Global vascular guidelines on the management of chronic limb-threatening ischemia

Mid-Term Results of Popliteal-Pedal Inframalleolar Vein Bypasses in Chronic Limb-Threatening Ischemia Patients After Previous Failed Tibial Endovascular Recanalization

BACKGROUND

Inframalleolar bypass still preserves its role in the modern endovascular era. Aim of this study was to evaluate the mid-term outcomes of "short" inframalleolar vein bypasses in patients with chronic limb-threatening ischemia (CLTI) after the previously failed tibial endovascular recanalization.

METHODS

Between January 2015 and December 2021,107 CLTI patients in 3 Italian Departments of Vascular Surgery underwent "short" inframalleolar vein bypass after failed tibial endovascular recanalization. Early (30-day) and 3-year outcomes were evaluated in terms of survival, primary patency, primary assisted patency, secondary patency, and amputation-free survival. Univariate analysis of the perioperative factors affecting outcomes were performed by the means of log-rank test. The associations of procedure variables were sought based on a multivariate Cox regression analysis.

RESULTS

Distal anastomosis (inframalleolar) was mostly performed on dorsal pedis (64, 59.8%). At 30 days, bypass occlusion was recorded in 5 cases (4.6%). The mean follow-up period was 20.5 ± 17.9 months. The estimated 3-year overall survival was 66.7%. Three-year estimates of primary patency, primary assisted patency, secondary patency, and amputation-free survival were 68.5%, 70.1%, 70.2%, and 76.7%, respectively. Multivariate analysis showed a negative association of insulin treatment with primary patency (HR 4.3, P = 0.04), primary assisted patency (HR 5.1, P = 0.02), and secondary patency (HR 5.1, P = 0.02). The negative association of long-term corticosteroid use was also found with primary patency (HR 7.8, P = 0.005), primary assisted patency (HR 8.7, P = 0.003), secondary patency (HR 8.7, P = 0.003), and amputation-free survival (HR 3.9, P = 0.05).

CONCLUSIONS

Short" vein bypasses to the foot arteries in CLTI patients yielded good mid-term overall patency and limb salvage rates after a failed tibial endovascular recanalization. Insulin-dependent diabetes mellitus and long-term corticosteroid use seemed to affect the outcomes.

Association of Controlling Nutritional Status Score With Mortality in Patients With Chronic Limb-Threatening Ischemia Following Endovascular Revascularization

BACKGROUND

Chronic limb-threatening ischemia (CLTI) represents the severest manifestation of peripheral artery disease. Malnutrition is closely associated with poor clinical outcomes in patients with chronic diseases. The Controlling Nutritional Status (CONUT) score is a tool to evaluate the systemic inflammation and nutritional status. This study aimed to investigate the association of baseline CONUT score with mortality in patients with CLTI following endovascular revascularization.

METHODS

A single-center retrospective analysis of patients with CLTI undergoing endovascular revascularization between January 2015 and December 2022 was performed. Preoperative nutritional status was evaluated using CONUT score, which was calculated using the serum albumin concentration, total peripheral lymphocyte count, and total cholesterol concentration. A CONUT score ≥5 indicates moderate or severe malnutrition. The Kaplan-Meier and multivariate Cox proportional hazards regression were used for survival analysis and to evaluate the risk factors associated with mortality.

RESULTS

Among 232 enrolled patients, 20.7% had moderate or severe malnutrition defined by the CONUT score. During a median follow-up of 2.1 (interquartile ranges, 1.0-3.5) years, 87 (37.5%) patients died. The 3-year overall survival rate in patients with CLTI who underwent endovascular revascularization was 63.7%. The high CONUT (≥5) group had significantly worse 3-year overall survival (42.0% vs. 68.8%, P = 0.004) and limb salvage (73.3% vs. 84.1%, P = 0.005) rates than the low CONUT (<5) group. Multivariate analysis showed that high CONUT score was significantly associated with increased risk for mortality in patients with CLTI after endovascular revascularization (hazard ratio, 1.687; 95% confidence interval, 1.031-2.759; P = 0.037).

CONCLUSIONS

The present study indicated that moderate or severe malnutrition defined by the CONUT score was significantly associated with increased mortality in patients with CLTI following endovascular revascularization. Future study is required to evaluate the efficacy of nutritional intervention in these patients.

