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Korosoglou G, Torsello G, Saratzis A, Isernia G, Kontopodis N, González TM, Jacobs K, Van Herzeele I, Zayed H, Stavroulakis K. Editor's Choice - Endovascular Versus Surgical Treatment for All Comer Patients With Prosthetic Bypass Graft Occlusion: The Multicentre ENSUPRO Study. Eur J Vasc Endovasc Surg 2024; 67:786-796. [PMID: 37543355 DOI: 10.1016/j.ejvs.2023.07.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 06/10/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE Bypass surgery plays a key role in complex lower limb lesions. However, there is a lack of evidence regarding the management of symptomatic prosthetic bypass graft (PBG) occlusion. This study aimed to report outcomes following open, hybrid, or endovascular management of patients presenting with symptomatic PBG occlusion. METHODS A multicentre, retrospective cohort study was conducted, including patients presenting with PBG occlusion between January 2014 and December 2021 from 18 centres. It assessed the comparative value of treatment strategies, including (1) recanalisation of native vessels, (2) endovascular treatment of the failed PBG, (3) hybrid treatment, and (4) open surgery. The primary outcome measure was amputation free survival (AFS, time to major amputation and or death), whereas all cause mortality, major amputation, PBG re-occlusion, target lesion revascularisation (TLR), and Rutherford category (RC) improvement during follow up were considered as secondary endpoints. RESULTS Of 260 patients with occluded PBGs, 108 (41.5%) were treated endovascularly (24 [22.2%] by recanalisation of native vessels and 84 [77.7%] by PBG re-opening), 57 (21.9%) underwent hybrid revascularisation, and 58 (22.3%) had surgery. In addition, 27 (10.4%) were treated conservatively and 10 (3.8%) received systemic thrombolysis. With a median follow up of 1.4 (0.6 - 3.0) years, AFS was 95.5%, 76.4%, 45.5%, and 37.1%, respectively in Groups 1 - 4 (p = .007). Older age and non-endovascular treatment (HR 1.05 and 1.70; p < .01 for both) were independent predictors of poor AFS. Endovascular treatment was associated with lower rates of major amputation (p = .04), PBG re-occlusion (p < .001), and TLR (p = .037), and higher RC improvements (p < .001), whereas all cause mortality was comparable between treatment groups (p = .21). CONCLUSION Endovascular treatment is associated with higher rates of AFS and RC improvement and lower rates of PBG re-occlusion and TLR in patients with PBG occlusion.
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Affiliation(s)
| | - Giovanni Torsello
- University Hospital Münster, Institute for Vascular Research, Franziskus Hospital, Münster, Germany
| | - Athanasios Saratzis
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Giacomo Isernia
- Department of Vascular and Endovascular Surgery, University Hospital of Perugia, Perugia, Italy
| | | | | | - Karen Jacobs
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Hany Zayed
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Kobayashi S, Furukawa M, Ichioka S, Horiuchi K, Kitano I, Fujii M, Ayabe S, Tanaka R, Ohura N, Ohura T. A novel low-density lipoprotein/fibrinogen apheresis method for chronic limb-threatening ischemia in patients with poor options for revascularization: A multicenter, single-arm clinical trial. Ther Apher Dial 2023; 27:361-369. [PMID: 36858047 DOI: 10.1111/1744-9987.13915] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/13/2022] [Accepted: 07/27/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Low-density lipoprotein (LDL) apheresis is a treatment option for patients with unhealed chronic limb-threatening ischemia (CLTI) after revascularization. The newly developed AS-25 is a direct hemoperfusion-type apheresis device that differs from conventional LDL apheresis therapy and is designed to specifically adsorb both LDL-C and fibrinogen. We evaluate the efficacy and safety of AS-25. METHODS This study included 61 patients whose ulcers failed to heal after revascularization or were ineligible for revascularization. Of these, 50 were undergoing hemodialysis. The primary endpoint was the healing rate of a target lesion of interest (ulcer), using historical data as control. RESULTS The ulcer healing rate of 45.9% was significantly higher than the historical data. No significant safety concerns were observed. CONCLUSIONS AS-25 was effective in healing ulcers and preventing major amputation even in CLTI refractory patients on hemodialysis, thus showing potential clinical applicability and high significance. CLINICAL TRIAL REGISTRATION UMIN study ID UMIN000020336.
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Affiliation(s)
- Shuzo Kobayashi
- Kidney Disease and Transplant Center, Shonan Kamakura General Hospital, Kamakura, Japan
| | | | - Shigeru Ichioka
- Department of Plastic and Reconstructive Surgery, Saitama Medical University, Moroyama, Japan
| | - Katsumi Horiuchi
- Department of Plastic and Reconstructive Surgery, Sapporo City General Hospital, Sapporo, Japan
| | - Ikuro Kitano
- Department of Vascular Surgery, Shinsuma General Hospital, Kobe, Japan
| | - Miki Fujii
- Department of Plastic and Reconstructive Surgery, Critical Limb Ischemia Center, Kitaharima Medical Center, Ono, Japan
| | - Shinobu Ayabe
- Department of Plastic and Reconstructive Surgery, Yao Tokushukai General Hospital, Osaka, Japan
| | - Rica Tanaka
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Norihiko Ohura
- Department of Plastic and Reconstructive Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Takehiko Ohura
- Pressure Ulcers and Wound Healing Research Center, Sapporo, Japan
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3
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Ryu GW, Park YS, Kim J, Yang YS, Ko YG, Choi M. Incidence and Prevalence of Peripheral Arterial Disease in South Korea: Retrospective Analysis of National Claims Data. JMIR Public Health Surveill 2022; 8:e34908. [PMID: 36399371 PMCID: PMC9719060 DOI: 10.2196/34908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 10/01/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Peripheral arterial disease (PAD) causes blood vessel narrowing that decreases blood flow to the lower extremities, with symptoms such as leg pain, discomfort, and intermittent claudication. PAD increases risks for amputation, poor health-related quality of life, and mortality. It is estimated that more than 200 million people worldwide have PAD, although the paucity of PAD research in the East detracts from knowledge on global PAD epidemiology. There are few national data-based analyses or health care utilization investigations. Thus, a national data analysis of PAD incidence and prevalence would provide baseline data to enable health promotion strategies for patients with PAD. OBJECTIVE This study aims to identify South Korean trends in the incidence and prevalence of PAD and PAD treatment, in-hospital deaths, and health care utilization. METHODS This was a retrospective analysis of South Korean national claims data from 2009 to 2018. The incidence of PAD was determined by setting the years 2010 and 2011 as a washout period to exclude previously diagnosed patients with PAD. The study included adults aged ≥20 and <90 years who received a primary diagnosis of PAD between 2011 and 2018; patients were stratified according to age, sex, and insurance status for the incidence and prevalence analyses. Descriptive statistics were used to assess incidence, prevalence, endovascular revascularization (EVR) events, amputations, in-hospital deaths, and the health care utilization characteristics of patients with PAD. RESULTS Based on data from 2011 to 2018, there were an average of 124,682 and 993,048 incident and prevalent PAD cases, respectively, in 2018. PAD incidence (per 1000 persons) ranged from 2.68 to 3.09 during the study period. From 2012 to 2018, the incidence rate in both sexes showed an increasing trend. PAD incidence continued to increase with age. PAD prevalence (per 1000 persons) increased steadily, from 3.93 in 2011 to 23.55 in 2018. The number of EVR events varied between 933 and 1422 during the study period, and both major and minor amputations showed a decreasing trend. Health care utilization characteristics showed that women visited clinics more frequently than men, whereas men used tertiary and general hospitals more often than women. CONCLUSIONS The number of incident and prevalent PAD cases generally showed an increasing trend. Visits to tertiary and general hospitals were higher among men than women. These results indicate the need for attention not only to Western and male patients, but also to Eastern and female patients with PAD. The results are generalizable, as they are based on national claims data from the entire South Korean population, and they can promote preventive care and management strategies for patients with PAD in clinical and public health settings.
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Affiliation(s)
- Gi Wook Ryu
- Department of Nursing, Hansei University, Gunpo-si, Republic of Korea
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul, Republic of Korea
- College of Nursing, Yonsei University, Seoul, Republic of Korea
| | - Young Shin Park
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul, Republic of Korea
| | - Jeewuan Kim
- Department of Statistics and Data Science, Yonsei University, Seoul, Republic of Korea
| | - Yong Sook Yang
- College of Nursing, Yonsei University, Seoul, Republic of Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Mona Choi
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul, Republic of Korea
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Portas L, Bauersachs R, Bowrin K, Briere JB, Cohen A, Huelsebeck M, Jones S, Quint JK. Assessment of the burden of disease for patients with peripheral artery disease undergoing revascularization in England. Vasc Med 2022; 27:440-449. [PMID: 35670290 PMCID: PMC9551319 DOI: 10.1177/1358863x221096704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Symptoms, severity, and acuteness of peripheral artery
disease (PAD) are major determinants of severe limb symptoms, subsequent risk of
cardiovascular events, and mortality. Lower-extremity revascularization (LER) is
a key option to relieve symptoms and to prevent limb loss in symptomatic
patients with PAD. This study aimed to quantify the burden of disease among
patients with PAD-LER in England. Methods: A retrospective
population-based study of linked primary and secondary care electronic health
records, included 13,869 adult patients (aged ⩾ 18 years) with PAD-LER from 2003
to 2018. The incidence of first ever PAD-LER was estimated both overall and by
type of procedure (endovascular/surgical). Health resource utilization
associated with PAD-related complications and treatment patterns were assessed.
Results: A high annual incidence of lower-limb
revascularization (41.2 per 1000 person years) and a nearly double incidence of
endovascular first revascularization compared with open surgery were observed.
More than 70% of patients with PAD-LER had a history of hyperlipidemia and
hypertension and roughly one-third were diabetic and had a history of coronary
artery disease. Cardiovascular mortality accounted for one-third (34.1 per 1000
person years) of all-cause mortality. Over 93% of patients were hospitalized for
any reason and the commonest reasons for hospitalization were cardiovascular
diseases and PAD with about one-third hospitalized for revascularization
reoccurrence. Conclusion: There is a significant burden of PAD-LER
to the individual and society with ongoing healthcare resource utilization,
treatment, and increasing mortality.
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Affiliation(s)
- Laura Portas
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Rupert Bauersachs
- Department of Vascular Medicine - Angiology, Klinikum Darmstadt, Darmstadt, Germany
| | | | | | - Alexander Cohen
- Department of Hematological Medicine, Guy's & St Thomas' NHS Foundation Trust, King's College London, London, UK
| | | | - Schuyler Jones
- Duke Clinical Research Institute, Durham, NC, USA.,Duke University Medical Center, Durham, NC, USA
| | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK
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Meulenbroek AL, Faes MC, van Mil SR, Buimer MG, de Groot HGW, Veen EJ, Ho GH, Boonman-de Winter LJM, de Vries J, van Gorkom R, Toonders F, van Alphen R, van Overveld K, Verbogt N, Steyerberg EW, van der Laan L. Multicomponent Prehabilitation as a Novel Strategy for Preventing Delirium in Older Chronic Limb Threatening Ischemia Patients: A Study Protocol. Clin Interv Aging 2022; 17:767-776. [PMID: 35586779 PMCID: PMC9109801 DOI: 10.2147/cia.s357812] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/11/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Chronic limb threatening ischemia is the final stage of peripheral arterial disease. Current treatment is based on revascularization to preserve the leg. In the older, hospitalized chronic limb threatening ischemia patient, delirium is a frequent and severe complication after revascularization. Delirium leads to an increased length of hospital stay, a higher mortality rate and a decrease in quality of life. Currently, no specific guidelines to prevent delirium in chronic limb threatening ischemia patients exist. We aim to evaluate the effect of a multicomponent, multidisciplinary prehabilitation program on the incidence of delirium in chronic limb threatening ischemia patients ≥65 years. Design A prospective observational cohort study to investigate the effects of the program on the incidence of delirium will be performed in a large teaching hospital in the Netherlands. This manuscript describes the design of the study and the content of this specific prehabilitation program. Methods Chronic limb threatening ischemia patients ≥65 years that require revascularization will participate in the program. This program focuses on optimizing the patient's overall health and includes delirium risk assessment, nutritional optimization, home-based physical therapy, iron infusion in case of anaemia and a comprehensive geriatric assessment in case of frailty. The primary outcome is the incidence of delirium. Secondary outcomes include quality of life, amputation-free survival, length of hospital stay and mortality. Exclusion criteria are the requirement of acute treatment or patients who are mentally incompetent to understand the procedures of the study or to complete questionnaires. A historical cohort from the same hospital is used as a control group. Discussion This study will clarify the effect of a prehabilitation program on delirium incidence in chronic limb threatening ischemia patients. New insights will be obtained on optimizing a patient's preoperative mental and physical condition to prevent postoperative complications, including delirium. Trial This protocol is registered at the Netherlands National Trial Register (NTR) number: NL9380.
