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Harting MT, Drucker NA, Chen W, Cotton BA, Wang SK, DuBose JJ, Cox CS. Principles and Practice in Pediatric Vascular Trauma: Part 2: Fundamental Vascular Principles, Pediatric Nuance, and Follow-up Strategies. J Pediatr Surg 2024:161655. [PMID: 39168787 DOI: 10.1016/j.jpedsurg.2024.07.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 07/25/2024] [Indexed: 08/23/2024]
Abstract
As of 2020, penetrating injuries became the leading cause of death among children and adolescents ages 1-19 in the United States. For those patients who survive and receive advanced medical care, vascular injuries are a significant cause of morbidity and trigger notable trauma team angst. Moreover, penetrating injuries can lead to life-threatening hemorrhage and/or limb-threatening ischemia if not addressed promptly. Vascular injury management demands timely and unique expertise, particularly for pediatric patients. In part 1 of this review, we discussed the scope and extent of the epidemic of traumatic vascular injuries in pediatric patients, reviewed current evidence and outcomes, discussed various challenges and advantages of a myriad of existing team structures, and outlined potential outcome targets and solutions. However, in order to optimize care for pediatric vascular trauma, we must also understand the fundamental best practice principles, surgical options and approaches, medical management, and recommendations for ongoing, outpatient follow-up. In part 2, we will address the best evidence, combined with expert consensus, regarding strategies for diagnosing, managing, and ongoing follow-up of vascular trauma, with particular focus on the nuances that define the unique approaches to pediatric patients. LEVEL OF EVIDENCE: n/a.
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Affiliation(s)
- Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA; Red Duke Trauma Institute at Memorial Hermann - Texas Medical Center, Houston, TX, USA; Children's Memorial Hermann Hospital, Houston, TX, USA.
| | - Natalie A Drucker
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA; Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Wendy Chen
- Children's Memorial Hermann Hospital, Houston, TX, USA; Department of Surgery, Division of Pediatric Plastic Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA
| | - Bryan A Cotton
- Red Duke Trauma Institute at Memorial Hermann - Texas Medical Center, Houston, TX, USA; Department of Surgery, Division of Acute Care Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - S Keisin Wang
- Department of Cardiothoracic and Vascular Surgery, Division of Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA; Heart and Vascular Institute, Memorial Hermann - Texas Medical Center, Houston, TX, USA
| | - Joseph J DuBose
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Charles S Cox
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center, Houston, TX, USA; Red Duke Trauma Institute at Memorial Hermann - Texas Medical Center, Houston, TX, USA; Children's Memorial Hermann Hospital, Houston, TX, USA.
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Hoitz NCC, Nugteren MJ, Huizing E, Fioole B, Mees BME, de Borst GJ, Ünlü Ç. Duplex Ultrasound Surveillance After Femoropopliteal Endovascular Treatment for Peripheral Arterial Disease: A Systematic Review and Narrative Synthesis. Ann Vasc Surg 2024:S0890-5096(24)00422-9. [PMID: 39009126 DOI: 10.1016/j.avsg.2024.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 05/18/2024] [Accepted: 05/21/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND To review the current literature and establish a consensual recommendation on duplex ultrasound (DUS) surveillance after endovascular treatment of the femoropopliteal tract. METHODS This systematic review conducted literature searches on DUS surveillance after endovascular treatment of the femoropopliteal tract, and event rates. The primary end point was primary assisted patency. Secondary end points were primary patency, secondary patency, and limb salvage for double-armed studies, and sensitivity and specificity of DUS compared with other surveillance methods for single-armed studies. PubMed, Embase, and the Cochrane Library were searched. A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement. Articles were eligible if they compared DUS surveillance others surveillance methods. Prospective, large cohort studies reporting on long-term events after endovascular treatment were also included. RESULTS The initial search resulted in 5 studies. Only one double-armed nonrandomized study compared DUS surveillance with ankle-brachial index (ABI) follow-up after femoropopliteal stenting. The DUS group demonstrated improved primary assisted patency (84% vs. 76% at 12 months and 68% vs. 38% at 36 months, P = 0.008) and limb salvage (97% vs. 83% at 12 months and 90% vs. 50% at 36 months, P < 0.001) compared with ABI follow-up. In one single-armed study, DUS surveillance showed a high sensitivity (91%) and specificity (100%) in detecting restenosis. ABI and clinical follow-up demonstrated a low sensitivity (55-67% and 52-64%, respectively) but reasonable specificity (80-85% and 82-88%, respectively) in detecting restenosis. CONCLUSIONS The scarce available evidence suggests a clinical benefit of DUS surveillance after endovascular treatment of the femoropopliteal tract.
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Affiliation(s)
- Nathalie C C Hoitz
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, The Netherlands
| | - Michael J Nugteren
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, The Netherlands; Department of Vascular Surgery, UMCU, Utrecht, The Netherlands
| | - Eline Huizing
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, The Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Barend M E Mees
- Department of Vascular Surgery, MUMC+, Maastricht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, UMCU, Utrecht, The Netherlands
| | - Çağdaş Ünlü
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, The Netherlands.
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2497-2604. [PMID: 38752899 DOI: 10.1016/j.jacc.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Srinivasan A, Miranda J, Mills JL. Appropriate care in chronic limb threatening ischemia: A review of current evidence and outcomes. Semin Vasc Surg 2024; 37:249-257. [PMID: 39152003 DOI: 10.1053/j.semvascsurg.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/27/2024] [Accepted: 04/04/2024] [Indexed: 08/19/2024]
Abstract
Chronic limb threatening ischemia (CLTI) poses a significant treatment challenge for vascular surgeons, interventionalists, podiatrists, and associated medical specialists. The evidence for what constitutes appropriate care is rapidly evolving and new treatment options are in constant development. This review examines the current guidelines for CLTI care, as well as reported outcomes for multiple care strategies in this patient population, including revascularization and medical optimization. We performed a literature review of the PubMed database, reviewing articles that reported outcomes for CLTI care between 2000 and 2023, and described these outcomes as they relate to the current state of CLTI treatment. Significant data are still forthcoming regarding CLTI care, but widespread adoption of appropriate CLTI care is essential for the treatment of this vulnerable population.
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Affiliation(s)
- Arvind Srinivasan
- Division of Vascular Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030.
| | - Jorge Miranda
- Division of Vascular Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030
| | - Joseph L Mills
- Division of Vascular Surgery, Michael E. Debakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030
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Hoitz N, Kraima A, Fioole B, Mees B, de Borst GJ, Ünlü Ç. Surveillance After Surgical and Endovascular Treatment for Peripheral Artery Disease: a Dutch Survey. Eur J Vasc Endovasc Surg 2024; 67:980-986. [PMID: 38159674 DOI: 10.1016/j.ejvs.2023.12.029] [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: 06/19/2023] [Revised: 10/18/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE At present, there is no clear, optimal approach to surveillance after invasive treatment of peripheral artery disease (PAD) in terms of modality, duration, clinical benefit, and cost effectiveness. The ongoing debate on the clinical benefit and cost effectiveness of standard surveillance creates a clear knowledge gap and may result in overtreatment or undertreatment. In this study, a survey was conducted among vascular surgeons in the Netherlands to assess the currently applied surveillance programmes. METHODS All vascular surgeons from the Dutch Society for Vascular Surgery received an online survey on follow up after open and endovascular revascularisation in patients with PAD. Surveillance was defined as at least one follow up visit after intervention with or without additional imaging or ankle brachial index (ABI) measurement. Ten types of PAD intervention were surveyed. RESULTS Surveys were returned by 97 (46.2%) of 210 vascular surgeons, and 76% reported using a routine follow up protocol after an invasive intervention. Clinical follow up only is most commonly performed after femoral endarterectomy (53%). After peripheral bypass surgery, clinical follow up only is applied rarely (4 - 8%). In six of the 10 interventions surveyed, duplex ultrasound (DUS) was the most used imaging modality for follow up. After bypass surgery, 76 - 86% of vascular surgeons perform DUS with or without ABI measurement. After endovascular interventions, 21 - 60% performed DUS surveillance. Lifelong surveillance is most often applied after aortobifemoral bypass (57%). Surveillance frequency and duration vary greatly within the same intervention. Frequencies range from every three or six months to annually. Duration ranges from one time surveillance to lifelong follow up. CONCLUSION There is significant practice variation in surveillance after surgical and endovascular treatment of patients with PAD in the Netherlands. Prospective studies to evaluate treatment outcomes and to define the clinical need and cost effectiveness of standardised surveillance programmes for patients with PAD are recommended.