Comparison of Early Outcomes in Patients Who Underwent Common Femoral Thromboendarterectomy with Vein versus Bovine Pericardial Patches

BACKGROUND

The treatment outcomes of vein and bovine pericardial patches in thromboendarterectomy (TEA) for common femoral artery (CFA) lesions in patients with peripheral arterial disease (PAD) remain unclear. The purpose of this study was to evaluate the efficacy and safety of the bovine pericardial patch by comparing it with vein patch angioplasty.

METHODS

This was a multicenter retrospective study. We reviewed the data of patients who underwent TEA with patch angioplasty (vein versus bovine pericardial patch angioplasty) for PAD between January 2018 and December 2022. Indication for revascularization is patients with PAD with claudication symptoms to rest pain and foot ulcers that interfere with daily life, with lesions in the CFA region. The primary end point was 2-year patency. The secondary end points were postoperative wound complications, including patch rupture, and safety of remote-phase puncture of the patch area after patch angioplasty.

RESULTS

Within the observation period, TEA was performed on 157 limbs in 136 patients using vein patches and on 86 limbs in 79 patients using bovine pericardial patches. The number of claudication/rest pain/tissue loss was 110/13/34 cases in the vein patch group and 57/14/15 cases in the bovine pericardial patch group, respectively. No significant differences were observed in patient characteristics. No significant between group differences were observed in operative time, blood loss, or percentage of patients who underwent concomitant revascularization during the procedure. The 2-year primary patency rates of the vein and bovine pericardial patch were 95.6% and 92.8%, respectively (P = 0.49). The rate of surgical site infection in this study was 2.5% in the vein patch group and 5.8% in the bovine pericardial patch group, respectively (P = 0.29). Rupture of the patch occurred in 4 (2.5%) and 4 (4.7%) patients in the vein and bovine pericardial patch groups, respectively (P = 0.46), and the percentage of cases requiring revision of the patch site was 7 (4.5%) and 5 (5.8%) in the vein and bovine pericardial patch groups, respectively (P = 0.76). Postoperatively, 23 patients in the vein and 13 patients in the bovine pericardial patch groups underwent patch puncture during the remote period. The median follow-up duration from the date of the surgery to the date of the puncture was 544 days and 374 days in the vein and bovine pericardial patch groups, respectively. No patch-related complications were observed during remote stage puncture.

CONCLUSIONS

Compared with vein patches, TEA with bovine pericardial patches had acceptable outcomes in terms of patency and postoperative complications.

The Impact of Sociodemographic Variables on Functional Recovery following Lower Extremity Amputation

BACKGROUND

We hypothesize that sociodemographic variables, particularly disadvantaged financial environments, impact both rate of prosthetic utilization and the achievement of ambulation post major amputation.

METHODS

All cases in the Vascular Quality Initiative amputation module were queried between April 2013 and January 2024. Inclusion was limited to patients who underwent below knee, through knee, and above knee amputation. Two primary outcomes were investigated: Nonambulatory status after amputation (minimum of 120 days follow-up); and, not having obtained a prosthetic limb (minimum of 90 days follow-up). The ambulation status and prosthetic status analyses had 6,984 and 6,793 patients meet inclusion, respectively. Multivariable binary logistic regression analysis was performed utilizing variables which achieved univariable significance (P < 0.05) for the outcomes.

RESULTS

Mean follow-up for those meeting inclusion was 432 days. Among all patients meeting inclusion, 46.7% of patients did not acquire a prosthetic limb and 44.1% were nonambulatory. Sociodemographic factors with significant multivariable association for the outcome of no prosthetic limb acquisition in follow-up were as follows: advancing age (adjusted odds ratio [aOR] 1.011/year (1.006-1.016), P < 0.001); female sex (aOR 1.43 (1.28-1.61), P < 0.001); top 20% area deprivation index representing highest deprivation (aOR 1.24 (1.09-1.41) P = 0.001); race (P = 0.002) insurance status (P = 0.028) with protective status for commercial insurance (39% rate of no prosthetic) and non-US insurance (33%) versus Medicare (51%), Medicaid (48%), Veterans Affairs insurance (49%), Self-pay (42%), and Medicare Advantage (51%). There were numerous comorbidities which also had association with lack of prosthetic limb acquisition. Sociodemographic variables which achieved multivariable significance (P < 0.05) for the outcome of nonambulatory status after major amputation were as follows: female sex (aOR 1.37 (1.23-1.54), P < 0.001); Medicare insurance (P = 0.016); advancing age (aOR 1.009/year (1.004-1.014), P < 0.001); congestive heart failure (aOR 1.15 (1.02-1.31), P = 0.028); and, not living at home in follow-up (aOR (3.53 (2.99-4.17) P < 0.001). Physical therapy at any point after surgery (aOR 0.742 (0.662-0.832), P < 0.001) and commercial insurance (aOR 0.839 (0.737-0.956), P = 0.008) were protective. There were numerous comorbidities which also had association with nonambulatory status in follow-up.