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Affiliation(s)
| | - Miriam C Faes
- Department of Geriatrics, Amphia Hospital, Breda, the Netherlands
| | | | - M G Buimer
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | | | - Eelco J Veen
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Gwan H Ho
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Leandra J M Boonman-de Winter
- Department of Scientific Research, Amphia Hospital, Breda, the Netherlands
- Admiraal de Ruyter Ziekenhuis, Goes, the Netherlands
| | - Jolanda de Vries
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, the Netherlands
- Board, Admiraal de Ruyter Hospital, Goes, the Netherlands
| | | | - Fleur Toonders
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Rene van Alphen
- Department of Physical Therapy, Amphia Hospital, Breda, the Netherlands
| | | | | | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
| | - Lijckle van der Laan
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
- Department of Cardiovascular Science, University Hospitals Leuven, Leuven, Belgium
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6
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Meulenbroek AL, van Mil SR, Faes MC, Mattace-Raso FUS, Fourneau I, van der Laan L. A systematic review of strategies for preventing delirium in patients undergoing vascular surgery. Ann Vasc Surg 2022; 85:433-443. [PMID: 35460860 DOI: 10.1016/j.avsg.2022.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/29/2022] [Accepted: 04/03/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Elderly patients undergoing vascular surgery are at risk of developing postoperative delirium, which is associated with a high mortality. Delirium prevention is difficult and is investigated in surgical patients from various specialisms, but little is known about delirium prevention in vascular surgery. For this reason we performed a systematic review on strategies for delirium prevention in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta. METHODS This systematic review included studies describing strategies for preventing delirium in patients undergoing elective surgery for peripheral arterial disease or for an aneurysm of the abdominal aorta. The search was conducted using the keywords 'vascular surgery', 'prevention' and 'delirium', and was last run on October 21st, 2021 in the electronic databases Pubmed, MEDLINE, Embase, Web of Science, the Cochrane library and Emcare. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized controlled trials and the ROBINS-1 tool for observational studies. RESULTS Four studies including 565 patients were included in the systematic review. A significant decrease in the incidence of delirium was reported by a study investigating the effect of comprehensive geriatric assessments within patients undergoing surgery for an aneurysm of the abdominal aorta or lower limb bypass surgery (24% in the control group versus 11% in the intervention group, p = 0.018), and in the total group of a study evaluating the effect of outpatient clinic multimodal prehabilitation for patients with an aneurysm of the abdominal aorta (11.7% in the control group versus 8.2% in the intervention group, p = 0.043, OR = 0.56). A non-significant decrease in delirium incidence was described for patients receiving a multidisciplinary quality improvement at the vascular surgical ward (21.4% in the control group versus 14.6% in the intervention group, p = 0.17). The study concerning the impact of the type of anaesthesia on delirium in eleven older vascular surgical patients, of which three developed delirium, did not differentiate between the different types of anaesthesia the patients received. CONCLUSION Despite the high and continuous increasing incidence of delirium in the growing elderly vascular population, little is known about effective preventive strategies. An approach to address multiple risk factors simultaneously seems to be promising in delirium prevention, whether through multimodal prehabilitation or comprehensive geriatric assessments. Several strategies including prehabilitation programs have been proven to be successful in other types of surgery and more research is required to evaluate effective preventive strategies and prehabilitation programs in vascular surgical patients.
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Affiliation(s)
| | | | - Miriam C Faes
- Department of Geriatrics, Amphia Hospital, Breda, the Netherlands
| | - Francesco U S Mattace-Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Inge Fourneau
- Department of Cardiovascular science and Vascular Surgery, University Hospitals Leuven, Belgium
| | - Lijckle van der Laan
- Department of Surgery, Amphia Hospital, Breda, the Netherlands; Department of Cardiovascular science and Vascular Surgery, University Hospitals Leuven, Belgium
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Ruemenapf G, Morbach S, Sigl M. Therapeutic Alternatives in Diabetic Foot Patients without an Option for Revascularization: A Narrative Review. J Clin Med 2022; 11:jcm11082155. [PMID: 35456247 PMCID: PMC9032488 DOI: 10.3390/jcm11082155] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/05/2022] [Accepted: 04/08/2022] [Indexed: 12/30/2022] Open
Abstract
Background: The healing of foot wounds in patients with diabetes mellitus is frequently complicated by critical limb threatening ischemia (neuro-ischemic diabetic foot syndrome, DFS). In this situation, imminent arterial revascularization is imperative in order to avoid amputation. However, in many patients this is no longer possible (“too late”, “too sick”, “no technical option”). Besides conservative treatment or major amputation, many alternative methods supposed to decrease pain, promote wound healing, and avoid amputations are employed. We performed a narrative review in order to stress their efficiency and evidence. Methods: The literature research for the 2014 revision of the German evidenced-based S3-PAD-guidelines was extended to 2020. Results: If revascularization is impossible, there is not enough evidence for gene- and stem-cell therapy, hyperbaric oxygen, sympathectomy, spinal cord stimulation, prostanoids etc. to be able to recommend them. Risk factor management is recommended for all CLTI patients. With appropriate wound care and strict offloading, conservative treatment may be an effective alternative. Timely amputation can accelerate mobilization and improve the quality of life. Conclusions: Alternative treatments said to decrease the amputation rate by improving arterial perfusion and wound healing in case revascularization is impossible and lack both efficiency and evidence. Conservative therapy can yield acceptable results, but early amputation may be a beneficial alternative. Patients unfit for revascularization or major amputation should receive palliative wound care and pain therapy. New treatment strategies for no-option CLTI are urgently needed.
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Affiliation(s)
- Gerhard Ruemenapf
- Vascular Center Oberrhein Speyer-Mannheim, Department of Vascular Surgery, Diakonissen-Stiftungs-Krankenhaus, 67346 Speyer, Germany
- Correspondence: ; Tel.: +49-6232-22-1955; Fax: +49-6232-22-1994
| | - Stephan Morbach
- Department of Diabetology und Angiology, Marienkrankenhaus, 59494 Soest, Germany;
| | - Martin Sigl
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site, 68199 Mannheim, Germany;
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ELSHERIF M, ELSHARKAWI M, TAWFICK W, GHONEIM B, HYNES N, SULTAN S. Two decades of peripheral arterial disease intervention in a tertiary vascular referral center. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.23736/s1824-4777.21.01476-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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9
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Kotov A, Peters F, Debus ES, Zeller T, Heider P, Stavroulakis K, Remig J, Gussmann A, Hoffmann J, Friedrich O, Nolte T, Behrendt CA. The prospective GermanVasc cohort study. VASA 2021; 50:446-452. [PMID: 34279120 DOI: 10.1024/0301-1526/a000966] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Previous observational studies reported a wide variation and possible room for improvement in the treatment of patients suffering from symptomatic peripheral artery disease (PAD). Yet, systematic assessment of everyday clinical practice is lacking. A General Data Protection Regulation (GDPR) compliant registry was developed and used to collect comprehensive data on clinical treatment and outcomes regarding PAD in Germany. Here, we report baseline characteristics of patients prospectively enrolled until the end of 2020. Methods: The GermanVasc registry study is a prospective longitudinal multicentre cohort study. Between 1st May 2018 and 31st December 2020, invasive endovascular, open-surgical, and hybrid revascularisations of patients suffering from chronic symptomatic PAD were prospectively included after explicit informed consent (NCT03098290). For ensuring high quality of the data, we performed comprehensive risk-based and random-sample external and internal validation. Results: In total, 5608 patients from 31 study centres were included (34% females, median 69 years). On-site monitoring visits were performed at least once in all centres. The proportion of chronic limb-threatening ischaemia was 30% and 13% were emergent admissions. 55% exhibited a previous revascularisation. Endovascular techniques made 69% among all documented invasive procedures (n=6449). Thirty-five percent were classified as patients with severe systemic disease, and 3% exhibited a constant threat to life according to the American Society of Anaesthesiologists classification. The risk profile comprised of 75% former or current smokers, 36% diabetes mellitus, and in 30% a current ischemic heart disease was present. At discharge, 93% of the patients received antiplatelets and 77% received statins. Conclusions: The GermanVasc registry study provides insights into real-world practice of treatment and outcomes of 5,608 patients with symptomatic PAD in Germany. The cohort covers a broader range of disease severity and types of interventions than usually found in trials. In future studies, comparative outcomes will be analysed in more detail.
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Affiliation(s)
- Artur Kotov
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Frederik Peters
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Thomas Zeller
- University Heart Center Freiburg-Bad Krozingen, Germany
| | | | | | - Jürgen Remig
- Bonn Community Hospital, Haus St. Petrus, Bonn, Germany
| | | | | | | | - Thomas Nolte
- Bad Bevensen Heart and Vascular Centre, Bad Bevensen, Germany
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Woronowicz-Kmiec S, Betz T, Töpel I, Bröckner S, Steinbauer M, Uhl C. Short and long-term outcome after common femoral artery hybrid procedure in patients with intermittent claudication and chronic limb threatening ischemia. VASA 2021; 50:363-371. [PMID: 33973817 DOI: 10.1024/0301-1526/a000954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: This study aimed to evaluate the differences between the outcomes of patients with intermittent claudication (IC) and chronic limb threatening ischemia (CLTI) who underwent a hybrid procedure comprising common femoral artery endarterectomy and endovascular therapy. Patients and methods: This was a retrospective single-center study of all patients with peripheral arterial occlusive disease (PAD) who underwent the hybrid procedure between March 2007 and August 2018. The primary endpoint was primary patency after 7 years. The secondary endpoints were primary-assisted patency, secondary patency, limb salvage, and survival. Results: During the follow-up period, 427 limbs in 409 patients were treated. A total of 267 and 160 patients presented with clinical signs of IC and CLTI, respectively. The 30-day mortality was 1.4% (IC: 0% vs. CLTI: 3.8%, p=0.001). The overall 30-day major amputation rate was 1.6% (IC: 0% vs. CLTI: 4.4, p=0.001). The rates of primary and secondary patency after 7 years were 63% and 94%, respectively, in the IC group and 57% and 88%, respectively, in the CLTI group; the difference was not significant. Limb salvage (94% vs. 82%, p=0.000) and survival (58% vs. 29%, p=0.000) were significantly higher in the IC group. In a multivariate analysis, CLTI was the only risk factor for major amputation. CLTI and single vessel run-off were risk factors for death. Statin therapy was a protective factor. Conclusions: The hybrid procedure provides excellent results as a treatment option for multilevel lesions in patients with PAD. However, patients with CLTI had a shorter long-term survival and lower limb salvage rate.