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Affiliation(s)
- Nathalie Hoitz
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands.
| | - Annelot Kraima
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Barend Mees
- Department of Vascular Surgery, MUMC+, Maastricht, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, UMCU, Utrecht, the Netherlands
| | - Çağdaş Ünlü
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands
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Luo X, Tahabi FM, Rollins DM, Sawchuk AP. Predicting future occlusion or stenosis of lower extremity bypass grafts using artificial intelligence to simultaneously analyze all flow velocities collected in current and previous ultrasound examinations. JVS Vasc Sci 2024; 5:100192. [PMID: 38455094 PMCID: PMC10918260 DOI: 10.1016/j.jvssci.2024.100192] [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] [Received: 05/31/2023] [Accepted: 11/26/2023] [Indexed: 03/09/2024] Open
Abstract
Objective Routine surveillance with duplex ultrasound (DUS) examination is recommended after femoral-popliteal and femoral-tibial-pedal vein bypass grafts with various intervals postoperatively. The presently used methodology to analyze bypass graft DUS examination does not use all the available data and has been shown to have a significant rate for missing impending bypass graft failure. The objective of this research is to investigate recurrent neural networks (RNNs) to predict future bypass graft occlusion or stenosis. Methods This study includes DUS examinations of 663 patients who had bypass graft operations done between January 2009 and June 2022. Only examinations without missing values were included. We developed two RNNs (a bidirectional long short-term memory unit and a bidirectional gated recurrent unit) to predict bypass graft occlusion and stenosis based on peak systolic velocities collected in the 2 to 5 previous DUS examinations. We excluded the examinations with missing values and split our data into training and test sets. Then, we applied 10-fold cross-validation on training to optimize the hyperparameters and compared models using the test data. Results The bidirectional long short-term memory unit model can gain an overall sensitivity of 0.939, specificity of 0.963, and area under the curve of 0.950 on the prediction of bypass graft occlusion, and an overall sensitivity of 0.915, specificity of 0.909, and area under the curve of 0.912 predicting the development of a future critical stenosis. The results on different bypass types show that the system performs differently on different types. The results on subcohorts based on gender, smoking status, and comorbidities show that the performance on current smokers is lower than the never smoker. Conclusions We found that RNNs can gain good sensitivity, specificity, and accuracy for the detection of impending bypass graft occlusion or the future development of a critical bypass graft stenosis using all the available peak systolic velocity data in the present and previous bypass graft DUS examinations. Integrating clinical data, including demographics, social determinants, medication, and other risk factors, together with the DUS examination may result in further improvements. Clinical Relevance Detecting bypass graft failure before it occurs is important clinically to prevent amputations, salvage limbs, and save lives. Current methods evaluating screening duplex ultrasound examinations have a significant failure rate for detecting a bypass graft at risk for failure. Artificial intelligence using recurrent neural networks has the potential to improve the detection of at-risk bypass graft before they fail. Additionally, artificial intelligence is in the news and is being applied to many fields. Vascular surgeons need to know its potential to improve vascular outcomes.
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Affiliation(s)
- Xiao Luo
- School of Engineering and Technology, Indiana University Purdue University at Indianapolis, Indianapolis, IN
| | - Fattah Muhammad Tahabi
- School of Engineering and Technology, Indiana University Purdue University at Indianapolis, Indianapolis, IN
| | | | - Alan P. Sawchuk
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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McKenna M, Elghazaly H, Bergman H, Wingate L, Robbins D, Davies AH, Thapar A. Meta-Analysis of Duplex Surveillance Following Lower Limb Endovascular Intervention. J Endovasc Ther 2023:15266028231215215. [PMID: 38049939 DOI: 10.1177/15266028231215215] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
INTRODUCTION The aim of this systematic review was to identify the evidence in the literature for limb salvage with the introduction of duplex surveillance. METHODS A systematic review and meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA) methodology for all studies which compared a group undergoing clinical surveillance with a group undergoing combined clinical and duplex surveillance after endovascular therapy for peripheral arterial disease. MEDLINE, EMBASE, the Cochrane Database for Systematic Reviews, and ClinicalTrials.gov were searched for relevant studies by 2 reviewers. Studies were quality assessed using the ROBINS-I tool. An individual patient data survival analysis and meta-analysis for 1- and 2-year amputation outcomes using a random-effects model were performed. RESULTS Two low-quality nonrandomized studies met the inclusion criteria. There was a statistically and clinically significant reduction in major amputation in patients undergoing combined clinical and duplex surveillance (log-rank p<0.001). The number needed to treat to prevent 1 amputation at 2 years was 5 patients. At 1 year, the odds ratio (OR) for amputation was 0.22, 95% confidence interval (CI)=0.10-0.48, with no statistical heterogeneity. At 2 years, the numbers of patients were low and the effect on amputation was less certain OR=0.25, 95% CI=0.04-1.58. CONCLUSIONS Preliminary, low-quality data suggests that there may be a clinically significant reduction in major amputation with the introduction of duplex surveillance. It is recommended that a randomized controlled trial is performed to confirm these findings and identify the anatomical subgroups that benefit the most from surveillance. CLINICAL IMPACT "Two low-quality studies reveal a significant clinical impact: combined clinical and duplex surveillance markedly reduces major amputations (log-rank p<0.001). At 1-year, the odds ratio for amputation is 0.22 (95% CI=0.10-0.48), emphasizing limb salvage benefits. Despite less certainty at 2-years, a notable absolute risk reduction of 19% is seen, with a number needed to treat of 5. This underscores the urgent need for a randomized controlled trial to validate findings and identify key subgroups. The meta-analysis strongly advocates implementing duplex surveillance for a year post-endovascular interventions, especially in patients fit for reintervention, with important considerations for cost-effectiveness and focused clinical trials."