CONCLUSIONS

Living within the most financially disadvantaged areas and race both have a significant independent association with lack of prosthetic limb acquisition following major amputation. Black, Native American, and Pacific Islander demographic patients experience lack of acquisition at a higher rate than White and Asian patients independent of comorbidities and socioeconomic covariables. Female patients obtain a prosthetic limb and ambulate less frequently than males after major amputation, largely due to a higher rate of above knee amputation. Comorbidities and not socioeconomic variables are the leading drivers of nonambulation.

Impact of Below-the-Knee Runoff in Patients With Lower Extremity Artery Disease Who Underwent Endovascular Therapy Using Drug-Coated Balloons in Femoropopliteal Lesions

BACKGROUND

The impact of below-the-knee (BK) runoff after drug-coated balloon (DCB) treatment in femoropopliteal (FP) lesions has not been well investigated.

METHODS

This retrospective multicenter observational study enrolled 291 consecutive patients with lower extremity artery disease who underwent endovascular therapy with DCBs for FP lesions between January 2018 and December 2021. Patients were classified into four groups based on the BK runoff. Outcome measures included primary patency, freedom from clinically driven target lesion revascularization (CD-TLR) and amputation, and overall survival rates at 24 months. The predictors of restenosis at 24 months were also investigated.

RESULTS

In total, 43, 98, 117, and 33 patients were classified into three, two, one, and no BK runoff groups, respectively. In three, two, one, and no BK runoff groups, the primary patency rates were 72.1%, 67.3%, 61.4%, and 44.1% (p = 0.028); freedom from CD-TLR rates were 87.1%, 78.8%, 71.7%, and 47.1% (p < 0.001); freedom from amputation rates were 95.2%, 97.9%, 92.8%, and 91.5% (p = 0.499); and overall survival rates were 89.4%, 83.2%, 76.6%, and 61.2% (p = 0.007), respectively, at 24 months. Multivariate analysis showed that chronic limb-threatening ischemia, no BK runoff, Lutonix use, and residual stenosis > 30% were independent predictors of primary patency loss at 24 months. The risk score, calculated as the number of predictors, reflected the risk of restenosis.

CONCLUSION

No BK runoff was associated with worse midterm primary patency, freedom from CD-TLR, and overall survival rates than at least one BK runoff.

Apolipoprotein and peripheral artery disease: Mendelian randomization analysis

BACKGROUND

The prevalence of peripheral arterial disease (PAD) is on the rise globally, leading to adverse clinical outcomes. Our aim was to investigate the causal relationship between apolipoprotein and PAD, as well as the potential mediating role of smoking, diabetes, hypertension, myocardial infarction, and ischemic stroke.

METHODS

We employed two-sample Mendelian randomization (TSMR) to assess the causal effect of apoB/A1 on the risk of PAD and potential mediators (smoking, diabetes mellitus, hypertension, myocardial infarction, and ischemic stroke), as well as the causal effect of those mediators on PAD. The use of multivariate MR (MVMR) allowed us to explore and quantify the mediating role of these factors in the causal association between apoB/A1 and the risk of PAD.

RESULTS

Our MR analysis showed that each standard deviation increase in apoB/A1 increased the risk of PAD by 46% (OR = 1.460, 95% CI: 1.255-1.697, P = 8.74E-07). Hypertension, myocardial infarction, and ischemic stroke were ultimately recognized as the mediators of the causal relationship between apoB/A1 and PAD, explaining 7.5%, 19.7%, and 62.5% of the causal effect, respectively, and the proportion combined of the three together was 81%.

CONCLUSIONS

These studies demonstrated that elevated apoB/A1 increases the risk of developing PAD and that this association may be mediated by hypertension, myocardial infarction, and ischemic stroke.