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Affiliation(s)
| | - Thomas Betz
- Department of Vascular Surgery, Barmherzige Brüder Hospital Regensburg, Germany
| | - Ingolf Töpel
- Department of Vascular Surgery, Barmherzige Brüder Hospital Regensburg, Germany
| | - Stefan Bröckner
- Department of Vascular Surgery, Barmherzige Brüder Hospital Regensburg, Germany
| | - Markus Steinbauer
- Department of Vascular Surgery, Barmherzige Brüder Hospital Regensburg, Germany
| | - Christian Uhl
- Department of Vascular Surgery, Barmherzige Brüder Hospital Regensburg, Germany
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11
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Kim C, Yang YS, Ryu GW, Choi M. Risk factors associated with amputation-free survival for patients with peripheral arterial disease: a systematic review. Eur J Cardiovasc Nurs 2021; 20:295-304. [PMID: 33786599 DOI: 10.1093/eurjcn/zvaa022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/01/2020] [Accepted: 11/09/2020] [Indexed: 12/24/2022]
Abstract
AIMS Peripheral arterial disease (PAD) is associated with morbidity and mortality, comprising a significant percentage of amputations. As it affects the quality of life of patients with PAD, it is an important health issue. Therefore, the risk factors affecting the outcomes of limb salvage after revascularization should be well investigated. The aim of this review is to summarize risk factors of amputation-free survival (AFS) after interventions targeting patients with PAD to develop evidence-based intervention for improving patient outcomes. METHODS AND RESULTS A systematic review following PRISMA guidelines was conducted, and the protocol was registered on PROSPERO (CRD42020183076). PubMed, CINAHL, EMBASE, Cochrane Library, and Web of Science were searched for observational studies published between 2008 and 2019. Search terms included 'peripheral arterial disease', 'risk factors', and 'amputation-free survival'. The quality of the studies was evaluated using the Joanna Briggs Institute's Critical Appraisal Tools. Seventeen cohort studies were included in our study, and 16 risk factors were identified. Risk factors exemplifying a significant influence on decreased AFS were divided into three categories: sociodemographic (e.g. older age, male gender, African-American race, low body mass index, high nutritional risk, frailty), disease-related characteristics (e.g. severity of the disease, intervention site), and comorbidities (e.g. cardiovascular disease, kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, dementia, wide pulse pressure). CONCLUSION We found that managing modifiable risk factors, as well as addressing high-risk populations, has the potential to improve outcomes of PAD interventions. More high-quality cohort studies are needed to confirm these findings.
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Affiliation(s)
- Changhwan Kim
- Department of Critical Care Nursing, Samsung Medical Center, 81, Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
| | - Yong Sook Yang
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1 Yonsei-ro, College of Nursing Yonsei University, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Gi Wook Ryu
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1 Yonsei-ro, College of Nursing Yonsei University, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Mona Choi
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1 Yonsei-ro, College of Nursing Yonsei University, Seodaemun-gu, Seoul 03722, Republic of Korea.,Yonsei Evidence Based Nursing Centre of Korea, JBI Centre of Excellence, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
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Hemmati H, Farzalizadeh S, Jafariparvar Z, Esmaeili Delshad MS, Hemmati G, Poorhabibi Z. The consequences of angiography and angioplasty of the lower limb in one stage by simultaneous ipsilateral double puncture technique and in two-stage delayed technique: a comparative study. Chirurgia (Bucur) 2021. [DOI: 10.23736/s0394-9508.20.05069-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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13
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Rümenapf G, Morbach S, Rother U, Uhl C, Görtz H, Böckler D, Behrendt CA, Hochlenert D, Engels G, Hohneck A, Sigl M. [Diabetic foot syndrome-Part 2 : Revascularization, treatment alternatives, care structures, recurrency prophylaxis]. Chirurg 2021; 92:173-186. [PMID: 33237367 PMCID: PMC7875854 DOI: 10.1007/s00104-020-01313-5] [Citation(s) in RCA: 4] [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] [Indexed: 12/28/2022]
Abstract
Diabetic foot syndrome (DFS) is the most frequent reason for major amputations in Germany. The majority of foot lesions are triggered by repetitive pressure in diabetic polyneuropathy. Peripheral arterial occlusive disease (PAOD) impairs wound healing and is the main risk factor for amputations. The treatment of wounds and infections as well as timely revascularization are decisive. The use of endovascular and vascular surgical methods depends on the distribution pattern and length of the occlusion processes. Both procedures are complementary. Bypass surgery is of great importance for neuroischemic DFS. Multidisciplinary centers that provide revascularization in DFS can achieve an improvement of arterial blood flow in 90% of the cases and reduce the amputation rate by up to 80%. Due to the high recurrence rate of diabetic foot lesions, measures for secondary prophylaxis are of exceptional importance (podological and orthopedic technical care, foot surgery).
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Affiliation(s)
- G Rümenapf
- Oberrheinisches Gefäßzentrum Speyer, Diakonissen-Stiftungs-Krankenhaus Speyer, Paul-Egell-Straße 33, 67346, Speyer, Deutschland.
| | - S Morbach
- Abteilung Diabetologie und Angiologie, Fachbereich , Innere Medizin, Marienkrankenhaus gGmbH Soest, Soest, Deutschland
| | - U Rother
- Gefäßchirurgische Abteilung, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - C Uhl
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - H Görtz
- Klinik für Gefäßchirurgie, Bonifatius Hospital Lingen, Lingen, Deutschland
| | - D Böckler
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C A Behrendt
- Klinik und Poliklinik für Gefäßmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - D Hochlenert
- Centrum für Diabetologie, Endoskopie und Wundheilung Köln, Köln, Deutschland
| | - G Engels
- Chirurgische Praxis am Bayenthalgürtel, Köln, Deutschland
| | - A Hohneck
- Abteilung für Angiologie, 1. Medizinische Klinik, Universitätsklinik Mannheim, Mannheim, Deutschland
| | - M Sigl
- Abteilung für Angiologie, 1. Medizinische Klinik, Universitätsklinik Mannheim, Mannheim, Deutschland
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Peters AS, Meisenbacher K, Weber D, Bisdas T, Torsello G, Böckler D, Bischoff MS. Isolated femoral artery revascularisation with or without iliac inflow improvement - a less invasive surgical option in critical limb ischemia. VASA 2021; 50:217-223. [PMID: 33435742 DOI: 10.1024/0301-1526/a000934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Isolated femoral artery revascularisation (iFAR) represents a well-established surgical method in the treatment of peripheral arterial disease (PAD) involving common femoral artery disease. Data for iFAR in multilevel PAD are inconsistent, particularly in patients with critical limb ischemia (CLI). The aim of the study was to evaluate the outcome of iFAR in CLI regarding major amputation and reintervention and to identify associated risk factors for this outcome. Patients and methods: The data used have been derived from the German Registry of Firstline Treatment in Critical Limb Ischemia (CRITISCH). A total of 1200 patients were enrolled in 27 vascular centres. This sub-analysis included patients, which were treated with iFAR with/without concomitant iliac intervention. For detection of risk factors for the combined endpoint of major amputation and/or reintervention, selection of variables for multiple regression was conducted using stepwise forward/backward selection by Akaike's information criterion. Results: 95 patients were included (mean age: 72 years ± 10.82; 64.2% male). Of those, 32 (33.7%) participants reached the combined endpoint. Risk factor analysis revealed continued tobacco use (odds ratio [OR] 2.316, confidence interval [CI] 0.832-6.674), TASC D-lesion (OR: 2.293, CI: 0.869-6.261) and previous vascular intervention in the trial leg (OR: 2.720, CI: 1.037-7.381) to be associated with reaching the combined endpoint. Conclusions: iFAR provides a reasonable, surgical option to treat CLI. Lesion length (TASC D) seems to have a negative impact on outcome. Further research is required to better define the future role of iFAR for combined femoro-popliteal lesions in CLI - best in terms of a randomised controlled trial.
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Affiliation(s)
- Andreas S Peters
- Department of Vascular and Endovascular Surgery Heidelberg, University Hospital Heidelberg, Germany
| | - Katrin Meisenbacher
- Department of Vascular and Endovascular Surgery Heidelberg, University Hospital Heidelberg, Germany
| | - Dorothea Weber
- Institute of Medical Biometry and Informatics, University of Heidelberg, Germany
| | - Theodosios Bisdas
- Department of Vascular Surgery, St. Franziskus Hospital Münster GmbH, Münster, Germany
| | - Giovanni Torsello
- Department of Vascular Surgery, St. Franziskus Hospital Münster GmbH, Münster, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery Heidelberg, University Hospital Heidelberg, Germany
| | - Moritz S Bischoff
- Department of Vascular and Endovascular Surgery Heidelberg, University Hospital Heidelberg, Germany
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15
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Gkremoutis A, Bisdas T, Torsello G, Schmitz-Rixen T, Tsilimparis N, Stavroulakis K. Early outcomes of patients with chronic kidney disease after revascularization for critical limb ischemia. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 62:104-110. [PMID: 33307644 DOI: 10.23736/s0021-9509.20.11661-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study was to report early outcomes of patients with non-dialysis-dependent chronic kidney disease (NDD-CKD) after revascularization for critical limb-threatening ischemia (CLTI). METHODS Perioperative data of patients from the CRITISCH (critical limb ischemia) Registry, who also had NDD-CKD (stages 3 and 4), were compared to their counterparts with normal renal function (NRF) or mild renal insufficiency (stages 1 and 2). Patient characteristics and type of first-line treatment were assessed. Amputation-free survival was the primary composite endpoint. Secondary endpoints included major adverse cardiovascular and cerebral events (MACCE) and hemodynamic failure of revascularization. Multivariable logistic regression determined risk factors for the endpoints. RESULTS 424 patients with NDD-CKD were identified. Endovascular revascularization (ER) was performed in 251 patients (59.2%). Eighty-six patients (20.3%) underwent bypass surgery (BS) and 29 patients (6.8%) femoral artery patchplasty (FAP). Conservative treatment (CT) was offered to 46 patients (10.9%); 12 patients (2.8%) underwent primary major amputation (PMA). Logistic regression analysis showed an increased early risk for amputation/death (OR=1.92, 95% CI: 1.09-3.40), death (OR=5.53, 95% CI: 1.92-15.90) and hemodynamic failure of the revascularization (OR=1.80, 95% CI: 1.19-2.72) compared to patients with NRF. Patients with NDD-CKD also seem to carry a higher risk for MACCE (OR=1.82, 95% CI: 0.99-3.36). NDD-CKD was not a risk factor for limb loss alone (OR=1.05, 95% CI: 0.49-2.22). CONCLUSIONS NDD-CKD was an independent risk factor for early postoperative mortality, morbidity and reduced patency, but not for limb loss. Robust follow-up is necessary to monitor for such events, as well as to prevent readmission.