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Affiliation(s)
- Mervyn McKenna
- Academic Vascular Ultrasound Scientist and Research Fellow, Mid and South Essex Vascular Unit, Mid and South Essex NHS Foundation Trust, Biomechanics, Optics, Robotics and Imaging Group, Anglia Ruskin University, Cambridge, UK
| | - Hussein Elghazaly
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Henry Bergman
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Laura Wingate
- Lead vascular ultrasound scientist, Mid and South Essex Vascular Unit, Mid and South Essex NHS Foundation Trust, Basildon, UK
| | - Dan Robbins
- Biomechanics, Optics, Robotics and Imaging Group, Anglia Ruskin University, Cambridge, UK
| | - Alun H Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ankur Thapar
- Circulatory Health Group, Anglia Ruskin University, Consultant Vascular and Endovascular Surgeon, Mid and South Essex NHS Foundation Trust, Basildon, UK
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Graham A, Weaver ML, Holscher C, Reifsnyder T. Expected Duplex Ultrasound Results in Distal Revascularization and Interval Ligation Conduits. Ann Vasc Surg 2023; 97:157-162. [PMID: 37460015 DOI: 10.1016/j.avsg.2023.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/07/2023] [Accepted: 06/17/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND There are no published standards for the expected findings on noninvasive testing following distal revascularization and interval ligation (DRIL). This study evaluated the hemodynamic results and duplex ultrasound characteristics of DRIL. METHODS A retrospective chart review of patients who underwent DRIL using autogenous vein between 2008 and 2019 was performed. Patients with both preoperative and follow-up noninvasive testing were included. RESULTS Thirty-eight patients were included in the study. Median time to first follow-up was 30 days (range 1-226 days), where 12 had complete resolution of their symptoms and 26 had partial resolution. Of the 27 patients that had preoperative and postoperative testing, the wrist brachial index improved from 0.56 to 0.90 with the median finger pressure improving from 56 to 73 (P < 0.001). Seventeen patients had a second follow-up (sFU) at a median time from DRIL of 196 days (range 106-843 days). There was no significant difference in wrist brachial index or finger pressures between first follow-up and sFU. Duplex ultrasound of the DRIL conduits (n = 32) showed a very consistent pattern with elevated median velocities proximally (inflow 235 cm/sec, proximal anastomosis 217.7 cm/sec) and distinctly slower median velocities distally (midconduit 46.4 cm/sec, distal anastomosis 78.3 cm/sec, outflow 59.3 cm/sec). The same pattern of velocities was held constant at the sFU (n = 16). CONCLUSIONS In this study, velocities at the proximal anastomosis were significantly higher than velocities more distal in the DRIL bypass without evidence of stenosis. This may be due to hemodynamic changes in the brachial artery associated with presence of a fistula. Elevated velocities at the proximal anastomosis do not necessarily warrant further evaluation or intervention without other evidence of conduit compromise.
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Affiliation(s)
- Alexis Graham
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
| | - M Libby Weaver
- Division of Vascular Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Courtenay Holscher
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA
| | - Thomas Reifsnyder
- Division of Vascular Surgery, Department of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD
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Zhang H, Miao H, Yue D, Xia J. Clinical Significance of Action Research-Based Seamless Care to Improve Imaging Efficiency and Patients' Cognition, and Alleviate Patient Anxiety. Int J Gen Med 2023; 16:3427-3433. [PMID: 37593673 PMCID: PMC10427471 DOI: 10.2147/ijgm.s423957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/25/2023] [Indexed: 08/19/2023] Open
Abstract
Objective The present study was undertaken to assess the clinical significance of action research-based seamless care to improve imaging efficiency and alleviate patient anxiety. Methods A total of eighty patients who underwent imaging examinations in our hospital between May 2019 and November 2020 were recruited for this study. The patients were randomly assigned to two groups: the control group receiving routine care and the observation group receiving seamless care based on action research. The random assignment was conducted using a simple random sampling technique, ensuring an equal allocation of participants to each group at a 1:1 ratio, resulting in 40 cases in each group. Outcome measures included imaging examination duration, mean nursing duration, examination cognition, and negative emotion scores. Results Seamless care provided shorter imaging examination duration and nursing duration, and better ensured uneventful examinations than routine care (P<0.05). Patients given seamless care exhibited higher examination cognition versus those receiving routine care (P<0.05). Seamless care offered more mitigation of negative emotions for patients than routine care (P<0.05). Conclusion Action research-based seamless care effectively improves imaging efficiency and patients' awareness of imaging examinations and contributes to alleviating patients' adverse events.
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Affiliation(s)
- Haiqin Zhang
- Medical Imaging Department, Hai’an People’s Hospital, Jiangsu, 226600, People’s Republic of China
| | - Hui Miao
- Medical Imaging Department, Hai’an People’s Hospital, Jiangsu, 226600, People’s Republic of China
| | - Donglan Yue
- Medical Imaging Department, Hai’an People’s Hospital, Jiangsu, 226600, People’s Republic of China
| | - Jue Xia
- Department of Radiology, Nanjing Medical University Affiliated Wuxi People’s Hospital, Jiangsu, 2l4023, People’s Republic of China
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Sarpe AK, Flumignan CD, Nakano LC, Trevisani VF, Lopes RD, Guedes Neto HJ, Flumignan RL. Duplex ultrasound for surveillance of lower limb revascularisation. Cochrane Database Syst Rev 2023; 7:CD013852. [PMID: 37470266 PMCID: PMC10357487 DOI: 10.1002/14651858.cd013852.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
BACKGROUND Lower extremity atherosclerotic disease (LEAD) - also known as peripheral arterial disease - refers to the obstruction or narrowing of the large arteries of the lower limbs, most commonly caused by atheromatous plaque. Although in many cases of less severe disease patients can be asymptomatic, the major clinical manifestations of LEAD are intermittent claudication (IC) and critical limb ischaemia, also known as chronic limb-threatening ischaemia (CLTI). Revascularisation procedures including angioplasty, stenting, and bypass grafting may be required for those in whom the disease is severe or does not improve with non-surgical interventions. Maintaining vessel patency after revascularisation remains a challenge for vascular surgeons, since approximately 30% of vein grafts may present with restenosis in the first year due to myointimal hyperplasia. Restenosis can also occur after angioplasty and stenting. Restenosis and occlusions that occur more than two years after the procedure are generally related to progression of the atherosclerosis. Surveillance programmes with duplex ultrasound (DUS) scanning as part of postoperative care may facilitate early diagnosis of restenosis and help avoid amputation in people who have undergone revascularisation. OBJECTIVES To assess the effects of DUS versus pulse palpation, arterial pressure index, angiography, or any combination of these, for surveillance of lower limb revascularisation in people with LEAD. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and LILACS databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 1 February 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that compared DUS surveillance after lower limb revascularisation versus clinical surveillance characterised by medical examination with pulse palpation, with or without any other objective test, such as arterial pressure index measures (e.g. ankle-brachial index (ABI) or toe brachial index (TBI)). Our primary outcomes were limb salvage rate, vessel or graft secondary patency, and adverse events resulting from DUS surveillance. Secondary outcomes were all-cause mortality, functional walking ability assessed by walking distance, clinical severity scales, quality of life (QoL), re-intervention rates, and functional walking ability assessed by any validated walking impairment questionnaire. We presented the outcomes at two time points: two years or less after the original revascularisation (short term) and more than two years after the original revascularisation (long term). DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We used the Cochrane RoB 1 tool to assess the risk of bias for RCTs and GRADE to assess the certainty of evidence. We performed meta-analysis when appropriate. MAIN RESULTS We included three studies (1092 participants) that compared DUS plus pulse palpation and arterial pressure index (ABI or TBI) versus pulse palpation and arterial pressure index (ABI or TBI) for surveillance of lower limb revascularisation with bypass. One study each was conducted in Sweden and Finland, and the third study was conducted in the UK and Europe. The studies did not report adverse events resulting from DUS surveillance, functional walking ability, or clinical severity scales. No study assessed surveillance with DUS scanning after angioplasty or stenting, or both. We downgraded the certainty of evidence for risk of bias and imprecision. Duplex ultrasound plus pulse palpation and arterial pressure index (ABI or TBI) versus pulse palpation plus arterial pressure index (ABI or TBI) (short-term time point) In the short term, DUS surveillance may lead to little or no difference in limb salvage rate (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.49 to 1.45; I² = 93%; 2 studies, 936 participants; low-certainty evidence) and vein graft secondary patency (RR 0.92, 95% CI 0.67 to 1.26; I² = 57%; 3 studies, 1092 participants; low-certainty evidence). DUS may lead to little or no difference in all-cause mortality (RR 1.11, 95% CI 0.70 to 1.74; 1 study, 594 participants; low-certainty evidence). There was no clear difference in QoL as assessed by the 36-item Short Form Health Survey (SF-36) physical score (mean difference (MD) 2 higher, 95% CI 2.59 lower to 6.59 higher; 1 study, 594 participants; low-certainty evidence); the SF-36 mental score (MD 3 higher, 95% CI 0.38 lower to 6.38 higher; 1 study, 594 participants; low-certainty evidence); or the EQ-5D utility score (MD 0.02 higher, 95% CI 0.03 lower to 0.07 higher; 1 study, 594 participants; low-certainty evidence). DUS may increase re-intervention rates when considered any therapeutic intervention (RR 1.38, 95% CI 1.05 to 1.81; 3 studies, 1092 participants; low-certainty evidence) or angiogram procedures (RR 1.53, 95% CI 1.12 to 2.08; 3 studies, 1092 participants; low-certainty evidence). Duplex ultrasound plus pulse palpation and arterial pressure index (ABI or TBI) versus pulse palpation plus arterial pressure index (ABI or TBI) (long-term time point) One study reported data after two years, but provided only vessel or graft secondary patency data. DUS may lead to little or no difference in vessel or graft secondary patency (RR 0.83, 95% CI 0.19 to 3.51; 1 study, 156 participants; low-certainty evidence). Other outcomes of interest were not reported at the long-term time point. AUTHORS' CONCLUSIONS Based on low certainty evidence, we found no clear difference between DUS and standard surveillance in preventing limb amputation, morbidity, and mortality after lower limb revascularisation. We found no studies on DUS surveillance after angioplasty or stenting (or both), only studies on bypass grafting. High-quality RCTs should be performed to better inform the best medical surveillance of lower limb revascularisation that may reduce the burden of peripheral arterial disease.