The Impact of Follow-Up on Mortality in Chronic Limb Threatening Ischemia

OBJECTIVES

Chronic Limb Threatening Ischemia (CLTI) is associated with high morbidity and mortality. As such, close follow-up is recommended to ensure patency of revascularization, limb viability, and optimization of cardiovascular risk factors. This study aimed to test the association between follow-up adherence and mortality, and to identify risk factors for non-adherence with recommended vascular follow-up.

METHODS

All patients hospitalized from 2019-2023 with infrainguinal CLTI and at least 30 days of post-hospitalization survival were included. Patients were stratified based on adherence with any outpatient vascular follow-up within one year defined as any outpatient visit conducted after the index hospitalization in which CLTI of the index limb was addressed. The primary endpoint was one-year mortality and risk factors for follow-up non-adherence were assessed to identify targets for improvement. Multivariable models adjusted for other relevant contributors to mortality including age, clinical comorbidities, medical therapies, and anatomic/clinical limb severity among others. Additional sensitivity analyses were conducted using various definitions of follow-up adherence to enhance reliability of the findings.

RESULTS

A total of 131 patients with a median age of 73 years were included. A majority had tissue loss (97, 74.1%), 118 (90.1%) underwent index revascularization and 13 (9.9%) received no intervention due to non-salvageable disease or patient preference. The overall one-year mortality rate was 19.8% and follow-up adherence was 83.2%. Non-adherence with vascular follow-up was associated with greater one-year mortality (40.9% vs 15.6%, OR 6.67, p=0.005), a finding which persisted when all definitions of follow-up were tested. Risk factors for follow-up non-adherence include transfer from another institution (30.2% vs 10.2%, OR 3.704, p=0.014) and lack of a primary care provider (PCP) (66.7% vs 11.8%, OR 14.603, p<0.001).

CONCLUSIONS

Non-adherence with vascular follow-up is associated with higher one-year mortality among patients with CLTI. Improved referral of CLTI patients to a vascular surgeon in the outpatient setting prior to the need for urgent interhospital transfer as well as care coordination through a PCP may help improve adherence with vascular follow-up.

Wound formation in patients with Rutherford category IV disease after endovascular therapy: rates and risk factors

BACKGROUND

Lower limb peripheral artery disease classified as Rutherford category IV, is characterized by lower limb ischemic pain both during exertion and at rest. This disease has an unclear course. We aimed to evaluate outcome predictors in this patient group after endovascular therapy. This single-center, retrospective, observational study included 234 consecutive patients (264 limbs), between April 2007 and December 2020. We investigated the disease clinical course after endovascular therapy. The primary endpoint was the wound formation rate 3 years after endovascular therapy.

RESULTS

The mean observation period was 48.2 ± 8.9 months. The patients (61.9% male; mean age, 76 ± 10 years) presented with diabetes (64.1%), and received hemodialysis with chronic kidney disease (35.0%) and ambulatory treatment (85.0%). The average ankle-brachial index before endovascular therapy was 0.69 ± 0.23. Skin perfusion pressure on the dorsal and plantar sides was 38 ± 13 mmHg and 36 ± 12 mmHg, respectively. The wound incidence rates at 1, 2, and 3 years after endovascular therapy were 8.3%, 11.4%, and 14.4%, respectively. Multivariate analysis revealed the following factors associated with wound formation: P2 in inframalleolar/pedal disease category in the Global Limb Anatomical Staging System (hazard ratio: 1.73, 95% confidence interval: 1.22-2.83, P = 0.01), non-ambulatory status (hazard ratio: 1.09, 95% confidence interval: 1.11-1.36, P = 0.02), intervention up to infrapopliteal lesion (hazard ratio: 1.55, 95% confidence interval: 1.17-2.46, P = 0.03), and patient with chronic kidney disease on hemodialysis (hazard ratio: 1.61, 95% confidence interval: 1.32-2.18, P = 0.03).

CONCLUSIONS

The 3-year incidence of wound onset in this study was 14.4%. Factors associated with this outcome included P2 in the Global Limb Anatomical Staging System, non-ambulatory status, intervention up to infrapopliteal lesion, and patient with chronic kidney disease on hemodialysis.

Advanced WIfI Stage is Associated with Poor Outcomes in the BEST-CLI Trial

OBJECTIVE

Wound, ischemia, and foot infection (WIfI) staging was established to provide objective classification in patients with chronic limb threatening ischemia (CLTI) and to predict 1-year major amputation risk. Our goal was to validate WIfI staging using data from the Best Endovascular versus Best Surgical Therapy in Patients with CLTI (BEST-CLI) trial.