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Affiliation(s)
| | - Theodosios Bisdas
- Department of Vascular and Endovascular Surgery, Athens Medical Center, Athens, Greece
| | - Giovanni Torsello
- Department of Vascular Surgery, St. Franziskus Hospital Münster, Münster, Germany
| | - Thomas Schmitz-Rixen
- Department of Vascular and Endovascular Surgery, University Hospital of Frankfurt, Frankfurt am Main, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery, Ludwig-Maximillians-University Hospital, Munich, Germany
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16
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Bisdas T, Patelis N, Argyrakopoulou G, Tsiachris D, Kurtis A, Gargalianos-Kakoliris P, Stefanadis C. Limb Salvage in Patients With Severe Critical Limb Ischemia (CLI) After Referral for a Second Opinion to a Dedicated CLI Center. INT J LOW EXTR WOUND 2020; 21:174-181. [PMID: 32594790 DOI: 10.1177/1534734620933069] [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: 11/17/2022]
Abstract
The complexity of critical limb ischemia (CLI) requires dedicated multidisciplinary teams of different care providers, who will supervise the full cycle of CLI care. Until CLI treatment is fully centralized, such dedicated teams may work as second-opinion tools before major amputation is undertaken in CLI patients. The aim of the study is to assess the effectiveness of a well-timed referral to a dedicated CLI-center of patients scheduled to major amputation elsewhere. A retrospective analysis of all CLI-patients treated in our department between January 2019 and March 2020 was conducted. Only patients scheduled for a major amputation elsewhere and referred to our clinic were included. Primary endpoint was amputation-free survival, whereas technical success, limb salvage, minor amputation rate, re-admission at 30 days, and frequency of medication change from other disciplines were the secondary endpoints. Sixteen patients with 19 treated limbs were identified and included in this analysis. The WIfI (wound, infection and foot ischemia) clinical stage on admission was 2 in 4 limbs (21%), 3 in 5 limbs (26%), and 4 in 10 limbs (53%). All patients underwent advanced endovascular revascularization. Minor amputation was performed in 8 patients (42%). Amputation-free survival at 6 months was 93% with limb salvage rate of 100%. Technical success and re-admission rates at 30 days was 95% and 6%, respectively. There was a medication adjustment from other specialties in 13 (81%) patients. Patients in severe stages of CLI scheduled to major amputation reached high limb salvage and survival rate, since they are referred for a second opinion to a dedicated multidisciplinary CLI team.
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17
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Bisdas T, Koutsias S. Carbon Dioxide As a Standard of Care for Zero Contrast Interventions: When, Why and How? Curr Pharm Des 2020; 25:4662-4666. [PMID: 31782359 DOI: 10.2174/1381612825666191129093823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/25/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Traditional contrast media containing iodine remain the gold standard for vessel visualization during endovascular procedures. On the other hand, their use has several side effects and implications and may cause contrast medium-induced nephropathy. Carbon dioxide (CO2) angiography is an old alternative technique used only for critical patients in order to prevent kidney damages or allergic reactions. Zero contrast procedure: The availability of automated CO2 injectors has led to an increase in the use of CO2 angiography, providing an option for zero contrast interventions, preserving patient renal function and saving costs for the hospital facility. Taking advantage of the properties of CO2 gas, it is possible to improve the performance of some complex procedures such as atherectomy and the detection of type II endoleaks after EVARs. However, a learning curve is needed to get good imaging, and learn about the qualities and limitations of the technique. CONCLUSIONS The use of automatic delivery systems for CO2 angiography appears to be a good choice for the use of CO2 as the first imaging option. The standardization of injection protocols and the extensive use of this technique could lead to significant benefits both for the patient's prospects and health facilities.
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Affiliation(s)
- Theodosios Bisdas
- Clinic of Advanced Endovascular Services, Athens Medical Centre, Athens, Greece
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18
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Giannopoulos S, Varcoe RL, Lichtenberg M, Rundback J, Brodmann M, Zeller T, Schneider PA, Armstrong EJ. Balloon Angioplasty of Infrapopliteal Arteries: A Systematic Review and Proposed Algorithm for Optimal Endovascular Therapy. J Endovasc Ther 2020; 27:547-564. [DOI: 10.1177/1526602820931488] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Endovascular revascularization has been increasingly utilized to treat patients with chronic limb-threatening ischemia (CLTI), particularly atherosclerotic disease in the infrapopliteal arteries. Lesions of the infrapopliteal arteries are the result of 2 different etiologies: medial calcification and intimal atheromatous plaque. Although several devices are available for endovascular treatment of infrapopliteal lesions, balloon angioplasty still comprises the mainstay of therapy due to a lack of purpose-built devices. The mechanism of balloon angioplasty consists of adventitial stretching, medial necrosis, and dissection or plaque fracture. In many cases, the diffuse nature of infrapopliteal disease and plaque complexity may lead to dissection, recoil, and early restenosis. Optimal balloon angioplasty requires careful attention to assessment of vessel calcification, appropriate vessel sizing, and the use of long balloons with prolonged inflation times, as outlined in a treatment algorithm based on this systematic review. Further development of specific devices for this arterial segment are warranted, including devices for preventing recoil (eg, dedicated atherectomy devices), treating dissections (eg, tacks, stents), and preventing neointimal hyperplasia (eg, novel drug delivery techniques and drug-eluting stents). Further understanding of infrapopliteal disease, along with the development of new technologies, will help optimize the durability of endovascular interventions and ultimately improve the limb-related outcomes of patients with CLTI.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Ramon L. Varcoe
- Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, University of New South Wales, The Vascular Institute, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | | | - John Rundback
- Advanced Interventional & Vascular Services LLP, Teaneck, NJ, USA
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Thomas Zeller
- Department of Angiology, Universitäts-Herzzentrum Bad Krozingen, Germany
| | - Peter A. Schneider
- Division of Vascular and Endovascular Surgery, University of California at San Francisco, CA, USA
| | - Ehrin J. Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Lamaina M, Childers CP, Liu C, Mak SS, Booth MS, Conte MS, Maggard-Gibbons M, Shekelle PG. Clinical Effectiveness and Resource Utilization of Surgery versus Endovascular Therapy for Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2020; 68:510-521. [PMID: 32439522 DOI: 10.1016/j.avsg.2020.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND The clinical effectiveness of surgical versus endovascular therapy for chronic limb-threatening ischemia (CLTI) continues to be debated, and the resources required for each therapy are unclear. METHODS Systematic review of randomized controlled trials (RCTs) and observational studies comparing surgery with endovascular therapy for CLTI, which reported clinical effectiveness and resource utilization. Short-term and long-term clinical outcomes were examined. RESULTS The search yielded 4,231 titles, of which 17 publications met our inclusion criteria. Five publications were all from 1 RCT, and 12 publications were observational studies. In the RCT, the surgical approach had greater resource use in the first year (total hospital days across all admissions for surgery versus angioplasty: 46.14 ± 53.87 vs. 36.35 ± 51.39; P < 0.001; also true for days in high-dependency and intensive therapy units), but differences were not statistically significant in subsequent years. All-cause mortality presented a nonsignificant difference favoring angioplasty in the first 2 years (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [95% CI], 0.75-2.15), but after 2 years, it favored surgical treatment (aHR, 0.34; 95% CI, 0.17-0.71). The observational studies reported short-term effectiveness and resource utilization favoring endovascular therapy, but most differences were not statistically significant. Long-term outcomes were more mixed; in particular, mortality outcomes generally favored surgery, although concluding that cause and effect is not possible as endovascularly treated patients tended to be older and may have had a shorter life expectancy regardless of therapy. CONCLUSIONS The clinical effectiveness and resource utilization of surgery compared with endovascular therapy for CLTI is not known with certainty and will not be known until ongoing trials report results. It is likely that findings will vary by the time horizon, where initial outcomes and utilization tend to favor endovascular interventions, but long-term outcomes favor surgical revascularization.
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Affiliation(s)
- Margherita Lamaina
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Charles Liu
- Department of Surgery, Stanford University, Stanford, CA; David Geffen School of Medicine, National Clinician Scholars Program, University of California Los Angeles, Los Angeles, CA; Department of Surgery, Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Selene S Mak
- Department of Surgery, West Los Angeles Veterans Affairs Medical Center, Los Angeles, CA
| | | | - Michael S Conte
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | | | - Paul G Shekelle
- Department of Surgery, Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA
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Stella J, Engelbertz C, Gebauer K, Hassu J, Meyborg M, Freisinger E, Malyar NM. Outcome of patients with chronic limb-threatening ischemia with and without revascularization. VASA 2020; 49:121-127. [DOI: 10.1024/0301-1526/a000831] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Summary: Background: Patients with chronic critical limb-threatening ischemia (CLTI) are at high risk of amputation and death. Despite the general recommendation for revascularization in CTLI in the guidelines, the underlying evidence for such a recommendation is limited. The aim of our study was to assess the outcome of patients with CLTI depending on the use of revascularization in a retrospective real-world cohort. Patients and methods: Administrative data of the largest German Health insurance (BARMER GEK) were provided for all patients that were hospitalized for the treatment of CLTI Rutherford category (RF) 5 and 6 between 2009 and 2011. Patients were followed-up until December 31st, 2012 for limb amputation and death in relation to whether patients did (Rx +) or did not have (Rx −) revascularization during index-hospitalization. Results: We identified 15,314 patients with CLTI at RF5 (n = 6,908 (45.1%)) and RF6 (n = 8,406 (54.9%)), thereof 7,651 (50.0%) underwent revascularization (Rx +) and 7,663 (50.0%) were treated conservatively (Rx −). During follow-up (mean 647 days; 95% CI 640–654 days) limb amputation (46.5% Rx− vs. 40.6% Rx+, P < 0.001) and overall mortality (48.2% Rx− vs. 42.6% Rx+, P < 0.001) were significantly lower in the subgroup Rx+. Conclusions: In a real-world setting, only half of CLTI were revascularized during the in-hospital treatment. Though, revascularization was associated with significantly better observed short- and long-term outcome. These data do not allow causal conclusion due to lack of data on the underlying reason for applied or withheld revascularization and therefore may involve a relevant selection bias.
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Affiliation(s)
- Jacqueline Stella
- Department of Cardiology I – Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Münster, Germany
| | - Christiane Engelbertz
- Department of Cardiology I – Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Münster, Germany
| | - Katrin Gebauer
- Department of Cardiology I – Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Münster, Germany
| | - Juan Hassu
- Department of Cardiology I – Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Münster, Germany
| | - Matthias Meyborg
- Department of Cardiology I – Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Münster, Germany
| | - Eva Freisinger
- Department of Cardiology I – Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Münster, Germany
| | - Nasser M. Malyar
- Department of Cardiology I – Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Münster, Germany
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Abdoli S, Katz S, Ochoa C. Long-Term Patency and Clinical Outcomes of Nitinol Stenting for Femoropopliteal Atherosclerotic Disease. Ann Vasc Surg 2019; 66:566-572. [PMID: 31705987 DOI: 10.1016/j.avsg.2019.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/18/2019] [Accepted: 11/01/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment of peripheral arterial disease (PAD) has become increasingly dominated by endovascular interventions. The short-term outcomes of endovascular therapy have been well studied, but late outcomes remain largely unpublished; in this series, we report the late outcomes of primary nitinol stenting. METHODS All patients undergoing primary nitinol stenting of the superficial femoral artery (SFA) and/or popliteal artery (PA) during a 10-year period by a single surgeon (S.K.) were reviewed. No attempts were made on patients with orificial or total occlusion of the SFA, PA, and proximal tibial arteries. Differences in primary patency, primary-assisted patency, secondary patency, and freedom from bypass were evaluated at 1, 5, and 9 years. RESULTS A total of 294 limbs in 240 patients were treated. One hundred and thirty additional endovascular procedures were observed during the study period averaging to 0.16 endovascular interventions per limb per year. Primary patency in TASC A/B limbs at 1, 5, and 9 years was 79%, 35%, and 19%, respectively, and in TASC C/D limbs was 62%, 11%, and 3%, respectively. Secondary patency in TASC A/B limbs at 1, 5, and 9 years was 96%, 81%, and 65%, respectively, and in TASC C/D limbs was 92%, 64%, and 41%, respectively. Freedom from bypass in TASC A/B limbs at 1, 5, and 9 years was 98%, 89%, and 85%, respectively, and in TASC C/D limbs was 95%, 78%, and 69%, respectively. Five below-the-knee amputations were observed during the study period. CONCLUSIONS An endovascular-first approach can be applied to the vast majority of femoropopliteal lesions. While the late outcomes of TASC C/D lesions are inferior to those of TASC A/B lesions, an endovascular-first approach still provides durable outcomes.