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Affiliation(s)
- Anna Kp Sarpe
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Carolina Dq Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis Cu Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Virginia Fm Trevisani
- Disciplines of Emergency Medicine and Rheumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo and Universidade de Santo Amaro, São Paulo, Brazil
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Durham, USA
| | - Henrique J Guedes Neto
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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12
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Neufang A. Tipps und Tricks zur erfolgreichen kruropedalen Bypasschirurgie. GEFÄSSCHIRURGIE 2023. [DOI: 10.1007/s00772-023-00977-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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13
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Dar T, Li L, Basra M, Crockett S, Chowdhury MM, Zielinski LP, Ambler GK, Coughlin PA. Comparing the Benefit of Duplex Ultrasound Surveillance Following Both Infrainguinal Bypass Surgery and Stenting for Femoro-Popliteal Disease. Vasc Endovascular Surg 2022; 57:11-18. [PMID: 35972881 DOI: 10.1177/15385744221119627] [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: 11/15/2022]
Abstract
OBJECTIVE Duplex ultrasound surveillance (DUS) is commonly used following infrainguinal vein bypass. The role of DUS following endovascular revascularisation is as yet unclear. This study focuses on the role of DUS in a contemporary group of patients undergoing infrainguinal bypass or stent insertion. METHODS All patients undergoing either an infrainguinal vein graft bypass or stent insertion into the femoro-popliteal segment (November 2014 - January 2017) were identified. Patients were followed up for 2 years. Data on entry into DUS, pre-operative characteristics, adjunctive pharmacotherapy and reintervention were collated. The primary outcomes were major lower limb amputation and mortality at 2 years post revascularisation. RESULTS One hundred and thirty-five patients underwent infrainguinal vein bypass and 100 patients underwent stent insertion. 107 patients in the bypass cohort and 58 patients in the stent cohort entered DUS. For the bypass cohort, entering DUS was associated with a lower mortality rate (P = .003) but was not associated with an improvement in amputation rates. The odds ratio of major amputation or mortality was greater in the no surveillance group (4.58, 95% CI: 1.855 - 11.364). In the stent cohort, DUS was not associated with a significant improvement in either major amputation or death (odds ratio 2.13 (95% CI 0.903 - 5.051; P = .081). CONCLUSION DUS was associated with improved survival rates in patients undergoing lower limb bypass but had no benefit in those patients undergoing stent insertion. The role of DUS following stent insertion in the femoropopliteal segment needs to be better defined.
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Affiliation(s)
- Than Dar
- University of Cambridge, Cambridge, UK
| | - Lanxin Li
- University of Cambridge, Cambridge, UK
| | - Melvinder Basra
- Cambridge Vascular Unit, 2153Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen Crockett
- Cambridge Vascular Unit, 2153Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Mohammed M Chowdhury
- Cambridge Vascular Unit, 2153Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Lukasz Piotr Zielinski
- Cambridge Vascular Unit, 2153Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Patrick A Coughlin
- Cambridge Vascular Unit, 2153Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Thomas JP, So KL, Turner JT, Malanowski AJ, Colvard BD. Optimal conduit choice for open lower extremity bypass in critical limb threatening ischemia. Semin Vasc Surg 2022; 35:172-179. [DOI: 10.1053/j.semvascsurg.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/02/2022] [Accepted: 05/02/2022] [Indexed: 11/11/2022]
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15
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Gensicke N, Nicholson R, Sharp W. Lower extremity aneurysmal degeneration of great saphenous venous allograft bypass in an adolescent boy. J Vasc Surg Cases Innov Tech 2022; 8:5-8. [PMID: 35024522 PMCID: PMC8731692 DOI: 10.1016/j.jvscit.2021.10.007] [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] [Received: 08/07/2021] [Accepted: 10/10/2021] [Indexed: 12/05/2022] Open
Abstract
Chronic limb-threatening ischemia in the pediatric population is a rare phenomenon. When open repair is necessitated, an autogenous conduit is preferred. However, venous grafts are prone to their own long-term complications. We have presented the case of a 10-year-old boy with chronic limb-threatening ischemia due to popliteal artery thrombosis that was treated with an ipsilateral great saphenous vein bypass. Seven years after the initial procedure, the venous graft had developed aneurysmal degeneration with acute thrombosis, necessitating bypass revision. Through the present case, we have discussed the surgical approach and highlighted the importance of long-term postoperative surveillance after open repair in the pediatric population.
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Affiliation(s)
- Nicole Gensicke
- Department of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Rachael Nicholson
- Department of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - William Sharp
- Department of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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16
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Bryde R, Applewhite AI, Abu Dabrh AM, Taylor BJ, Heckman MG, Filmalter SE, Pujalte G, Rojas C, Heckman AJ, Brigham TJ, Prokop LJ, Shapiro BP. Cardiac structure and function in elite female athletes: A systematic review and meta-analysis. Physiol Rep 2021; 9:e15141. [PMID: 34894105 PMCID: PMC8665377 DOI: 10.14814/phy2.15141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/05/2021] [Accepted: 11/10/2021] [Indexed: 02/01/2023] Open
Abstract
We conducted a meta-analysis to synthesize the best available evidence comparing cardiac biventricular structure and function using cardiac magnetic resonance imaging (CMR) and transthoracic echocardiography (TTE) in elite female athletes and healthy controls (HC). Chronic exposure to exercise may induce cardiac chamber enlargement as a means to augment stroke volume, a condition known as the "athlete's heart." These changes have not been clearly characterized in female athletes. Multiple databases were searched from inception to June 18, 2019. Outcomes of interest included left ventricular (LV) and right ventricular (RV) dimensional, volumetric, mass, and functional assessments in female athletes. Most values were indexed to body surface area. The final search yielded 22 studies, including 1000 female athletes from endurance, strength, and mixed athletic disciplines. CMR-derived LV end-diastolic volume (LVEDV) and RV end-diastolic volume (RVEDV) were greater in endurance athletes (EA) versus HC (17.0% and 18.5%, respectively; both p < 0.001). Similarly, TTE-derived LVEDV and RVEDV were greater in EA versus HC (16.8% and 28.0%, respectively; both p < 0.001). Both LVEF and RVEF were lower in EA versus HC, with the most pronounced difference observed in RVEF via TTE (9%) (p < 0.001). LV stroke volume was greater in EA versus HC via both CMR (18.5%) and TTE (13.2%) (both p < 0.05). Few studies reported data for the mixed athlete (MA) population and even fewer studies reported data for strength athletes (SA), therefore a limited analysis was performed on MA and no analysis was performed on SA. This evidence-synthesis review demonstrates the RV may be more susceptible to ventricular enlargement. General changes in LV and RV structure and function in female EA mirrored changes observed in male counterparts. Further studies are needed to determine if potential adverse outcomes occur secondary to these changes.