METHODS

Data from the BEST-CLI Trial, a prospective randomized trial comparing surgical (OPEN) and endovascular (ENDO) revascularization, were used to assess the association of WIfI stage on long-term outcomes in an intention to treat analysis. Patients were prospectively allocated to two cohorts - cohort 1 and 2 - which included patients with and without adequate single segment greater saphenous vein (SSGSV), respectively. The primary outcome of this analysis was major amputation.

RESULTS

There were 1,568 patients analyzed, representing 86% of the entire trial population; of these 35.5%, 29.6% and 34.9% were categorized as WIfI 4, WIfI 3, and WIfI 1/2, respectively. There were 1223 patients (606 OPEN, 617 ENDO) and 345 patients (OPEN 172, ENDO 173) in cohorts 1 and 2, respectively. On unadjusted Kaplan-Meier analysis, WIfI clinical stages 4 and 3, compared to WIfI 1/2, were associated with higher rates of major amputation (21.4%, 16.2% vs. 10.7%), death (33.5%, 35.7% vs. 24.6%), amputation/death (44.9%, 44.5% vs. 31.3%), MALE/death (34.4%, 33.9% vs. 29.5%), and reintervention/amputation/death (69.9% vs. 69% vs. 60.4%) (P<.05 for all) at 3 years. On risk adjusted analysis, compared to WIfI 1/2, major amputation was associated with WIfI 4 (HR 2.06, 95% CI 1.44 - 2.96, P<.001) and WIfI 3 (HR 1.62, 95% CI 1.1-2.37, P=.013) stages. Death was associated with both WIfI 4 (HR 1.3, 95% CI 1.03 - 1.63, P=.027) and WIfI 3 (HR 1.42, 95% CI 1.13-1.79, P=.003). MALE/death was associated with WIfI 4 (HR 1.29, 95% CI 1.02 - 1.63, P=.036. Reintervention amputation/death was associated with WIfI 4 (HR 1.28, 95% CI 1.09 - 1.50, P=.03) and WIfI 3 (HR 1.22, 99% CI 1.03 - 1.43), P=.018). When examining OPEN vs. ENDO revascularization by each WIfI stage, OPEN intervention was favored in cohort 1 for MALE/death for each stage.

CONCLUSION

In BEST-CLI WIfI stage was strongly associated with major amputations, death, and MALE/death after revascularization for CLTI. Cohort 1 patients, with adequate preoperative SSGSV, had lower MALE/death with OPEN intervention across all WIfI stages. This validation of WIfI score in a prospective multicenter trial reinforces its importance in shared-decision making, informed consent, and prognostication.

Using Vascular Deserts as a Guide for Limb Preservation Outreach Programs Successfully Targets Underserved Populations

BACKGROUND

Vascular deserts, regions without vascular providers, previously described targets for limb salvage efforts. The Comprehensive Heart and Multidisciplinary Limb Preservation Outreach Networks (CHAMPIONS) programs targeted regions for outreach and evaluated the population using desert maps.

METHODS

At 2 events targeting underserved regions between 2022 and 2023, providers screened and educated participants on peripheral arterial and cardiovascular disease (PACD). Demographics and cardiovascular risk factors were collected. Using Arc geographic information system, vascular surgeons, and Vascular Quality Initiative (VQI) participating facilities were mapped with a 30-mile buffer. Participants were mapped with census data, and the healthy places index (HPI) was overlayed for population and social determinants of health data analysis in medical service study areas (MSSA), a geographical analysis unit. (Figure 1) Results were compared to prior statewide deserts.

RESULTS

Outreach program participants' mean age was 56 (range 6-88); 39% were male, and the majority were Hispanic (86%). 27% had no primary care provider (PCP). 30% had diabetes, 10% undiagnosed before the event, 38% had hypertension, 40% undiagnosed prior to the event, and 21% described intermittent claudication. 81% made <$30,000 annually, and 28% reported no health insurance. Similarities were observed when comparing program participant demographics to the population-level data from the targeted regions. Patients were more frequently Hispanic than other desert regions (68% vs. 36%, P < 0.001). Compared to other vascular desert regions, the target population was more disadvantaged in all HPI domains, including economic (18 vs. 38%, P < 0.001), education (21 vs. 39%, P < 0.001), and transportation (30 vs. 40%, P < 0.001). Worse education, financial, and transportation resources correspond to decreased care access due to poor literacy and travel burdens.