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Affiliation(s)
- Sherwin Abdoli
- Department of Surgery, Huntington Memorial Hospital, Pasadena, CA.
| | - Steven Katz
- Department of Surgery, Huntington Memorial Hospital, Pasadena, CA; Division of Vascular Surgery and Endovascular Therapy, University of Southern California, Los Angeles, CA
| | - Christian Ochoa
- Department of Surgery, Huntington Memorial Hospital, Pasadena, CA; Division of Vascular Surgery and Endovascular Therapy, University of Southern California, Los Angeles, CA
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Survival after major lower extremity amputation in patients with end-stage renal disease. J Vasc Surg 2019; 70:1291-1298. [DOI: 10.1016/j.jvs.2018.12.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 12/22/2018] [Indexed: 11/18/2022]
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Percutaneous Vascular Interventions Versus Bypass Surgeries in Patients With Critical Limb Ischemia: A Comprehensive Meta-analysis. Ann Surg 2019; 267:846-857. [PMID: 28654542 DOI: 10.1097/sla.0000000000002344] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The aim of our study was to compare percutaneous vascular interventions (PVI) versus bypass surgeries (BSX) in patients with critical limb ischemia (CLI). BACKGROUND Previous relevant reviews with limited numbers of included studies did not strictly confine the inclusion criteria to CLI, also involving patients with severe claudication, which may introduce bias in the decision-making of CLI revascularization. Current treatment strategies for CLI still remain controversial. METHODS We performed a meta-analysis of all available randomized controlled trials and observational clinical studies comparing PVI with BSX in CLI patients. Primary endpoints included overall survival, amputation-free survival, 30-day mortality, and major adverse cardiovascular and cerebrovascular events. RESULTS We identified 45 cohorts and 1 RCT in over 20,903 patients. In overall population, PVI reduced the risks of 30-day mortality [odds ratio (OR) 0.69, 95% confidence interval (CI) 0.51-0.95), major adverse cardiovascular and cerebrovascular events (OR 0.42, 95% CI 0.29-0.61), and surgical site infection (OR 0.31, 95% CI 0.19-0.51), but increased the risks of long-term all-cause mortality [hazard ratio (HR) 1.16, 95% CI 1.05-1.27) and primary patency failure (HR 1.31, 95% CI 1.08-1.58). When compared with autogenous BSX, PVI was also associated with additional increased risks of long-term death or amputation (HR 1.41, 95% CI 1.02-1.94) and secondary patency failure (HR 1.51, 95% CI 1.17-1.95). In patients with infrapopliteal lesions, we found PVI had inferior primary patency (HR 1.39, 95% CI 1.10-1.75) compared with BSX. CONCLUSION For patients in good physical condition with long life-expectancy, BSX may represent a better choice compared with PVI, particularly when autogenous bypass is available. While enhanced perioperative care for cardiovascular events and surgical site should be considered in patients underwent BSX to achieve comparable short-term outcomes provided by PVI.
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Simons JP, Schanzer A, Flahive JM, Osborne NH, Mills JL, Bradbury AW, Conte MS. Survival prediction in patients with chronic limb-threatening ischemia who undergo infrainguinal revascularization. Eur J Vasc Endovasc Surg 2019; 58:S120-S134.e3. [DOI: 10.1016/j.ejvs.2019.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 08/01/2018] [Indexed: 01/15/2023]
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Simons JP, Schanzer A, Flahive JM, Osborne NH, Mills JL, Bradbury AW, Conte MS. Survival prediction in patients with chronic limb-threatening ischemia who undergo infrainguinal revascularization. J Vasc Surg 2019; 69:137S-151S.e3. [DOI: 10.1016/j.jvs.2018.08.169] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 08/01/2018] [Indexed: 12/24/2022]
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Geiger MA, Guillaumon AT. Primary stenting for femoropopliteal peripheral arterial disease: analysis up to 24 months. J Vasc Bras 2019; 18:e20160104. [PMID: 31191625 PMCID: PMC6542323 DOI: 10.1590/1677-5449.010416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 10/16/2018] [Indexed: 11/22/2022] Open
Abstract
Background Primary stenting is a well-established treatment option for femoropopliteal arterial obstructive disease. There is a shortage of Brazilian studies of the subject. Objectives To evaluate short and mid-term clinical and radiological outcomes in patients classified as Rutherford 3-6 and treated with stenting of femoropopliteal lesions. Methods Analysis based on a prospectively populated database of patients treated from July 2012 to July 2015. The primary endpoint was primary patency. Secondary endpoints were clinical and ankle/brachial index changes. Target Vessel Revascularization, limb salvage rate and death, within a 24-month follow-up period. Results 64 patients were enrolled, including 61 TASC II A / B lesions (95%). The primary patency rates at 6, 12, and 24 months were 95.2%, 79.1% and 57.9%, respectively. Cox regression analysis revealed lower patency rates in patients with occlusive disease (hazard ratio [HR], 6.64; 95% confidence interval [CI], 1.52-28,99, p = 0.02), as well as patency loss about 6 times higher in TASC B than in TASC A patients ([HR], 5.95, 95% CI, 1.67-21.3, p = 0.0061). At 12 months, 90.38% of the patients remained asymptomatic. The limb salvage rate at 24 months was 94.3% (95% CI, 87.9-100%). Freedom from TVR at 24 months was 90.5% (95% CI 82.8-98.9%). Conclusions Results of primary patency were compatible with international studies, despite the more advanced stage of the vascular disease observed in our group. Occlusive disease and complex lesions were both associated with worse outcomes.
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Affiliation(s)
- Martin Andreas Geiger
- Universidade Estadual de Campinas - UNICAMP, Hospital de Clínicas, Disciplina de Moléstias Vasculares, Campinas, SP, Brasil
| | - Ana Terezinha Guillaumon
- Universidade Estadual de Campinas - UNICAMP, Hospital de Clínicas, Disciplina de Moléstias Vasculares, Campinas, SP, Brasil
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Arhuidese I, Nejim B, Locham S, Malas MB. Infrainguinal bypass surgery outcomes are worse in hemodialysis patients compared with patients with renal transplants. J Vasc Surg 2018; 69:850-856. [PMID: 30583904 DOI: 10.1016/j.jvs.2018.05.252] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 05/31/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Studies of infrainguinal bypass surgery (IBS) in patients with end-stage renal disease have focused on hemodialysis (HD) patients. Little is known of the applicability of their outcomes to patients with renal transplants (RTs). In this study, we sought to compare perioperative and long-term outcomes of IBS in a large population-based cohort of HD and RT patients. METHODS A retrospective review of all HD and RT patients who underwent IBS between January 2007 and December 2011 in the U.S. Renal Data System was performed. Univariable, Kaplan-Meier, multivariable logistic, and Cox regression analyses were employed to evaluate 30-day postoperative (graft failure, limb loss, conduit infection, death) and long-term (primary patency [PP], primary assisted patency [PAP], secondary patency [SP], limb salvage, mortality) outcomes. RESULTS There were 10,787 IBSs performed in 9739 (90%) HD patients and 1048 (10%) RT patients who presented predominantly with critical limb ischemia (72%). Bypass configurations were femoral-popliteal (48%), femoral-tibial (34%), and popliteal-tibial (18%). Comparing HD vs RT patients, PP, PAP, and SP were 18% vs 33%, 23% vs 38%, and 30% vs 48%, respectively, at 5 years among autogenous conduit recipients (all P < .001) and 20% vs 28% (P = .02), 23% vs 31% (P = .02), and 33% vs 53% (P < .001) among prosthetic conduit recipients. Limb salvage and patient survival were 39% vs 56% and 19% vs 48%, respectively, at 5 years (all P < .001). Risk-adjusted analyses demonstrated higher PP (adjusted hazard ratio [aHR], 1.32; 95% confidence interval [CI], 1.20-1.45; P < .001), PAP (aHR, 1.32; 95% CI, 1.19-1.45; P < .001), SP (aHR, 1.47; 95% CI, 1.31-1.65; P < .001), limb salvage (aHR, 1.48; 95% CI, 1.30-1.67; P < .001), and patient survival (aHR, 2.42; 95% CI, 2.17-2.71; P < .001) for RT compared with HD patients. CONCLUSIONS The HD-dependent state is associated with elevated bypass and patient-level risks after IBS compared with patients with RTs. These results show that the benefits of renal transplantation likely extend to infrainguinal bypass-specific outcomes. The estimates of risk reported herein should inform the patient's and provider's expectations at the point of care.
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Affiliation(s)
- Isibor Arhuidese
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md; Division of Vascular Surgery, University of South Florida, Tampa, Fla
| | - Besma Nejim
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md
| | - Satinderjit Locham
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md
| | - Mahmoud B Malas
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md.
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Arhuidese I, Nejim B, Craig-Schapiro R, Rizwan M, Malas MB. Outcomes of lower extremity bypass surgery in patients with renal transplants. J Vasc Surg 2018; 68:1833-1840.e2. [DOI: 10.1016/j.jvs.2017.12.086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 12/17/2017] [Indexed: 12/30/2022]
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Schmitz-Rixen T, Grundmann RT. [Multimorbid vascular patients-do endovascular techniques expand the limits?]. Chirurg 2018; 90:117-123. [PMID: 30382296 DOI: 10.1007/s00104-018-0760-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The answer to the question of whether endovascular techniques extend the barriers to treatment in multimorbid vascular patients depends on the localization of the vascular disease and its stage. In multimorbid vascular patients with limited life expectancy and asymptomatic carotid stenosis, neither an endovascular nor an open procedure is indicated but a conservative best medicinal treatment is to be preferred. In symptomatic carotid stenosis the endovascular procedure is indicated for special anatomical conditions, such as contralateral carotid artery occlusion, contralateral recurrent nerve palsy, recurrent stenosis following endarterectomy, radical neck dissection and radiotherapy in the cervical region. In the treatment of intact abdominal aortic aneurysms (AAA), endovascular procedures reduce the perioperative risk especially in older patients, allowing the indications for intervention in this group of patients to be expanded, provided that the life expectancy of such treated patients is still several years. There is no clear evidence as to whether endovascular repair should be preferred in ruptured AAAs but there are indications that with the establishment of EVAR the proportion of patients receiving treatment has increased in those patients who were previously denied surgery after arrival in hospital. In critical limb ischemia the propagation of endovascular techniques has not so much extended the indications for invasive therapy but instead the endovascular approach has superseded open bypass surgery, which is positively reflected in a lower perioperative morbidity, especially in older frail patients.
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Affiliation(s)
- T Schmitz-Rixen
- Klinik für Gefäß- und Endovascularchirurgie und Universitäres Wundzentrum, Klinikum der Goethe-Universität, Frankfurt/M, Deutschland
| | - R T Grundmann
- Deutsches Institut für Gefäßmedizinische Gesundheitsforschung (DIGG) der Deutschen Gesellschaft für Gefäßchirurgie und Gefäßmedizin, Berlin, Deutschland. .,, In den Grüben 144, 84489, Burghausen, Deutschland.