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Affiliation(s)
- Robyn Bryde
- Department of Cardiovascular DiseasesMayo ClinicJacksonvilleFloridaUSA
| | | | - Abd Moain Abu Dabrh
- Department of Family MedicineMayo ClinicJacksonvilleFloridaUSA
- Division of General Internal MedicineIntegrative Medicine and HealthMayo ClinicJacksonvilleFloridaUSA
| | - Bryan J. Taylor
- Department of Cardiovascular DiseasesMayo ClinicJacksonvilleFloridaUSA
| | | | - Sara E. Filmalter
- Department of Family MedicineMayo ClinicJacksonvilleFloridaUSA
- Division of Sports MedicineDepartment of OrthopedicsMayo ClinicJacksonvilleFloridaUSA
| | - George Pujalte
- Department of Family MedicineMayo ClinicJacksonvilleFloridaUSA
- Division of Sports MedicineDepartment of OrthopedicsMayo ClinicJacksonvilleFloridaUSA
| | - Carlos Rojas
- Department of RadiologyMayo ClinicJacksonvilleFloridaUSA
| | | | | | | | - Brian P. Shapiro
- Department of Cardiovascular DiseasesMayo ClinicJacksonvilleFloridaUSA
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17
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Debus ES, Nehler MR, Govsyeyev N, Bauersachs RM, Anand SS, Patel MR, Fanelli F, Capell WH, Brackin T, Hinterreiter F, Krievins D, Nault P, Piffaretti G, Svetlikov A, Jaeger N, Hess CN, Sillesen HH, Conte M, Mills J, Muehlhofer E, Haskell LP, Berkowitz SD, Hiatt WR, Bonaca MP. Effect of Rivaroxaban and Aspirin in Patients with Peripheral Artery Disease Undergoing Surgical Revascularization: Insights from the VOYAGER PAD Trial. Circulation 2021; 144:1104-1116. [PMID: 34380322 DOI: 10.1161/circulationaha.121.054835] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Patients with peripheral artery disease (PAD) requiring lower extremity revascularization (LER) are at high risk of adverse limb and cardiovascular events. VOYAGER PAD demonstrated that rivaroxaban significantly reduced this risk. The efficacy and safety of rivaroxaban has not been described in patients who underwent surgical LER. Methods: The VOYAGER PAD trial randomized patients with PAD after surgical and endovascular LER to rivaroxaban 2.5mg twice daily plus aspirin or matching placebo plus aspirin and followed for a median of 28 months. The primary endpoint was a composite of acute limb ischemia, major vascular amputation, myocardial infarction, ischemic stroke, or cardiovascular death. The principal safety outcome was Thrombolysis in Myocardial Infarction (TIMI) major bleeding. International Society on Thrombosis and Haemostasis (ISTH) bleeding was a secondary safety outcome. All efficacy and safety outcomes were adjudicated by a blinded independent committee. Results: Of the 6564 randomized, 2185 (33%) underwent surgical LER and 4379 (67%) endovascular. Compared to placebo, rivaroxaban reduced the primary endpoint consistently regardless of LER method (p-interaction 0.43). Following surgical LER, the primary efficacy outcome occurred in 199 (18.4%) patients in the rivaroxaban group and 242 (22.0%) patients in the placebo group with a cumulative incidence at 3 years of 19.7% and 23.9%, respectively (HR 0.81, 95% CI 0.67 - 0.98; p=0.026). In the overall trial, TIMI major bleeding and ISTH major bleeding were increased with rivaroxaban. There was no heterogeneity for TIMI major bleeding (p-interaction 0.17) or ISTH major bleeding (p-interaction 0.73) based on LER approach. Following surgical LER, the principal safety outcome occurred in 11 (1.0%) patients in the rivaroxaban group and 13 (1.2%) patients in the placebo group; 3-year cumulative incidence 1.3% and 1.4% respectively (HR 0.88, 95% CI 0.39-1.95; p=0.75) Among surgical patients, the composite of fatal bleeding or intracranial hemorrhage (p=0.95) and postprocedural bleeding requiring intervention (p=0.93) were not significantly increased. Conclusions: The efficacy of rivaroxaban is associated with a benefit in surgical LER patients. While bleeding was increased with rivaroxaban plus aspirin, the incidence was low, with no significant increase in fatal bleeding, intracranial hemorrhage or postprocedural bleeds requiring intervention. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT02504216.
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Affiliation(s)
- E Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery-Angiology-Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Mark R Nehler
- CPC Clinical Research, Aurora, CO; Department of Surgery, Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Nicholas Govsyeyev
- CPC Clinical Research, Aurora, CO; Department of Surgery, Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Rupert M Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt, Darmstadt, and Center for Thrombosis and Hemostasis, University of Mainz, Mainz, Germany
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Manesh R Patel
- Duke Clinical Research Institute, Division of Cardiology, Duke University, Durham, NC
| | - Fabrizio Fanelli
- Vascular and Interventional Radiology Department, Careggi University Hospital, University of Florence, Florence, Italy
| | - Warren H Capell
- CPC Clinical Research, Aurora, CO; Department of Medicine, Division of Endocrinology, University of Colorado School of Medicine, Aurora, CO
| | | | - Franz Hinterreiter
- Department for Vascular Surgery KH BHB Linz, Seilerstätte 2, 4020, Austria
| | | | - Patrice Nault
- Vascular and Endovascular Surgery, McGill University Montreal, Canada
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Alexei Svetlikov
- The I.I. Mechnikov North-Western State Medical University, Department of Cardio-Vascular surgery, St-Petersburg, Russia
| | | | - Connie N Hess
- CPC Clinical Research, Aurora, CO; Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO
| | - Henrik H Sillesen
- Department of Vascular Surgery, Rigshospitalet, Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Michael Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Joseph Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX
| | | | | | - Scott D Berkowitz
- Thrombosis Group Head, Clinical Development, Bayer U.S., Whippany, NJ
| | - William R Hiatt
- CPC Clinical Research, Aurora, CO; Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO; Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO
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AIUM Practice Parameter for the Performance of Peripheral Arterial Ultrasound Examinations Using Color and Spectral Doppler Imaging. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:E17-E24. [PMID: 33555645 DOI: 10.1002/jum.15643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 06/12/2023]
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19
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Mahé G, Boge G, Bura-Rivière A, Chakfé N, Constans J, Goueffic Y, Lacroix P, Le Hello C, Pernod G, Perez-Martin A, Picquet J, Sprynger M, Behar T, Bérard X, Breteau C, Brisot D, Chleir F, Choquenet C, Coscas R, Detriché G, Elias M, Ezzaki K, Fiori S, Gaertner S, Gaillard C, Gaudout C, Gauthier CE, Georg Y, Hertault A, Jean-Baptiste E, Joly M, Kaladji A, Laffont J, Laneelle D, Laroche JP, Lejay A, Long A, Loric T, Madika AL, Magnou B, Maillard JP, Malloizel J, Miserey G, Moukarzel A, Mounier-Vehier C, Nasr B, Nelzy ML, Nicolini P, Phelipot JY, Sabatier J, Schaumann G, Soudet S, Tissot A, Tribout L, Wautrecht JC, Zarca C, Zuber A. Disparities Between International Guidelines (AHA/ESC/ESVS/ESVM/SVS) Concerning Lower Extremity Arterial Disease: Consensus of the French Society of Vascular Medicine (SFMV) and the French Society for Vascular and Endovascular Surgery (SCVE). Ann Vasc Surg 2021; 72:1-56. [DOI: 10.1016/j.avsg.2020.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 11/05/2020] [Indexed: 12/24/2022]
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20