CONCLUSIONS

CHAMPIONS programs successfully targeted populations needing care based on vascular care desert maps, demonstrating that at-risk populations can be successfully identified and screened for cardiovascular disease.

The use of a novel toe-thumb pressure index for assessing arterial status in the lower limb. A reliability and validity study

AIMS

This study explored the reliability, validity and perceived comfort of a novel thumb pressure measure and calculation of a toe-thumb index to identify their suitability as an adjunct or alternatives to ankle-brachial and toe-brachial indices.

METHODS AND RESULTS

Repeated manual thumb and toe systolic blood pressures were conducted using two raters, over two time points, on 34 healthy participants. Concurrent automated toe, thumb and brachial systolic blood pressures as well as comfort ratings for these measures (using a 10 mm visual analogue scale) were captured once by a research assistant. Automated thumb and brachial measures showed fair correlation (ρ = 0.36, p = 0.03) and a toe-thumb index and toe-brachial index good correlation (ρ = 0.62, p < 0.01). Intraclass correlation coefficients (ICC) identified moderate intra-rater reliability for manual thumb pressures for Rater 1 and 2 (ICC 0.57, 95% CI [0.14, 0.79] and ICC 0.74, 95% CI [0.49, 0.87], respectively), while inter-rater reliability was poor (ICC = 0.16, 95% CI [-0.85, 0.47]). Concurrent validity comparing manual and automated measures for thumb pressure was also poor (ICC -0.05, 95% CI [-1.06, 0.72] and ICC 0.42, 95% CI [-0.16, 0.72] Rater 1 and 2 respectively). Thumb measures were significantly more comfortable than brachial measures (5 mm, p < 0.00).

CONCLUSION

Thumb systolic pressures are correlated with brachial systolic pressures, with reasonable intra-rater reliability, however, correlation is only fair and measurement error wider than clinically acceptable. Furthermore, manual measures are poorly correlated with automated units. Consequently, caution is required in applying these techniques. As thumb measures were perceived as significantly more comfortable than brachial measures and have an advantage where brachial pressures cannot, or should not, be obtained, further evaluation is warranted.

Patients with chronic limb-threatening ischemia: Experiences of their disease, treatment, and care in a cross-sectoral setting. A scoping review

INTRODUCTION

Patients facing chronic limb-threatening ischemia (CLTI) experience significant burdens, impacting their physical, emotional, and social well-being. They require extensive care from multidisciplinary healthcare professionals across primary and secondary settings. Managing CLTI necessitates strict patient adherence to treatment protocols to prevent severe complications. Surprisingly, previous studies have overlooked these patients' unique perspectives, highlighting the need to explore their experiences and challenges.

OBJECTIVE

The objective of this review was to systematically identify, examine, and conceptually map extant literature on patients with CLTI in the context of living with the condition, and explore their experiences of receiving treatment and care within a cross-sectoral setting.

METHODS

A systematic search was completed on 18 September 2023 with no methodological or format restrictions. We identified the population, concept, and context to pinpoint the delineate the focus of this review process. The JBI methodology for scoping reviews and the PRISMA-ScR checklist were followed.

RESULTS

Based on our search, we found ten relevant scientific qualitative and/or quantitative sources and one non-scientific source. We identified four main maps: 1) Dependency on others is my new life condition, 2) I'm more than the sum of my conditions, 3) I'm lost in chaos, be alert to all of me, and 4) Give me more time, my body and mind are under attack.

CONCLUSION

This scoping review describes how patients' lives are affected by CLTI and provides insights into their perception of shared decision-making, treatment, and care. The review reveals the need for a more person-centered approach to care. To nuance person-centred care further, it is necessary to consider the impact of patients' cultural values and preferences. However, this area is marked by a notable research gap.

Clinical validity of the Japanese below-the-knee chronic total occlusion scoring system for the prediction of successful guidewire crossing

OBJECTIVE

To validate the Japanese below-the-knee (J-BTK) chronic total occlusion (CTO) score for the prediction of successful guidewire crossing (S-GC) in angiographic evaluation.

METHODS

A prospective, multicenter, nonrandomized study examined 751 consecutive BTK CTOs in 497 patients treated with endovascular therapy in 16 Japanese medical centers from April 2021 to March 2022. The cohort was classified into 2 groups: an S-GC group and a failed guidewire crossing group.

