95% CI, 1.15-1.76; P = .001) and secondary patency (HR, 1.40; 95% CI, 1.10-1.77; P = .006) during the first year compared with men. Freedom from amputation was similar for men and women with CLI (HR, 1.17; 95% CI, 0.84-1.63; P = .36). There were no differences in late survival between women and men with claudication (HR, 0.89; 95% CI, 0.60-1.31; P = .36) or CLI (HR, 0.94; 95% CI, 0.81-1.09; P = .39). More female claudicants were not independently ambulatory at discharge (30% vs 19%; P = .002) and were discharged to a nursing home (15% vs 5%; P < .001) but these differences did not persist at 1 year. Women with CLI were more likely to be nonambulatory at discharge (13% vs 9%; P = .006) and at 1 year (13% vs 8%; P < .001). More women with CLI were discharged to a nursing home (44% vs 35%; P = .01) and resided there at 1 year (11% vs 7%; P = .02). CONCLUSIONS Women have complication rates similar to men with inferior early and late functional outcomes after LEB. The reduced patency rates in women with CLI did not translate into differences in limb salvage. These findings might help define physician and patient expectations for women before revascularization.
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Affiliation(s)
- Reshma P Duffy
- Division of Vascular Surgery, University of Vermont College of Medicine, Burlington, Vt
| | - Julie E Adams
- Division of Vascular Surgery, University of Vermont College of Medicine, Burlington, Vt
| | - Peter W Callas
- Division of Vascular Surgery, University of Vermont College of Medicine, Burlington, Vt
| | - Andres Schanzer
- Division of Vascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Michael A Ricci
- Division of Vascular Surgery, Central Maine Heart and Vascular Institute, Lewiston, Me
| | - Jack L Cronenwett
- Division of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Daniel J Bertges
- Division of Vascular Surgery, University of Vermont College of Medicine, Burlington, Vt.
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30
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Abstract
The prevalence of peripheral arterial occlusive disease (PAD) in women and men is equal. Studies to date present conflicting data of gender effects on the risk factors, clinical presentation, and treatment outcomes. Clinical trials have often failed to analyze results by gender or to recruit sufficient women to enable such an analysis. This review summarizes the management and outcome of limb salvage therapy with a particular focus in women.
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Affiliation(s)
- Tam T T Huynh
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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31
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Galyfos G, Sigala F, Filis K. Regarding 'the impact of sex on angioplasty and primary stenting for femoropopliteal occlusive disease: results of the DURABILITY II trial'. Ann Vasc Surg 2014; 28:1083-4. [PMID: 24530713 DOI: 10.1016/j.avsg.2014.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 02/05/2014] [Indexed: 10/25/2022]
Affiliation(s)
- George Galyfos
- Vascular Unit, First Department of Propedeutic Surgery, University of Athens Medical School, Ippokration Hospital, Athens, Greece.
| | - Fragiska Sigala
- Vascular Unit, First Department of Propedeutic Surgery, University of Athens Medical School, Ippokration Hospital, Athens, Greece
| | - Konstantinos Filis
- Vascular Unit, First Department of Propedeutic Surgery, University of Athens Medical School, Ippokration Hospital, Athens, Greece
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32
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Pulli R, Dorigo W, Guidotti A, Fargion A, Alessi Innocenti A, Pratesi C. The role of infrainguinal bypass surgery in the endovascular era. Ann Vasc Dis 2014; 7:7-10. [PMID: 24719655 DOI: 10.3400/avd.ra.13-00124] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 12/19/2013] [Indexed: 11/13/2022] Open
Abstract
The current worldwide trend in the treatment of peripheral arterial disease (PAD) is towards an increase in endovascular procedures either in the aorto-iliac area or in the infrainguinal district. However, the role of the open repair with a femoro-popliteal bypass is still debated and in our opinion there still a room for traditional surgery in the presence of complex lesions involving the superficial femoral artery and the popliteal and tibial vessels. In this field, vein bypass provides better results than prosthetic grafts, but in selected cases and not only in the absence of a suitable vein, new modified grafts may be used with satisfactory results. The choice between the two options, open and endovascular, that in some cases can be associated in hybrid procedures, depends on several factors. Only if we are able to take into account all the different preoperative issues, we could choose the right procedure in the right patient.