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Zielinski LP, Chowdhury MM, Coughlin PA. Patient and Institutional Costs of Failure of Angioplasty of the Superficial Femoral Artery. Ann Vasc Surg 2021; 72:218-226. [PMID: 32889162 DOI: 10.1016/j.avsg.2020.08.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/09/2020] [Accepted: 08/11/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Debate surrounds the optimal management of superficial femoral artery (SFA) disease. Randomized trial data rarely reflect real world findings, specifically the consequences to the patient of angioplasty failure. We observed the effect of a failed SFA angioplasty on the need for repeated clinic visits, hospital readmissions, imaging requirements, and reinterventions. METHODS We reviewed a consecutive series of 148 patients (94 men, median age 72 years) undergoing solely SFA angioplasty over a 2-year period. Patient preangioplasty demographics and 2-year post-PTA follow-up data were collated, including hospital attendances (inpatient/outpatient), further imaging (including radiation exposure) and revascularization attempts. We defined "failed angioplasty" as presence of clinical symptoms with radiological evidence of significant restenosis after an initial successful primary SFA angioplasty. RESULTS Fifty-four patients represented with a failed angioplasty (median time of 4 months after index PTA). In this group, failure of index angioplasty resulted in a further 185 restenosis-related clinic visits and a total of 537 bed days of inpatient stay. This group underwent a further 149 imaging events and required a further 34 endovascular revascularization procedures and 12 infrainguinal bypass procedures. These interventions and investigations corresponded to overall effective radiation dose across all patients of 190.69 mSv. Of the cohort of 99 patients who did not have a "failed angioplasty," they required 100 clinic visits, 21 further scans (total radiation dose 6.42 mSv), and 36 bed days of inpatient admission. CONCLUSIONS Failed angioplasty results in significant additional consequences for patients and health-care systems. Further work should focus on refining decision-making, providing the right procedure to the right patient at the right time.
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Affiliation(s)
- Lukasz Piotr Zielinski
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation trust, Cambridge, United Kingdom
| | - Mohammed M Chowdhury
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation trust, Cambridge, United Kingdom
| | - Patrick A Coughlin
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation trust, Cambridge, United Kingdom.
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21
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Miyake K, Nakamura T, Fujimura H, Shibuya T, Sawa Y. Role of Bypass with Preoperatively Diagnosed Small Caliber Veins in Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2021; 74:344-355. [PMID: 33549802 DOI: 10.1016/j.avsg.2020.12.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND In chronic limb-threatening ischemia (CLTI), although recent studies suggested that limbs classified as a higher Wound, Ischemia, foot Infection (WIfI) stage would benefit more from bypass surgery than endovascular therapy (EVT), graft unavailability is a major limitation for bypass. However, such graft unavailability is not clearly defined. This study aimed to assess whether bypass with veins judged as small by preoperative ultrasound is acceptable to achieve wound healing. METHODS Ninety-five limbs classified as WIfI stage 3/4 that underwent infrainguinal bypass with veins were enrolled and divided into two groups based on the preoperative inner diameter of veins. Those with a diameter <2.5 mm were classified as small caliber grafts (SMGs, n=28) and those with a diameter ≥2.5 mm as sufficient caliber grafts (SUGs, n=67), and wound-related outcomes were evaluated. Wound healing rate (WHR) was analyzed in all cohort, and wound recurrence-free rate (WRF) and wound recurrence-free amputation-free survival rate (WRAFS) were calculated for limbs that achieved wound healing. A propensity score matched analysis was also performed to minimize the background difference, and 21 matched pairs were included for the analysis. RESULTS Although the primary patency rate was significantly worse in SMGs (1-year patency, Crude model: 82.1% in SUGs and 51.0% in SMGs, P=0.0003; matched model: 77.7% in SUGs and 41.6% in SMGs, P = 0.005), the secondary patency rate was maintained in the equivalent level (1-year patency, Crude model: 81.8% in SUGs and 83.1% in SMGs, P=0.26; matched model: 77.7% in SUGs and 78.4% in SMGs, P = 0.24). One-year WHR was equivalent between the groups in both crude and matched models (Crude model: 87.0% in SUGs and 83.8% in SMGs, P=0.13; matched model: 66.3% in SUGs and 61.4% in SMGs, P = 0.65). One-year WRF and WRAFS were also equivalent (Crude model: WRF, 95.9% in SUGs and 100% in SMGs, P = 0.71; WRAFS, 87.2% in SUGs and 88.0% in SMGs, P = 0.78. Matched model: WRF, 100% in SUGs and 100% in SMGs, P = 0.85; WRAFS, 92.9% in SUGs and 78.6% in SMGs, P = 0.38). CONCLUSIONS Although bypass with small caliber veins showed an inferior primary patency rate, WHR and WRF were equally good if grafts are maintained patent. Bypass with small caliber vein grafts would be an important option to achieve wound healing.
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Affiliation(s)
- Keisuke Miyake
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan; Department of Vascular Surgery, Japan Organization of Occupational Health and Safety, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Takashi Nakamura
- Department of Vascular Surgery, Japan Organization of Occupational Health and Safety, Osaka Rosai Hospital, Sakai, Osaka, Japan.
| | - Hironobu Fujimura
- Department of Cardiovascular Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Takashi Shibuya
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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22
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Endovascular Relining of Chronically Occluded Infrainguinal Venous Bypass Grafts. Ann Vasc Surg 2021; 74:339-343. [PMID: 33508456 DOI: 10.1016/j.avsg.2020.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/30/2020] [Accepted: 12/05/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Treatment of chronically occluded infrainguinal venous bypass grafts in patients presenting with recurrent chronic limb threatening limb ischemia (CLTI) represent a clinical challenge. Recent case reports have suggested the use of endovascular recanalization techniques without preceding thrombolysis. This study assesses feasibility and mid-term outcomes of this technique. RESULTS A retrospective review of 5 consecutive patients (3 men, 2 women, mean age 70 ± 5 years) presenting with chronic venous bypass graft occlusion and recurrence of CLTI during 1 year was performed. Patients were treated with relining of the bypass grafts. Patients were followed up at median 26 (6-36) months. All patients were treated successfully with restoration of flow in the grafts using recanalization and relining technique without thrombolysis. In 4 patients, a Viabahn stentgraft (SG) was used with the addition of interwoven nitinol stents (INS) in 3. In 1 patient, the graft was treated with INS without the addition of a stentgraft. No peripheral embolization was encountered during the procedures. One patient occluded the relined grafts after 6 months. The remaining 4 grafts were all patent at 24-month follow-up. A total of 6 reinterventions (in 3 patients) were performed to reach 80% secondary patency. CONCLUSIONS This case series demonstrate feasibility and promising mid-term results, from relining of chronically occluded infra-inguinal venous bypass grafts using stent grafts, interwoven and bare-metal stents without preceding thrombolysis. The technique could be an alternative treatment option in the treatment of these challenging cases.