RESULTS

The J-BTK CTO score, which assigned one point to "Blunt type at the proximal entry point," one point to "Calcification at the proximal entry point," one point to "Reference vessel diameter <2.0 mm," one point to "CTO length ≥200 mm," and two points to "No outflow of the target vessel," was used to categorize BTK CTOs into 4 grades with varying probabilities of S-GC: grade A (J-BTK CTO score of 0 and 1), grade B (score of 2 and 3), grade C (score of 4 and 5), and grade D (score of 6). Rates of S-GC in each grade (grades A, B, C, and D) were 97.5%, 89.1%, 62.5%, and 27.3%, respectively. The area under the receiver-operating characteristic curve for S-GC was 0.8304. Although the previous J-BTK CTO study enrolled only de novo lesions, both de novo and restenotic lesions were evaluated in this study. De novo lesions have a lower chance of S-GC (odds ratio: 0.24, 95% confidence interval: 0.09-0.67) in the multivariate analysis, and the area under the receiver-operating characteristic curve of the modified J-BTK CTO score, which additionally assigned two points to "De novo lesion," was 0.846. The modified J-BTK CTO score showed an appropriate calibration (Hosmer-Lemeshow P = .957).

CONCLUSIONS

The J-BTK CTO score and the modified J-BTK CTO score predict the probability of an S-GC of BTK CTOs and stratify the difficulty of endovascular therapy for BTK CTOs in angiographic evaluation.

Spinal cord stimulation trial can control pain caused by chronic limb-threatening ischemia

Background

Patients with chronic limb-threatening ischemia experience long-duration pain during ulcer treatment. Hence, painkillers are gradually increased, but adverse events often occur. Spinal cord stimulation trial is one of the methods used to manage such pain.

Method

The study was performed at the Limb Salvage Center in Kasukabe Chuo General Hospital. Total 41 patients with mean age 70.4 ± 9.58 years underwent spinal cord stimulation trial for 2 weeks. Among them, 33 (80 %) were male, and 8 (20 %) were female. Numerical rating scores, wound results, spinal cord stimulation-related adverse events, and total dose of oral painkillers were evaluated.

Results

Postoperatively, itching and bleeding were reported. The numerical rating scores improved from 7/10 before to 2/10 at 2 days after the spinal cord stimulation (P < 0.001). The total doses of oral painkillers showed no change before and after spinal cord stimulation (P > 0.05).

Conclusions

Spinal cord stimulation is recommended for peripheral artery disease because it can improve numerical rating scores for a short term. Therefore, this trial approach can sufficiently control pain against chronic limb-threatening ischemia, without undergoing implantation.

Dichotomous grouping of peripheral arterial calcification grades: A practical predictor of outcome after endovascular therapy in peripheral arterial disease

BACKGROUND

There is a general agreement that arterial calcification affects the results of endovascular therapy for peripheral arterial disease (PAD). In addition to lacking evidence for their impact, existing calcification scores are complex, and not practical in everyday decision making. The global limb anatomic staging system (GLASS) adopted dichotomous grouping of calcification grades.

OBJECTIVE

In this study we aim to investigate the impact of peripheral arterial calcification scoring after dichotomous grouping on midterm outcomes following endovascular therapy for PAD.

METHODS

This prospective study included all consecutive patients with PAD indicated for endovascular therapy procedure who presented to our tertiary referral center in the period between October 2020 and October 2021. Patients were grouped into Group A (n = 40): with no-to mild calcification (PACSS grade 0,1 and 2), and Group B (n = 53): with severe calcification (PACSS grades 3 and 4). Primary endpoints included technical success rate, primary patency rates, and major adverse limb events rate (MALE) during 2 years of follow-up.

RESULTS

The mean age of the studied cases (n = 93) was 59.31 ± 6.46 years (range 50-75). 70 patients (75.3%) were males, and 23 (24.7%) were females. There was no statistically significant difference between the two groups regarding technical success rate (97.5% in group A versus 94.33% in Group B, p = .457). The Primary patency rate after 1 year was lower in group B (74%) compared to group A (89.7%), but this difference was not statistically significant (p = .059). However, the 2-year primary patency rate was significantly lower in group B compared to group A (64% versus 84.6% respectively, p = .034). MALE rate after 2 years was significantly higher in group B (28%) as compared to group A (10.4%), P = .048. Studying suspected risk factors revealed that severe calcification was more common in patients with ischemic heart disease (34%) and chronic kidney disease (11%), P= .003 and .002 respectively. Logistic regression analysis showed that patients suffered from IHD and those with length of lesion ≥ 5 cm are about five times more likely to have severe calcification compared to their counterparts (OR = 4.875, 95%CI = 1.293-18.383, p = .019, and OR = 4.513, 95% CI = 11.138-17.893, p = .032), respectively.