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Affiliation(s)
- Raffaele Pulli
- Department of Vascular Surgery, University of Florence, Florence, Italy
| | - Walter Dorigo
- Department of Vascular Surgery, University of Florence, Florence, Italy
| | - Azzurra Guidotti
- Department of Vascular Surgery, University of Florence, Florence, Italy
| | - Aaron Fargion
- Department of Vascular Surgery, University of Florence, Florence, Italy
| | | | - Carlo Pratesi
- Department of Vascular Surgery, University of Florence, Florence, Italy
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33
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Dohi T, Iida O, Soga Y, Hirano K, Suzuki K, Takahara M, Uematsu M, Nanto S. Incidence, predictors, and prognosis of in-stent occlusion after endovascular treatment with nitinol stents for femoropopliteal lesions. J Vasc Surg 2013; 59:1009-1015.e1. [PMID: 24360237 DOI: 10.1016/j.jvs.2013.10.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 10/04/2013] [Accepted: 10/04/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Widespread use of self-expanding nitinol stent-based endovascular treatment (EVT) for femoropopliteal (FP) lesions has been fueled by its less-invasive nature and modest durability; however, prevalence, predictors and prognosis of in-stent occlusion are undefined and were investigated here. METHODS This study entailed a multicenter, retrospective analysis of a prospectively maintained database. Between January 2004 and December 2011, 2447 de novo FP lesions (mean length, 143 ± 87 mm; 52% chronic total occlusions) from 2008 patients (mean age, 73.0 ± 9.2 years; 71% male; 61% diabetics; 32% critical limb ischemia; and 24% on hemodialysis) were treated with nitinol stent-based EVT. Study outcome was in-stent occlusion: rates (1, 3, and 5 years), predictors and association with limb prognosis. RESULTS In-stent occlusion rate was 5.2%, 11.2%, and 16.4% at 1, 3, and 5 years, respectively (mean follow-up, 2.3 ± 1.7 years). Female sex, critical limb ischemia, and Transatlantic Inter-Society Consensus II class C/D (multivariate Cox proportional hazard ratio [HR], 1.75, 1.49, and 3.34, respectively) were independent predictors of in-stent occlusion after FP stenting, which was associated with poor limb prognosis (major amputation, HR 6.35; major adverse limb event, major adverse limb event, HR, 21.1). CONCLUSIONS Moderate in-stent occlusion rates were observed after nitinol stent-based EVT. Closer attention is warranted with high-risk cases because of poorer limb prognosis.
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Affiliation(s)
- Tomoharu Dohi
- Advanced Cardiovascular Therapeutics, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Osamu Iida
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan
| | - Keisuke Hirano
- Department of Cardiology, Saiseikai Yokohama-city Eastern Hospital, Yokohama, Japan
| | - Kenji Suzuki
- Department of Cardiology, Sendai Kosei Hospital, Sendai, Japan
| | - Mitsuyoshi Takahara
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masaaki Uematsu
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Shinsuke Nanto
- Advanced Cardiovascular Therapeutics, Osaka University Graduate School of Medicine, Suita, Japan
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Vogel TR, Petroski GF, Kruse RL. Functional status of elderly adults before and after interventions for critical limb ischemia. J Vasc Surg 2013; 59:350-8. [PMID: 24139567 DOI: 10.1016/j.jvs.2013.08.087] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 08/27/2013] [Accepted: 08/27/2013] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The impact of interventions for critical limb ischemia (CLI) on functional status in the elderly remains unclear. Open and endovascular procedures were evaluated. METHODS Medicare inpatient claims were linked with nursing home assessment data to identify elective admissions for lower extremity procedures for CLI. A functional impairment score (0-28; higher scores indicating greater impairment) based on residents' need for assistance with self-care activities, walking, and locomotion was calculated before and after interventions. Hierarchical modeling determined the effect of the surgery on residents' function, controlling for comorbidity, cognition, and prehospital function. RESULTS Three hundred fifty-two and 350 patients underwent open and endovascular procedures, respectively (rest pain, 84; ulceration, 351; gangrene, 267). Hospitalization was associated with a significant worsening in function following both procedures. Disease severity was associated with the amount of initial decline but not with the rate of recovery (P > .35). Residents who received open surgery improved more quickly following hospital discharge (P = .011). CONCLUSIONS In the frail elderly, open and endovascular procedures for CLI were associated with similar initial declines in functional status, suggesting that compared with open procedures, less invasive endovascular procedures were not associated with maintaining baseline function. In this select population, endovascular procedures for CLI were not associated with improved functional status over time compared with open. Six months posthospital, patients who received traditional open bypass had significantly better functional status than those who received endovascular procedures for all CLI diagnoses. Further analysis is required to assist stakeholders in performing procedures most likely to preserve functional status in the frail elderly and nursing home population.