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Sarpe AKP, Flumignan CDQ, Nakano LCU, Trevisani VFM, Lopes RD, Guedes Neto HJ, Flumignan RLG. Duplex ultrasound for surveillance of lower limb revascularisation. Hippokratia 2021. [DOI: 10.1002/14651858.cd013852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Anna KP Sarpe
- Department of Surgery, Division of Vascular and Endovascular Surgery; Universidade Federal de São Paulo; São Paulo Brazil
| | - Carolina DQ Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery; Universidade Federal de São Paulo; São Paulo Brazil
| | - Luis CU Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery; Universidade Federal de São Paulo; São Paulo Brazil
| | - Virginia FM Trevisani
- Disciplines of Emergency Medicine and Rheumatology; Escola Paulista de Medicina, Universidade Federal de São Paulo and Universidade de Santo Amaro; São Paulo Brazil
| | - Renato D Lopes
- Division of Cardiology; Duke University Medical Center; Durham USA
| | - Henrique J Guedes Neto
- Department of Surgery, Division of Vascular and Endovascular Surgery; Universidade Federal de São Paulo; São Paulo Brazil
| | - Ronald LG Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery; Universidade Federal de São Paulo; São Paulo Brazil
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Abola MTB, Golledge J, Miyata T, Rha SW, Yan BP, Dy TC, Ganzon MSV, Handa PK, Harris S, Zhisheng J, Pinjala R, Robless PA, Yokoi H, Alajar EB, Bermudez-delos Santos AA, Llanes EJB, Obrado-Nabablit GM, Pestaño NS, Punzalan FE, Tumanan-Mendoza B. Asia-Pacific Consensus Statement on the Management of Peripheral Artery Disease: A Report from the Asian Pacific Society of Atherosclerosis and Vascular Disease Asia-Pacific Peripheral Artery Disease Consensus Statement Project Committee. J Atheroscler Thromb 2020; 27:809-907. [PMID: 32624554 PMCID: PMC7458790 DOI: 10.5551/jat.53660] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 11/01/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Peripheral artery disease (PAD) is the most underdiagnosed, underestimated and undertreated of the atherosclerotic vascular diseases despite its poor prognosis. There may be racial or contextual differences in the Asia-Pacific region as to epidemiology, availability of diagnostic and therapeutic modalities, and even patient treatment response. The Asian Pacific Society of Atherosclerosis and Vascular Diseases (APSAVD) thus coordinated the development of an Asia-Pacific Consensus Statement (APCS) on the Management of PAD. OBJECTIVES The APSAVD aimed to accomplish the following: 1) determine the applicability of the 2016 AHA/ACC guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease to the Asia-Pacific region; 2) review Asia-Pacific literature; and 3) increase the awareness of PAD. METHODOLOGY A Steering Committee was organized to oversee development of the APCS, appoint a Technical Working Group (TWG) and Consensus Panel (CP). The TWG appraised the relevance of the 2016 AHA/ACC PAD Guideline and proposed recommendations which were reviewed by the CP using a modified Delphi technique. RESULTS A total of 91 recommendations were generated covering history and physical examination, diagnosis, and treatment of PAD-3 new recommendations, 31 adaptations and 57 adopted statements. This Asia-Pacific Consensus Statement on the Management of PAD constitutes the first for the Asia-Pacific Region. It is intended for use by health practitioners involved in preventing, diagnosing and treating patients with PAD and ultimately the patients and their families themselves.
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Affiliation(s)
- Maria Teresa B Abola
- Department of Clinical Research, Philippine Heart Center and University of the Philippines College of Medicine, Metro Manila, Philippines
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, and Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia
| | - Tetsuro Miyata
- Vascular Center, Sanno Hospital and Sanno Medical Center, Tokyo, Japan
| | - Seung-Woon Rha
- Dept of Cardiology, Internal Medicine, College of Medicine, Korea University; Cardiovascular Center, Korea University Guro Hospital, Seoul, South Korea
| | - Bryan P Yan
- Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Timothy C Dy
- The Heart Institute, Chinese General Hospital and Medical Center, Manila, Philippines
| | | | | | - Salim Harris
- Neurovascular and Neurosonology Division, Neurology Department, Universitas Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | | | | | | | - Hiroyoshi Yokoi
- Cardiovascular Center, Fukuoka Sanno Hospital; International University of Health and Welfare, Fukuoka, Japan
| | - Elaine B Alajar
- Section of Cardiology, Department of Internal Medicine, Manila Doctors Hospital; University of the Philippines College of Medicine, Manila, Philippines
| | | | - Elmer Jasper B Llanes
- Division of Cardiology, Department of Medicine, College of Medicine, University of the Philippines Philippine General Hospital, Manila, Philippines
| | | | - Noemi S Pestaño
- Section of Cardiology, Department of Internal Medicine, Manila Doctors Hospital, Manila, Philippines
| | - Felix Eduardo Punzalan
- Division of Cardiology, Department of Medicine, College of Medicine, University of the Philippines; Philippine General Hospital, Manila, Philippines
| | - Bernadette Tumanan-Mendoza
- Department of Clinical Epidemiology, University of the Philippines College of Medicine, Manila, Philippines
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Fisker L, Eiberg J, Sillesen H, Lawaetz M. The Role of Routine Ultrasound Surveillance after In Situ Infrainguinal Peripheral Vein Bypass for Critical Limb-Threatening Ischemia. Ann Vasc Surg 2020; 66:529-536. [DOI: 10.1016/j.avsg.2020.01.092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 01/12/2020] [Accepted: 01/18/2020] [Indexed: 10/25/2022]
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Lawaetz M, Fisker L, Lönn L, Sillesen H, Eiberg J. In Situ Vein Bypass Is Superior to Endovascular Treatment of Femoropopliteal Lesions in Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2020; 67:437-447. [PMID: 32234573 DOI: 10.1016/j.avsg.2020.03.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/09/2020] [Accepted: 03/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The objective of the study was to compare bypass surgery and endovascular revascularization of the femoropopliteal segment in patients with peripheral arterial disease and critical limb-threatening ischemia (CLTI). METHODS This is a single-center study including patients undergoing first-time lower extremity intervention with peripheral bypass surgery or percutaneous transluminal angioplasty with or without stenting (PTA/S) of the femoropopliteal segment because of CLTI from 2011 to 2015. Based on prospective entered data from the Danish Vascular Registry, the primary end points were amputation-free survival, overall mortality, and reinterventions. RESULTS A total of 679 patients with CLTI were included of which 35% (n = 239) were treated with PTA/S, 54% (n = 363) with vein bypass, and 11% (n = 77) with synthetic bypass. After 3 years, amputation-free survival was significantly better with a vein bypass (41.8% [95% CI: 35-48.4]) than both PTA/S (29.7% (95% CI: 22.7-37)) and synthetic bypass (31.7% [95% CI: 19-45.1]). Overall, the endovascular-treated patients faced more than 50% increased risk of major amputation or death than that of a vein bypass, after adjusting for comorbidity and Trans-Atlantic Inter-Society Consensus (TASC) classification (HR: 1.56 [95% CI: 1.21-2.05]). As expected, postoperative complications, length of hospital stay, and reinterventions were more frequent in the bypass groups. CONCLUSIONS In this nonrandomized study, autologous vein bypass was superior to both PTA/S and synthetic bypass in regard to amputation-free survival and overall mortality. Despite the increased frequency of surgical complications, a vein bypass appears justified in both shorter (TASC B-C) and longer (TASC D) femoropopliteal lesions.