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Zimmermann A, Balk S, Kuehnl A, Eckstein HH. Objective Performance Goals for Surgical Treatment of Critical Limb Ischemia. Ann Vasc Surg 2018; 55:104-111. [PMID: 30287288 DOI: 10.1016/j.avsg.2018.07.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/27/2018] [Accepted: 07/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Based on prospective vein bypass trials for lower leg ischemia, objective performance goals (OPG) were established by the Society for Vascular Surgery (SVS) and are used as a benchmark tool for open and endovascular treatments. This study aims to analyze OPG of all patients with critical limb ischemia (CLI) treated by open revascularization techniques at a tertiary care facility in routine practice. METHODS From January 2005 to March 2013, 315 patients (mean age 72 years) with CLI were retrospectively included in this study. Inclusion criteria were patients with Fontaine stage III and IV, realized revascularization with open surgical procedures (bypass grafting or endarterectomy), or hybrid method (open + endovascular). Exclusion criteria were primary major amputations, patients with revascularization treatments of the index leg within the last 3 months, and missing aftercare. Primary end point was "amputation-free survival" (AFS), and secondary end point was "freedom from major adverse limb event + perioperative death (30 days)" (MALE + POD) according to the SVS. The technical end point was primary patency. Mean follow-up was 34 months. The following variables were studied: clinical stage (Fontaine), previous interventions, bypass material used, and site of the distal anastomosis. The statistical evaluation and preparation was carried out using the Kaplan-Meier estimator and the log-rank test. A multivariate analysis was performed using the Cox proportional hazards model. A P value ≤0.05 was considered to be statistically significant. RESULTS A total of 128 patients (31%) fulfilling the adjusted SVS OPG criteria showed significantly better results for AFS, MALE + POD, and primary patency (P = 0.013, P = 0.015, P = 0.002, respectively). Regarding the AFS (1 year: 74%), multivariate analysis displayed significant worse results for patients with end-stage renal disease (hazard ratio [HR] 2.90, 95% confidence interval [CI] 1.83-4.60, P < 0.001) and Fontaine stage IV (HR 1.69, 95% CI 1.11-2.57, P = 0.015). Regarding MALE + POD (1 year: 64%), male patients (HR 0.64, 95% CI 0.46-0.90, P = 0.011) showed a significantly better outcome and patients without previous interventions of the index leg (HR 1.51, 95% CI 1.09-2.09, P = 0.013) showed a significantly worse outcome. CONCLUSIONS In this study, we were able to show that it is possible to reach the efficacy of OPGs set by SVS in a surgically treated all-comers cohort of CLI patients. Nevertheless, patients who did not fulfill the SVS OPG criteria showed significantly worse results for AFS and MALE + POD.
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Affiliation(s)
- Alexander Zimmermann
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.
| | - Stefanie Balk
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Andreas Kuehnl
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
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Martini R. Trends of the treatment of Critical Limb Ischemia during the last two decades. Clin Hemorheol Microcirc 2018; 69:447-456. [PMID: 29504528 DOI: 10.3233/ch-170352] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In this review 14 studies were identified reporting the treatment strategy in 4891 patients with Critical Limb Ischemia (CLI) with the aim to investigate if the strategy of treatment of the first episode of CLI has changed during the last 15-20 years. A computer research has been performed on PubMed and Scopus databases on November 2016. The used terms for the investigation about studies evaluating the strategy of treatment of CLI at the first-time presentation, have been "critical leg ischemia", "critical limb ischemia", "critical lower limb ischemia" along with the terms "placebo", "medical treatment" and/or "conservative" revascularisation, surgical revascularisation, endovascular revascularisation, hybrid revascularisation and primary amputation. Studies were included if they were either retrospective or prospective and reporting the rate of patients who underwent to any form of revascularization, conservative treatment and primary amputation. The one-year limb and life survival rates have been reported as major outcomes. The pooled rate of revascularization was 72.5% (95% CI 80-64.96) of which 54.5%, surgical, 38.3% endovascular and 7.1% hybrid. The bivariate regression of revascularisation procedures has been with not significant increase, from 68% in 1993 to 88% in 2015. The endovascular procedures have shown a significant increase of the trend, from 2% to more the 50% (p 0.007), while surgical and hybrid procedures have not. The pooled rate of conservative treatment was 18% (95% CI 11.6-24.5%) with a not significant increasing trend and primary amputation pooled rate was 8.7% (95% CI 12.0-5,4) with a significant decreasing trend (p 0.009). The one-year limb survival rate was 75,4% (95% CI 81.5-69.3%) and the life survival was 76%. (95% CI 85.4-66.1%) both with a not significant increasing trend. In conclusion, this review highlights how the treatment strategy of the first CLI manifestation has changed over the last 15-20 years. It has shown an increase of the rate of revascularization procedures, particularly for endovascular and a significant reduction of the rate of primary amputations. The rate of patients treated conservatively appears to be unchanged and maybe influencing the rate of limb and life survival, that have remained unchanged.
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Affiliation(s)
- Romeo Martini
- Unità Operativa di Angiologia, Azienda Ospedaliera Universitaria di Padova, Padova, Italy
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Outcomes of dialysis patients with critical limb ischemia after revascularization compared with patients with normal renal function. J Vasc Surg 2018; 68:822-829.e1. [DOI: 10.1016/j.jvs.2017.12.048] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 12/12/2017] [Indexed: 01/12/2023]
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Akagi D, Hoshina K, Akai A, Yamamoto K. Outcomes in Patients with Critical Limb Ischemia due to Arteriosclerosis Obliterans Who Did Not Undergo Arterial Reconstruction. Int Heart J 2018; 59:1041-1046. [DOI: 10.1536/ihj.17-592] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Daisuke Akagi
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo Hospital
| | - Katsuyuki Hoshina
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo Hospital
| | - Atsushi Akai
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo Hospital
| | - Kota Yamamoto
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo Hospital
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Vento V, Soler R, Fabre D, Gavit L, Majus E, Brenot P, Gargiulo M, Haulon S. Optimizing imaging and reducing radiation exposure during complex aortic endovascular procedures. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 60:41-53. [PMID: 30160093 DOI: 10.23736/s0021-9509.18.10673-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Improvements in endovascular technologies and development of custom-made fenestrated and branched endografts currently allow clinicians to treat complex aortic lesions such as thoraco-abdominal and aortic arch aneurysms once treatable with open repair only. These advances are leading to an increase in the complexity of endovascular procedures which can cause long operation times and high levels of radiation exposure. This in turn places pressure on the vascular surgery community to display more superior interventional skills and radiological practices. Advanced imaging technology in this context represents a strong pillar in the treatment toolbox for delivering the best care at the lowest risk level. Delivering the best patient care while managing the radiation and iodine contrast media risks, especially in frail and renal impaired populations, is the challenge aortic surgeons are facing. Modern hybrid rooms are equipped with a wide range of new imaging applications such as fusion imaging and cone-beam computed tomography (CBCT). If these technologies contribute to reducing radiation, they can be complex and intimidating to master. The aim of this review is to discuss the fundamentals of good radiological practices and to describe the various imaging tools available to the aortic surgeon, both those available today and those we anticipate will be available in the near future, from equipment to software, to perform safe and efficient complex endovascular procedures.
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Affiliation(s)
- Vincenzo Vento
- Aortic Center, Department of Aortic and Vascular Surgery, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Division of Vascular Surgery, Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Raphael Soler
- Aortic Center, Department of Aortic and Vascular Surgery, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Dominique Fabre
- Aortic Center, Department of Aortic and Vascular Surgery, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | | | | | - Philippe Brenot
- Aortic Center, Department of Aortic and Vascular Surgery, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Mauro Gargiulo
- Division of Vascular Surgery, Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Stéphan Haulon
- Aortic Center, Department of Aortic and Vascular Surgery, Hôpital Marie Lannelongue, Le Plessis-Robinson, France -
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Results from a multicenter registry of heparin-bonded expanded polytetrafluoroethylene graft for above-the-knee femoropopliteal bypass. J Vasc Surg 2018; 67:1463-1471.e1. [DOI: 10.1016/j.jvs.2017.09.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 09/07/2017] [Indexed: 11/21/2022]
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Stavroulakis K, Borowski M, Torsello G, Bisdas T. One-Year Results of First-Line Treatment Strategies in Patients With Critical Limb Ischemia (CRITISCH Registry). J Endovasc Ther 2018; 25:320-329. [PMID: 29968501 DOI: 10.1177/1526602818771383] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To examine the outcomes of all first-line strategies for the treatment of critical limb ischemia (CLI), identify factors that influenced the treatment choice, and determine the risk of amputation or death after each treatment. METHODS CRITISCH ( ClinicalTrials.gov identifier NCT01877252) is a multicenter, national, prospective registry evaluating all available treatment strategies applied in 1200 consecutive CLI patients in 27 vascular centers in Germany. The recruitment started in January 2013 and was completed in September 2014. Treatment options were endovascular revascularization (642, 53.5%), bypass surgery (284, 23.7%), femoral artery patchplasty (126, 10.5%) with or without concomitant peripheral intervention, conservative treatment (118, 9.8%), and primary major amputation (30, 2.5%). The primary endpoint of this study was amputation-free survival (AFS). The Society of Vascular Surgery's suggested objective performance goal (OPG) for AFS (71%) was used as the effectiveness criterion. Multivariable regression methods were employed to identify variables that influenced the treatment selection and AFS after each treatment; results are presented as the hazard ratio (HR) and 95% confidence interval (CI). RESULTS The 12-month AFS estimates following endovascular therapy, bypass grafting, femoral patchplasty, and conservative treatment were 75%, 72%, 73%, and 72%, respectively. Factors influencing treatment choice were age, chronic kidney disease (CKD), diabetes, smoking, prior vascular procedures in the index leg, TransAtlantic Inter-Society Consensus II C/D lesions, and absence of runoff vessels. Cox regression analysis identified CKD (HR 2.07, 95% CI 1.26 to 3.41, p=0.004), the use of a prosthetic bypass conduit (HR 1.97, 95% CI 1.23 to 3.14, p=0.004), and previous vascular intervention in the index limb (HR 1.52, 95% CI 0.94 to 2.43, p=0.085) as independent risk factors for diminished AFS after bypass surgery. CKD (HR 1.47, 95% CI 1.09 to 1.99, p=0.012) and Rutherford category 6 (HR 1.81, 95% CI 1.30 to 2.52, p<0.001) compromised the performance of endovascular revascularization. CONCLUSION CRITISCH registry data revealed that all first-line treatment strategies selected and indicated by the treating physicians met the suggested OPGs. CKD was an important determinant of patient prognosis after treatment regardless of the revascularization method.