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Affiliation(s)
- Todd R Vogel
- Department of Surgery, Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Mo.
| | - Gregory F Petroski
- Department of Health Management and Informatics, University of Missouri, School of Medicine, Columbia, Mo
| | - Robin L Kruse
- Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, Mo
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Sadaghianloo N, Jean-Baptiste E, Declemy S, Mousnier A, Brizzi S, Hassen-Khodja R. Percutaneous Angioplasty of Long Tibial Occlusions in Critical Limb Ischemia. Ann Vasc Surg 2013; 27:894-903. [DOI: 10.1016/j.avsg.2013.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Accepted: 02/11/2013] [Indexed: 12/01/2022]
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McCoach CE, Armstrong EJ, Singh S, Javed U, Anderson D, Yeo KK, Westin GG, Hedayati N, Amsterdam EA, Laird JR. Gender-related variation in the clinical presentation and outcomes of critical limb ischemia. Vasc Med 2013; 18:19-26. [PMID: 23439776 DOI: 10.1177/1358863x13475836] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Critical limb ischemia (CLI) is a major cause of limb loss and mortality among patients with advanced peripheral artery disease. Our objective was to evaluate the gender-specific differences in patient characteristics and clinical outcomes among patients with CLI. We performed a retrospective analysis of 97 women and 122 men presenting with CLI who underwent angiography from 2006 to 2010. Baseline demographics, procedural details, and lesion characteristics were assessed for each patient. Kaplan-Meier analysis was used to assess long-term patient and lesion-level outcomes. Cox proportional hazard modeling was used to evaluate the relationship between gender and major adverse cardiovascular events (MACE). Compared to men, women were less likely to have a history of coronary artery disease (39% vs 54%, p = 0.02) or diabetes (57% vs 70%, p = 0.05) but had similar baseline medical therapy. At angiography, women were more likely to have significant femoropopliteal (77% vs 67%, p = 0.02) and multi-level infrainguinal disease (63% vs 51%, p = 0.02). Women were also more likely to undergo multi-vessel percutaneous intervention (69% vs 55%, p = 0.05), but had similar rates of limb salvage after percutaneous intervention or surgical bypass (HR 0.94 [95% CI 0.45-1.94], p = 0.9). During follow-up, women had higher rates of subsequent major adverse cardiovascular events (HR 1.63 [95% CI 1.01-2.63], p = 0.04). In conclusion, women with CLI are more likely to present with femoropopliteal and multi-level infrainguinal disease. Despite similar rates of limb salvage, women with CLI have an increased rate of subsequent major adverse cardiovascular events.
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Affiliation(s)
- Caroline E McCoach
- Department of Internal Medicine, University of California, Davis, Sacramento, CA 95817, USA
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Meltzer AJ, Graham A, Connolly PH, Karwowski JK, Bush HL, Frazier PI, Schneider DB. Risk Factors for Early Failure After Peripheral Endovascular Intervention: Application of a Reliability Engineering Approach. Ann Vasc Surg 2013; 27:53-61. [DOI: 10.1016/j.avsg.2012.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 04/30/2012] [Accepted: 05/01/2012] [Indexed: 10/27/2022]
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Walker JP, Hiramoto JS. Diagnosis and management of peripheral artery disease in women. Int J Womens Health 2012; 4:625-34. [PMID: 23277744 PMCID: PMC3531989 DOI: 10.2147/ijwh.s31073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Peripheral artery disease (PAD) is a significant cause of morbidity and mortality in the USA. Not only is it a major cause of functional impairment and limb loss, but it is also strongly associated with an increased risk of myocardial infarction, stroke, and death. Large population studies have demonstrated high rates of PAD in women, but this is not widely recognized by the public or by clinicians. One potential reason for this is that women with PAD are more likely than men to be asymptomatic or have atypical symptoms. In addition, women with PAD experience higher rates of functional decline and may have poorer outcomes after surgical treatment for PAD compared with men. Currently, it is not known if there are sex-specific differences in risk factors for the onset, progression, and surgical outcomes of PAD. This review will focus on the diagnosis and management of PAD in women and examine sex-specific differences in the prevalence, risk factors, presentation, and outcomes of this disease.
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Affiliation(s)
- Joy Peacock Walker
- Department of Surgery, University of California, San Francisco, California, USA
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