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Affiliation(s)
- Martin Lawaetz
- Department of Vascular Surgery, Rigshospitalet, Denmark.
| | - Lasse Fisker
- Department of Vascular Surgery, Rigshospitalet, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars Lönn
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Radiology, Rigshospitalet, Denmark
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jonas Eiberg
- Department of Vascular Surgery, Rigshospitalet, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Copenhagen Academy for Medical Education and Simulation (CAMES), Copenhagen, Denmark
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Björck M, Earnshaw JJ, Acosta S, Bastos Gonçalves F, Cochennec F, Debus ES, Hinchliffe R, Jongkind V, Koelemay MJW, Menyhei G, Svetlikov AV, Tshomba Y, Van Den Berg JC, Esvs Guidelines Committee, de Borst GJ, Chakfé N, Kakkos SK, Koncar I, Lindholt JS, Tulamo R, Vega de Ceniga M, Vermassen F, Document Reviewers, Boyle JR, Mani K, Azuma N, Choke ETC, Cohnert TU, Fitridge RA, Forbes TL, Hamady MS, Munoz A, Müller-Hülsbeck S, Rai K. Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg 2019; 59:173-218. [PMID: 31899099 DOI: 10.1016/j.ejvs.2019.09.006] [Citation(s) in RCA: 230] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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28
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Venermo M, Sprynger M, Desormais I, Björck M, Brodmann M, Cohnert T, De Carlo M, Espinola-Klein C, Kownator S, Mazzolai L, Naylor R, Vlachopoulos C, Ricco JB, Aboyans V. Editor's Choice – Follow-up of Patients After Revascularisation for Peripheral Arterial Diseases: A Consensus Document From the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases and the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg 2019; 58:641-653. [DOI: 10.1016/j.ejvs.2019.06.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/08/2019] [Indexed: 10/25/2022]
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29
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Venermo M, Sprynger M, Desormais I, Björck M, Brodmann M, Cohnert T, De Carlo M, Espinola-Klein C, Kownator S, Mazzolai L, Naylor R, Vlachopoulos C, Ricco JB, Aboyans V. Follow-up of patients after revascularisation for peripheral arterial diseases: a consensus document from the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases and the European Society for Vascular Surgery. Eur J Prev Cardiol 2019; 26:1971-1984. [DOI: 10.1177/2047487319846999] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Peripheral arterial diseases comprise different clinical presentations, from cerebrovascular disease down to lower extremity artery disease, from subclinical to disabling symptoms and events. According to clinical presentation, the patient's general condition, anatomical location and extension of lesions, revascularisation may be needed in addition to best medical treatment. The 2017 European Society of Cardiology guidelines in collaboration with the European Society for Vascular Surgery have addressed the indications for revascularisation. While most cases are amenable to either endovascular or surgical revascularisation, maintaining long-term patency is often challenging. Early and late procedural complications, but also local and remote recurrences frequently lead to revascularisation failure. The rationale for surveillance is to propose the accurate implementation of preventive strategies to avoid other cardiovascular events and disease progression and avoid recurrence of symptoms and the need for redo revascularisation. Combined with vascular history and physical examination, duplex ultrasound scanning is the pivotal imaging technique for identifying revascularisation failures. Other non-invasive examinations (ankle and toe brachial index, computed tomography scan, magnetic resonance imaging) at regular intervals can optimise surveillance in specific settings. Currently, optimal revascularisation surveillance programmes are not well defined and systematic reviews addressing long-term results after revascularisation are lacking. We have systematically reviewed the literature addressing follow-up after revascularisation and we propose this consensus document as a complement to the recent guidelines for optimal surveillance of revascularised patients beyond the perioperative period.
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Affiliation(s)
- Maarit Venermo
- Department of Vascular Surgery, Helsinki University Hospital and University of Helsinki, Finland
| | - Muriel Sprynger
- Department of Cardiology, University of Liege Hospital, Belgium
| | - Ileana Desormais
- Department of Thoracic and Vascular Surgery and Vascular Medicine, Dupuytren University Hospital, France
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Sweden
| | | | - Tina Cohnert
- Department of Vascular Surgery, Graz University Hospital, Austria
| | - Marco De Carlo
- Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Christine Espinola-Klein
- Center for Cardiology – Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | | | - Lucia Mazzolai
- Division of Angiology, Lausanne University Hospital, Switzerland
| | - Ross Naylor
- Department of Vascular Surgery, Leicester Vascular Institute, UK
| | | | | | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital and Inserm 1098, France
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Abstract
Dermatologists encounter patients with a variety of lower extremity ulcers including those related to venous insufficiency and peripheral arterial disease. Vascular studies, including ankle brachial pressure index, toe pressure, toe brachial index, Doppler arterial waveform, Duplex ultrasonography, and angiography, play an essential role in the prevention, diagnosis, and management of vascular diseases. In fact, dermatologists are often the first medical providers to see patients with complex vascular conditions. Knowledge of the appropriate indications, interpretations, limitations, and advantages of the various vascular studies is critical to the successful and swift management of each patient presenting with a lower extremity ulcer. This study reviews the most commonly ordered arterial and venous studies and discusses the appropriate indications and interpretation of these studies.
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Affiliation(s)
- Ali Rajabi-Estarabadi
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ahmed Kayssi
- Division of Vascular Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Afsaneh Alavi
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- Division of Dermatology, Department of Medicine, Women's College Hospital, 76 Grenville Street, 5th Floor, Toronto, ON, M5S 1B2, Canada.
| | - Robert S Kirsner
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 756] [Impact Index Per Article: 151.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GUIDELINE SUMMARY Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69:3S-125S.e40. [PMID: 31159978 PMCID: PMC8365864 DOI: 10.1016/j.jvs.2019.02.016] [Citation(s) in RCA: 730] [Impact Index Per Article: 146.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minn
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34
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Zierler RE, Jordan WD, Lal BK, Mussa F, Leers S, Fulton J, Pevec W, Hill A, Murad MH. The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures. J Vasc Surg 2018; 68:256-284. [PMID: 29937033 DOI: 10.1016/j.jvs.2018.04.018] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/11/2018] [Indexed: 12/20/2022]
Abstract
Although follow-up after open surgical and endovascular procedures is generally regarded as an important part of the care provided by vascular surgeons, there are no detailed or comprehensive guidelines that specify the optimal approaches with regard to testing methods, indications for reintervention, and follow-up intervals. To provide guidance to the vascular surgeon, the Clinical Practice Council of the Society for Vascular Surgery appointed an expert panel and a methodologist to review the current clinical evidence and to develop recommendations for follow-up after vascular surgery procedures. For those procedures for which high-quality evidence was not available, recommendations were based on observational studies, committee consensus, and indirect evidence. Recognizing that there are numerous published reports on the role of duplex ultrasound for surveillance of infrainguinal vein bypass grafts, the Society commissioned a systematic review and meta-analysis on this topic. The panel classified the strength of each recommendation and the corresponding quality of evidence on the basis of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system: recommendations were graded either strong or weak, and the quality of evidence was graded high, moderate, or low. The resulting recommendations represent a wide variety of open surgical and endovascular procedures involving the extracranial carotid artery, thoracic and abdominal aorta, mesenteric and renal arteries, and lower extremity arterial revascularization. The panel also identified many areas in which there was a lack of high-quality evidence to support their recommendations. This suggests that there are opportunities for further clinical research on testing methods, threshold criteria, and the role of surveillance as well as on the modes of failure and indications for reintervention after vascular surgery procedures.
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Affiliation(s)
| | | | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, Md
| | - Firas Mussa
- Department of Surgery Palmetto Health/University of South Carolina School of Medicine, Columbia, SC
| | - Steven Leers
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Joseph Fulton
- Department of Surgery, Westchester Medical Center, Poughkeepsie, NY
| | - William Pevec
- Division of Vascular Surgery, University of California, Davis, Sacramento, Calif
| | - Andrew Hill
- Division of Vascular & Endovascular Surgery, The Ottawa Hospital & University of Ottawa, Ottawa, Ontario, Canada
| | - M Hassan Murad
- Division of Preventive Medicine, Mayo Clinic, Rochester, Minn
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