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Affiliation(s)
- Konstantinos Stavroulakis
- 1 Department of Vascular Surgery, St Franziskus Hospital GmbH, Münster, Germany.,2 Department of Vascular Surgery, University Clinic of Münster, Germany
| | - Matthias Borowski
- 3 Institute of Biostatistics and Clinical Research, Westfälische Wilhelms-Universität Münster, Germany
| | - Giovanni Torsello
- 1 Department of Vascular Surgery, St Franziskus Hospital GmbH, Münster, Germany.,2 Department of Vascular Surgery, University Clinic of Münster, Germany
| | - Theodosios Bisdas
- 1 Department of Vascular Surgery, St Franziskus Hospital GmbH, Münster, Germany.,2 Department of Vascular Surgery, University Clinic of Münster, Germany
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Stavroulakis K, Borowski M, Torsello G, Bisdas T, Adili F, Balzer K, Billing A, Böckler D, Brixner D, Debus SE, Eckstein HH, Florek HJ, Gkremoutis A, Grundmann R, Hupp T, Keck T, Gerß J, Klonek W, Lang W, May B, Meyer A, Mühling B, Oberhuber A, Reinecke H, Reinhold C, Ritter RG, Schelzig H, Schlensack C, Schmitz-Rixen T, Schulte KL, Spohn M, Steinbauer M, Storck M, Trede M, Uhl C, Weis-Müller B, Wenk H, Zeller T, Zhorzel S, Zimmermann A. Association between statin therapy and amputation-free survival in patients with critical limb ischemia in the CRITISCH registry. J Vasc Surg 2017; 66:1534-1542. [DOI: 10.1016/j.jvs.2017.05.115] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 05/15/2017] [Indexed: 01/04/2023]
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Armstrong EJ, Ryan MP, Baker ER, Martinsen BJ, Kotlarz H, Gunnarsson C. Risk of major amputation or death among patients with critical limb ischemia initially treated with endovascular intervention, surgical bypass, minor amputation, or conservative management. J Med Econ 2017; 20:1148-1154. [PMID: 28760065 DOI: 10.1080/13696998.2017.1361961] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIMS Patients with critical limb ischemia (CLI) have an increased risk of major amputation. The initial treatment approach for CLI may significantly impact the subsequent risk of major amputation or death. The objective of this study was to describe the initial treatment approaches of patients with CLI and the limb outcomes associated with each approach. METHODS Data from MarketScan Commercial and Medicare Supplemental Databases from January 2006-December 2014 was utilized. Cohorts of CLI patients were defined as follows: (1) peripheral vascular intervention (PVI); (2) peripheral vascular surgery (PVS); (3) minor amputation without concomitant PVI or PVS (MinAMP); and (4) Patients without PVI, PVS, or MinAMP (conservative therapy). The odds of major amputation or inpatient death were estimated using the Cox proportional hazards model. For those patients requiring a major amputation, the incremental expenditures per member per month (PMPM) were estimated using a gamma log-link model. RESULTS Conservative therapy was associated with significantly higher odds of major amputation or inpatient death compared to patients who underwent minor amputation (1.59-times), PVI (2.08-times), or PVS (2.12-times). Patients treated with an initial strategy of minor amputation also had higher odds of major amputation or inpatient death compared to PVS (1.31-times) or PVI (1.33-times). The estimated incremental expenditures PMPM for patients with a major amputation was $5,165. CONCLUSIONS Revascularization reduces the risk of a major amputation or inpatient death for patients with CLI when compared to conservative therapy. Major amputation is also associated with significantly higher healthcare expenditures.
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Affiliation(s)
| | - Michael P Ryan
- b CTI Clinical Trial and Consulting Services, Inc. , Covington , KY , USA
| | - Erin R Baker
- b CTI Clinical Trial and Consulting Services, Inc. , Covington , KY , USA
| | | | - Harry Kotlarz
- c Cardiovascular Systems, Inc. , St. Paul , MN , USA
| | - Candace Gunnarsson
- b CTI Clinical Trial and Consulting Services, Inc. , Covington , KY , USA
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Schaefers JF, Schwindt AG, Maritati G, Torsello G, Pannucio G. Outcome After Crossing Femoropopliteal Chronic Total Occlusions Based on Optical Coherence Tomography Guidance. Vasc Endovascular Surg 2017; 52:27-33. [PMID: 29084493 DOI: 10.1177/1538574417740057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
AIMS The crossing of chronic total occlusions (CTOs) is the key step for an endovascular treatment. The Ocelot system is a novel device that combines a steerable drilling tip with optical coherence tomography (OCT) technology. It provides intraluminal imaging to help the crossing of CTOs in the femoropopliteal segment. Aim of the study was to determine early and midterm results after recanalization with this device. METHODS AND RESULTS During a period of 16 months, 84 CTOs were treated using the Ocelot system and prospectively registered. The primary end points were technical success and the primary and secondary patency of the lesion. Risk factors associated with early and midterm results were also analyzed. In all, 58 (69.0%) lesions were treated for intermittent claudication, 26 (31.0%) for critical limb ischemia, 34 (40.5%) were classified as Trans-Atlantic Inter-Society Consensus II D lesions, and 22 (26.2%) showed severe calcifications. The technical success rate was 72.6%. During 36 months of follow-up (mean 25.9), there were 10 reinterventions. The primary and secondary patency at 36 months were 54.2% and 68.1%, respectively. CONCLUSIONS In our experience, the Ocelot system would appear to be a safe and effective tool for increasing the applicability of endovascular techniques. However, the midterm results did not show drastic improvement.
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Affiliation(s)
- Johannes F Schaefers
- 1 Department of Vascular and Endovascular Surgery, University of Münster, Münster, Germany.,2 Department of Vascular Surgery, St Franziskus-Hospital GmbH, Münster, Germany
| | - Arne G Schwindt
- 1 Department of Vascular and Endovascular Surgery, University of Münster, Münster, Germany.,2 Department of Vascular Surgery, St Franziskus-Hospital GmbH, Münster, Germany
| | | | - Giovanni Torsello
- 1 Department of Vascular and Endovascular Surgery, University of Münster, Münster, Germany.,2 Department of Vascular Surgery, St Franziskus-Hospital GmbH, Münster, Germany
| | - Giuseppe Pannucio
- 1 Department of Vascular and Endovascular Surgery, University of Münster, Münster, Germany.,2 Department of Vascular Surgery, St Franziskus-Hospital GmbH, Münster, Germany
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Schmitz-Rixen T, Grundmann RT. Zur Publikationsaktivität der deutschen Gefäßchirurgie und Gefäßmedizin im internationalen Vergleich. GEFÄSSCHIRURGIE 2017; 22:349-357. [DOI: 10.1007/s00772-017-0296-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Patient selection and perioperative outcomes of bypass and endovascular intervention as first revascularization strategy for infrainguinal arterial disease. J Vasc Surg 2017; 67:206-216.e2. [PMID: 28844467 DOI: 10.1016/j.jvs.2017.05.132] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 05/31/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The optimal initial revascularization strategy remains uncertain for patients with peripheral arterial disease. The purpose of this study was to evaluate current nationwide selection and perioperative outcomes of patients undergoing bypass or endovascular intervention for infrainguinal disease in those with no prior ipsilateral revascularization. METHODS Patients undergoing nonemergent first-time infrainguinal revascularization were identified in the Targeted Vascular module of the National Surgical Quality Improvement Program (NSQIP) for 2011 to 2014 and stratified by symptom status (chronic limb-threatening ischemia [CLTI] or claudication). Patients treated with endovascular intervention were compared with those who underwent bypass. Multivariable logistic regression was used to evaluate current selection of patients and to establish independent associations between first-time procedures and postoperative outcomes. RESULTS Of 5998 first-time infrainguinal revascularizations performed, 3193 were bypass procedures (63% for CLTI) and 2805 were endovascular interventions (64% for CLTI). Current patient characteristics associated with an endovascular-first approach as opposed to bypass-first in CLTI patients were age ≥80 years, tissue loss, nonsmoking, functional dependence, diabetes, dialysis, and tibial lesions, whereas age ≥80 years, nonwhite race, nonsmoking, diabetes, and tibial lesions were associated with an endovascular approach for claudication. In comparing first-time endovascular intervention with bypass, there was no difference in 30-day mortality in CLTI patients (univariate: 2.1% vs 2.2%; adjusted: odds ratio [OR], 0.7; 95% confidence interval [CI], 0.4-1.1) or claudication patients (0.3% vs 0.6%). Among CLTI patients, endovascular-first intervention was associated with lower rates of major adverse cardiovascular event (3.6% vs 4.7%; OR, 0.6; 95% CI, 0.4-0.9), surgical site infection (0.9% vs 7.7%; OR, 0.1; 95% CI, 0.1-0.2), bleeding (8.5% vs 17%; OR, 0.4; 95% CI, 0.3-0.5), unplanned reoperation (13% vs 17%; OR, 0.7; 95% CI, 0.5-0.8), and unplanned readmission (17% vs 18%; OR, 0.8; 95% CI, 0.7-0.9). Patients with claudication undergoing endovascular-first intervention also had lower rates of major adverse cardiovascular event (0.8% vs 1.6%; OR, 0.4; 95% CI, 0.2-0.95), surgical site infection (0.7% vs 6.6%; OR, 0.1; 95% CI, 0.04-0.2), bleeding (2.3% vs 6.0%; OR, 0.3; 95% CI, 0.2-0.5), unplanned reoperation (4.3% vs 6.6%; OR, 0.6; 95% CI, 0.4-0.9), and unplanned readmission (5.9% vs 9.0%; OR, 0.6; 95% CI, 0.4-0.8). Conversely, endovascular-first intervention was associated with a higher rate of secondary revascularizations within 30 days for CLTI (4.3% vs 3.1%; OR, 1.6; 95% CI, 1.04-2.3) but not for claudication (2.6% vs 1.9%; OR, 1.7; 95% CI, 0.9-3.4). CONCLUSIONS An endovascular-first approach as a revascularization strategy for infrainguinal disease was associated with substantially lower early morbidity but not mortality, at the cost of higher rates of postoperative secondary revascularizations. As a national representation of first-time revascularizations, this study highlights the early endovascular perioperative benefit, although more robust long-term data are needed to adopt either one strategy or the other in select patients with peripheral arterial disease.
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Uhl C, Grosch C, Hock C, Töpel I, Steinbauer M. Comparison of Long-term Outcomes of Heparin Bonded Polytetrafluoroethylene and Autologous Vein Below Knee Femoropopliteal Bypasses in Patients with Critical Limb Ischaemia. Eur J Vasc Endovasc Surg 2017; 54:203-211. [DOI: 10.1016/j.ejvs.2017.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 05/01/2017] [Indexed: 10/19/2022]
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Arhuidese I, Hicks CW, Locham S, Obeid T, Nejim B, Malas MB. Long-term outcomes after autogenous versus synthetic lower extremity bypass in patients on hemodialysis. Surgery 2017; 162:1071-1079. [PMID: 28712733 DOI: 10.1016/j.surg.2017.04.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 03/23/2017] [Accepted: 04/21/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Hemodialysis dependence confers unique physiologic conditions. Prior reports of outcomes after infrainguinal open bypass operations in patients on hemodialysis have been based on relatively small sample institutional series. In this study, we evaluate long-term outcomes after open bypass operations in a large contemporary population-based cohort of hemodialysis patients. We studied all hemodialysis patients who underwent infrainguinal open operation using autogenous versus prosthetic conduits in the United States Renal Data System between January 2007 and December 2011. METHODS Univariate methods (χ2, analysis of variance) were used to compare the characteristics of the patient and type of bypass. Kaplan-Meier, univariate and multivariate logistic, and Cox regression analyses were used to evaluate 30-day postoperative outcomes as well as patency, limb salvage, and mortality in the long term. RESULTS There were 9,739 (autogenous: 59%, prosthetic: 49%) infrainguinal open bypass operations performed in this cohort. Of these, 4,717 (48%) were femoral-popliteal, 3,321 (34%) were femoral-tibial, and 1,701 (18%) were popliteal-tibial bypasses. Bypass operations were performed most commonly for critical limb ischemia (72%). Primary patency was 18% for both types of conduits at 5 years (P = .16). Comparing autogenous versus prosthetic conduits, primary-assisted patency was 23% vs 20% at 5 years (P = .98), while secondary patency was 30% for both conduits at 5 years (P = .05). Limb salvage was 35% vs 41% at 5 years (P < .001). Multivariable analyses demonstrated greater patency (adjusted hazard ratio [aHR]: 1.16; 95% confidence interval, 1.05-1.28; P = .003) and limb salvage (aHR: 1.12; 95% confidence interval, 1.01-1.24; P = .03) for autogenous compared to prosthetic bypasses. The advantage conferred by autogenous conduits was most clinically relevant for femoral-tibial (aHR: 1.34; 95% confidence interval, 1.17-1.55; P < .001) and popliteal-tibial (aHR: 1.55; 95% confidence interval, 1.09-2.21; P = .014) configurations. CONCLUSION This large study evaluated the long-term outcomes of open bypass operations in patients on hemodialysis. The data confirm the long-term benefits of autogenous conduits compared with prosthetic conduits in this high-risk population of patients, especially for the treatment of distal lesions. Individual patient life expectancy, availability of adequate autogenous conduit options, indication for operation, level of disease, as well as potential need for future options for additional access for dialysis should be taken into consideration when deciding to construct an open bypass in a hemodialysis patient.
