Lower extremity bypass vs endovascular therapy for young patients with symptomatic peripheral arterial disease

Nationwide trends in the epidemiology of diabetic foot complications and lower-extremity amputation over an 8-year period

OBJECTIVE

To study the prevalence and trends of lower extremity complications of diabetes over an 8-year period in a single nation.

RESEARCH DESIGN AND METHODS

Nationwide data for people with type 2 diabetes (T2D) and diabetic foot complications (DFCs) were analyzed over an 8-year period (2007-2014) from National Health Insurance Research Database using the International Classification of Diseases, Ninth Revision disease coding. The DFCs were defined as ulcers, infections, gangrene, and hospitalization for peripheral arterial disease (PAD). Trends of patient characteristics, foot presentation, and the execution of major procedures were studied, including lower-extremity amputations (LEAs).

RESULTS

Along with the T2D population increasing over time, the absolute number of people with DFCs increased by 33.4%, but retained a prevalence of around 2% per year. The annual incident of LEAs decreased from 2.85 to 2.06 per 1000 T2D population (p=0.001) with the major LEA proportion decreasing from 56.2% to 47.4% (p<0.001).The mean age of patients increased from 65.3 to 66.3 years and most of the associated comorbidities of diabetes were increased. For example, end-stage renal disease increased from 4.9% to 7.7% (p=0.008). The incidence of gangrene on presentation decreased from 14.7% to 11.3% (p<0.001) with a concomitant increase in vascular interventions (6.2% to 19.5%, p<0.001).

CONCLUSIONS

DFCs remain a sustained major medical problem. These nationwide long-term data suggest trends toward older people with greater comorbidities such as PAD and renal disease. Nevertheless, promising trends of reducing gangrene on presentation paired with increases in vascular interventions support continued vigilance and rapid, coordinated interdisciplinary diabetic foot care.

Comparison of Outcomes and Cost of Endovascular Management Versus Surgical Bypass for the Management of Lower Extremities Peripheral Arterial Disease

The management of lower extremities peripheral arterial disease (LE-PAD) has always been debatable. We sought to explore in-hospital outcomes in hospitalizations that underwent endovascular or bypass surgery for LE-PAD from nation's largest, publicly available database. The National Inpatient Sample from 2012 to 2014 was queried to identify adult hospitalizations underwent endovascular management and bypass surgery for LE-PAD. Appropriate International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes were utilized to identify hospitalizations. A total of 89,256 hospitalizations were identified having endovascular management or bypass surgery for LE-PAD. More hospitalizations underwent endovascular intervention as compared with bypass surgery. Overall, hospitalizations for endovascular management had higher baseline co-morbidities and older age. A propensity score matched analysis was performed to compare in-hospital outcomes. After matching, 28,791 hospitalizations were included in each group. In-hospital mortality was significantly lower with endovascular intervention procedure as compared with surgical bypass group (1.5% vs 2.5%, p ≤0.001). All other secondary outcomes were noted lower with endovascular management except stroke and postprocedural infection. Taken together, these may account for higher discharges to home, lower length of stay, and less cost of hospitalizations associated with endovascular management. In conclusion, endovascular management is associated with lower in-hospital morbidity, mortality, length of stay, and cost when compared with bypass surgery in this study.

Efficacy of iliac inflow repair in patients with concomitant iliac and superficial femoral artery occlusive disease

BACKGROUND

In multilevel arterial disease, whether complete revascularization or staged runoff repair should be performed remains controversial. The aim of this study was to evaluate the efficacy of iliac inflow repair and to identify clinical conditions that are associated with the need for runoff repair in concomitant iliac and superficial femoral artery (SFA) occlusive disease.

METHODS

Patients undergoing inflow repair for complicated flow-limiting iliac lesions with diffuse SFA disease between 2007 and 2013 were retrospectively reviewed. Patients with poor response to inflow repair underwent infrainguinal revascularization (IIR).

RESULTS

The 29 ischemic limbs examined in this study represent 26 different patients (22 males; mean age, 77 ± 8 years). Indications for inflow repair were Rutherford Classifications III (31%), IV (31%), V (31%), and VI (7%). Severity of the complicated SFA disease was either TASC (TransAtlantic Inter-Society Consensus) type C (14%) or type D (86%). Overall, freedom from IIR was 90% after 30 days and 83% after 1 year. Patients having claudication, rest pain, and shallow ischemic ulcers experienced the relief of symptoms, whereas patients with deep gangrene that needed minor amputation required IIR more frequently (p < 0.01). Anatomical risk factors for poor response to inflow repair were poor quality of the deep femoral artery (p < 0.01) and the flow-limiting popliteal artery (p = 0.02), and poor below-knee runoff (≤ 1 vessel, p < 0.01).

CONCLUSION

Iliac inflow repair can reverse the symptoms in patients with multilevel arterial occlusive disease that are not associated with gangrenous toes.

Ulcer healing after peripheral intervention-can we predict it before revascularization?

Complete ulcer healing is one of the most important goals of treatment for critical limb ischemia; however, it is still difficult to inform patients of the time to ulcer healing before performing revascularization. The time to ulcer healing has a great impact on the cost of treatment and patient's quality of life. To predict it, the factors that influence delayed ulcer healing should be explored. According to a review of the literature investigating ulcer healing after revascularization, the influential factors can be classified into 5 categories: (1) systemic factors; (2) clinical state of tissue defect; (3) infection; (4) wound management strategy; and (5) revascularization strategy (endovascular or open repair, the angiosome concept). It is also important to ensure sufficient blood supply to predict ulcer healing probability in the individual patient. Several new methodologies, such as measuring tissue circulation around the tissue defect and intraoperative imaging techniques, have been reported. Because the status of ischemic tissue loss and wound healing ability can affect the decision-making process in selecting the revascularization strategy, understanding the many factors that influence ulcer healing after revascularization is indispensable for physicians performing revascularization. Accumulating ulcer healing data via well-designed clinical research can help to establish a new paradigm for the revascularization strategy from the viewpoint of ulcer healing.