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Affiliation(s)
- Isibor Arhuidese
- Division of Vascular Surgery, Johns Hopkins Medical Institution, Baltimore, MD; Division of Vascular Surgery, University of South Florida, Tampa, FL
| | - Caitlin W Hicks
- Division of Vascular Surgery, Johns Hopkins Medical Institution, Baltimore, MD
| | - Satinderjit Locham
- Division of Vascular Surgery, Johns Hopkins Medical Institution, Baltimore, MD
| | - Tammam Obeid
- Division of Vascular Surgery, Johns Hopkins Medical Institution, Baltimore, MD
| | - Besma Nejim
- Division of Vascular Surgery, Johns Hopkins Medical Institution, Baltimore, MD
| | - Mahmoud B Malas
- Division of Vascular Surgery, Johns Hopkins Medical Institution, Baltimore, MD.
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Kataoka S, Yamaguchi J, Nakao M, Jujo K, Hagiwara N. Clinical outcome and its predictors in hemodialysis patients with critical limb ischemia undergoing endovascular therapy. J Interv Cardiol 2017; 30:374-381. [DOI: 10.1111/joic.12393] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 04/26/2017] [Accepted: 04/28/2017] [Indexed: 11/28/2022] Open
Affiliation(s)
- Shohei Kataoka
- Department of Cardiology; The Heart Institute of Japan; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
| | - Junichi Yamaguchi
- Department of Cardiology; The Heart Institute of Japan; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
| | - Masashi Nakao
- Department of Cardiology; The Heart Institute of Japan; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
| | - Kentaro Jujo
- Department of Cardiology; The Heart Institute of Japan; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology; The Heart Institute of Japan; Tokyo Women's Medical University; Shinjuku-ku Tokyo Japan
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Uhl C, Steinbauer M, Torsello G, Bisdas T, Adili F, Balzer K, Billing A, Böckler D, Brixner D, Debus SE, Eckstein HH, Florek HJ, Gkremoutis A, Grundmann R, Hupp T, Hwang SW, Keck T, Wojciech K, Lang W, May B, Meyer A, Mühling B, Oberhuber A, Reinecke H, Reinhold C, Ritter RG, Schelzig H, Schlensack C, Schmitz-Rixen T, Schulte KL, Spohn M, Stavroulakis K, Storck M, Trede M, Weis-Müller B, Wenk H, Zeller T, Zhorzel S, Zimmermann A. Outcomes After Endovascular Revascularization in Octogenarians and Non-Octogenarians With Critical Limb Ischemia. J Endovasc Ther 2017; 24:471-477. [DOI: 10.1177/1526602817711424] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Christian Uhl
- Department of Vascular Surgery, Barmherzige Brueder Hospital, Regensburg, Germany
| | - Markus Steinbauer
- Department of Vascular Surgery, Barmherzige Brueder Hospital, Regensburg, Germany
| | - Giovanni Torsello
- Department of Vascular Surgery, University Clinic of Münster, Germany
- Department of Vascular Surgery, St Franziskus Hospital GmbH, Münster, Germany
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Shiraki T, Iida O, Takahara M, Soga Y, Mii S, Okazaki J, Kuma S, Yamaoka T, Kamoi D, Shintani Y, Ishikawa T, Kitano I, Uematsu M. Comparison of Clinical Outcomes after Surgical and Endovascular Revascularization in Hemodialysis Patients with Critical Limb Ischemia. J Atheroscler Thromb 2017; 24:621-629. [PMID: 27733731 PMCID: PMC5453687 DOI: 10.5551/jat.35915] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 09/14/2016] [Indexed: 11/11/2022] Open
Abstract
AIM The treatment strategy for hemodialysis (HD) patients with critical limb ischemia (CLI) has been clinically debatable. Here we compared clinical outcomes after bypass surgery (BSX) and after endovascular therapy (EVT) using propensity score matching. METHODS A retrospective multicenter database of 246 (68 BSX and 178 EVT) consecutive HD patients with CLI (79% with tissue loss) who underwent infrainguinal revascularization from 2007 to 2009 was used to compare clinical outcomes, including overall survival (OS), major amputation (MA), major adverse limb event (MALE: repeat EVT, surgical reconstruction, or MA), and MALE-free survival after BSX vs. EVT using propensity score matching. RESULTS The median (interquartile range) follow-up duration after revascularization was 21 (8-33) months. The analysis of the 63 propensity score-matched pairs revealed no significant difference in OS (53% vs. 52%, P=0.96), MA (25% vs. 14%, P=0.71), MALE (42% vs. 58%, P=0.63), and MALE-free survival (33% vs. 11%, P=0.37) at 3 year after BSX vs. EVT. CONCLUSIONS In HD patients with CLI who underwent infrainguinal revascularization, OS, MA, MALE, and MALE-free survival rates were not significantly different after EVT vs. BSX. The less invasive EVT should be considered as the first-choice therapeutic strategy for HD patients with CLI.
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Affiliation(s)
- Tatsuya Shiraki
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Osamu Iida
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Shinsuke Mii
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan
| | - Jin Okazaki
- Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Sosei Kuma
- Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Daisuke Kamoi
- Department of Cardiology, Nagoya Kyoritsu Hospital, Nagoya, Japan
| | | | | | - Ikuro Kitano
- Department of Surgery, Shinsuma General Hospital, Kobe, Japan
| | - Masaaki Uematsu
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
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Li Y, Esmail A, Donas KP, Pitoulias G, Torsello G, Bisdas T, Michelagnoli S, Troisi N. Antegrade vs Crossover Femoral Artery Access in the Endovascular Treatment of Isolated Below-the-Knee Lesions in Patients With Critical Limb Ischemia. J Endovasc Ther 2017; 24:331-336. [DOI: 10.1177/1526602817701251] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To evaluate the safety and effectiveness of antegrade vs crossover femoral artery access in the endovascular treatment of isolated below-the-knee (BTK) lesions in patients with critical limb ischemia (CLI). Methods: Between January 2014 and December 2015, 224 high-risk patients (mean age 75.8±9.8 years; 151 men) with CLI underwent infragenicular interventions on 292 crural vessels in 3 European vascular centers. All patients had isolated TransAtlantic Inter-Society Consensus (TASC) C (n=26) or D (n=198) BTK lesions. Primary endpoints were freedom from access-related complications and technical success comparing the antegrade vs crossover access groups. Results: Balloon angioplasty was the most used treatment modality (169 vessels, 75.4%). The technical success rate was 88.4% in the entire cohort and 88.0% in the antegrade group vs 90.4% in the crossover group (p>0.99). In all patients, the technical success rate was higher for stenotic lesions (100%) vs occlusions (85.5%, p=0.002) and in patients with TASC C BTK lesions (100%) vs TASC D (86.9%, p=0.033). The overall freedom from access-related complications was 97.8%: 99% in the antegrade group and 90.6% in the crossover group (p=0.022). Larger sheath size (5/6-F vs 4-F) was associated with a significantly higher risk for access-related complications (7.1% vs 1.1%, respectively; p=0.047). Conclusion: The present multicenter study showed high technical success and a low incidence of access-related complications in the treatment of isolated BTK lesions using either antegrade or crossover femoral access. The antegrade approach with the use of a 4-F system seems to have a significantly lower rate of access-related complications.
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Affiliation(s)
- Yukun Li
- Department of Vascular Surgery, St Franziskus Hospital Münster, Germany
- Clinic of Vascular and Endovascular Surgery, University of Münster, Germany
| | - Ali Esmail
- Department of Vascular Surgery, Sana Klinikum Hameln, Germany
| | - Konstantinos P. Donas
- Department of Vascular Surgery, St Franziskus Hospital Münster, Germany
- Clinic of Vascular and Endovascular Surgery, University of Münster, Germany
| | - Georgios Pitoulias
- Department of Vascular Surgery, St Franziskus Hospital Münster, Germany
- Clinic of Vascular and Endovascular Surgery, University of Münster, Germany
- Division of Vascular Surgery, Aristotle University of Thessaloniki, Greece
| | - Giovanni Torsello
- Department of Vascular Surgery, St Franziskus Hospital Münster, Germany
- Clinic of Vascular and Endovascular Surgery, University of Münster, Germany
| | - Theodosios Bisdas
- Department of Vascular Surgery, St Franziskus Hospital Münster, Germany
- Clinic of Vascular and Endovascular Surgery, University of Münster, Germany
| | - Stefano Michelagnoli
- Department of Surgery, Vascular and Endovascular Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
| | - Nicola Troisi
- Department of Surgery, Vascular and Endovascular Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
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Azuma N, Kikuchi S, Okuda H, Miyake K, Koya A. Recent Progress of Bypass Surgery to the Dialysis-Dependent Patients with Critical Limb Ischemia. Ann Vasc Dis 2017; 10. [PMID: 29147171 PMCID: PMC5684170 DOI: 10.3400/avd.ra.17-00076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
According to expansion of dialysis-dependent population, more than half of patients with critical ischemic limbs are dialysis-dependent in Japan. Although patients with end-staged renal disease are well-known as poor life prognosis, well-managed dialysis patients in Japan can survive much longer compared to dialysis patients in the United States and Europe. Therefore, some dialysis patients can enjoy the long-term benefits of bypass surgery. To decide the indication of bypass surgery, patient’s general condition, nutrition status, and vein availability are more important rather than arterial disease anatomy. Ultrasound guided nerve block anesthesia blocking both sciatic and femoral nerve is contributing greatly to quick postoperative recovery of high risk patients. Preoperative ultrasound examination also contribute to not only vein mapping but also find out the graftable segment of artery. The selection of distal target should be decided based on the degree of arterial disease (luminal surface as well as wall calcification), and arterial run-off. Several tips regarding anastomosis to heavily calcified artery have been established including how to create bloodless operative field without arterial clamps. Adequate wound management after bypass surgery is also important. Detection of deep infection such as osteomyelitis and the adequate treatment may avoid major amputation of salvageable limbs. In the era of endovascular treatment, the evidences guiding how to select dialysis patients suitable for bypass surgery are awaiting. (This is a translation of Jpn J Vasc Surg 2017; 26: 33–39.)
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Affiliation(s)
- Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Shinsuke Kikuchi
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Hiroko Okuda
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Keisuke Miyake
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Atsuhiro Koya
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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Bisdas T, Borowski M, Stavroulakis K, Torsello G, Adili F, Balzer K, Billing A, Böckler D, Brixner D, Debus SE, Eckstein HH, Florek HJ, Gkremoutis A, Grundmann R, Hupp T, Keck T, Gerß J, Klonek W, Lang W, May B, Meyer A, Mühling B, Oberhuber A, Reinecke H, Reinhold C, Ritter RG, Schelzig H, Schlensack C, Schmitz-Rixen T, Schulte KL, Spohn M, Steinbauer M, Storck M, Trede M, Uhl C, Weis-Müller B, Wenk H, Zeller T, Zhorzel S, Zimmermann A. Endovascular Therapy Versus Bypass Surgery as First-Line Treatment Strategies for Critical Limb Ischemia. JACC Cardiovasc Interv 2016; 9:2557-2565. [DOI: 10.1016/j.jcin.2016.09.039] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 09/21/2016] [Accepted: 09/25/2016] [Indexed: 12/19/2022]
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50
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Results of primary stent therapy for femoropopliteal peripheral arterial disease at 7 years. J Vasc Surg 2016; 64:1696-1702. [DOI: 10.1016/j.jvs.2016.05.073] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 05/24/2016] [Indexed: 11/19/2022]
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