CONCLUSION

The presence of severe calcification is associated with significantly lower midterm primary patency rates and higher rate of major adverse limb events after endovascular intervention for lower limb denovo arterial lesions.

Increased anti-thrombotic therapy is associated with decreased major adverse limb events in patients with low wound and foot infection scores

INTRODUCTION

The optimal anti-thrombotic management of patients after lower extremity bypass has yet to be fully elucidated, in part due to significant heterogeneity in patient presentation and practice patterns. The Wound, Ischemia, and foot Infection (WIfI) score is a validated scoring system to assist in the management of patients with chronic limb threatening ischemia (CLTI). We hypothesized that performing a restriction analysis based on WIFI scores would assist in the postoperative anti-thrombotic management of patients undergoing infrainguinal bypass.

METHODS

A retrospective cohort of infrainguinal bypass procedures completed at a single hospital system between January 2018 and January 2021 was selected, and preoperative WIfI scores were extracted for each patient. Patients with either Wound scores of 2 and 3, or Ischemia Scores of 0 and 1, or Foot Infection Scores of 3 were excluded. Based on the type of anti-thrombotic regimen on discharge, demographics, comorbidities, type of bypass, 30-day rates of graft occlusion, major amputation, mortality, and major adverse limb events (MALE) were analyzed. Statistical analysis included t-tests, chi square tests, and time-to-event survival analysis.

RESULTS

230 procedures were included in the study. 69 (30.0%) patients were discharged on single antiplatelet therapy (SAPT), compared to 161 (70.0%) who were discharged on either dual antiplatelet therapy or anticoagulation (DAPT/AC). There was a higher prevalence of bypasses using prosthetic conduit in the DAPT/AC group (45.9 vs 31.8%, p = .047); no other demographic or procedural variable analyzed had any significant differences. At 30-days postoperatively, there was no significant difference in postoperative reintervention rates, however, the DAPT/AC group had significantly lower rates of mortality (1.2 vs 7.2%, p = .01), major amputation (1.2% vs 5.8%, p = .04), and MALE (3.7 vs 13.0%, p < .01). There were no significant differences in bleeding complications. Survival analysis demonstrated that MALE-free survival was higher in the DAPT/AC group compared to the SAPT group (p < .01). On Cox regression analysis, DAPT/AC was associated with significantly decreased rates of MALE + mortality (Hazard Ratio (HR) 0.20 [0.06 - 0.66]).

CONCLUSION

Lower extremity bypasses patients with low Wound and low foot Infection scores who are discharged on DAPT/AC postoperatively have a significantly higher 30-day MALE-free survival rate compared to patients discharged on SAPT; consideration could be made to preferentially discharge such post-bypass patients on DAPT/AC.

Ten-year experience with use of cryopreserved allografts for redo infrapopliteal bypass

INTRODUCTION

The aim of this study is to report the early and late outcomes of cryopreserved saphenous vein (CSV) in redo infrainguinal bypass and to investigate possible predictors of primary patency loss.

METHODS

All patients who underwent a redo bypass for critical limb ischemia from January 2010 to December 2020 were reviewed. Early and late complications were analyzed and included. The endpoints of the study were all cause mortality, major limb amputation, and primary patency (PP).

RESULTS

Data were collected from 95 patients. Among the entire cohort, 16 (16.8%) patients received a cryopreserved vessel bypass with anastomosis in the popliteal artery and 79 (83.2%) patients had cryopreserved vessel bypasses with distal anastomosis in tibial vessels. Median duration of follow-up was 73 months; during this, period estimated survival at 5 years was 80.5 ± 4% (95% CI, 78.0-91.2) and estimates of freedom from limb amputation was 90.3 ± 3.2% (95% CI, 87.3-98.1). Overall, the estimated primary patency of the bypass was 43.7 ± 6.7% (95% CI, 30.2-51.4). On multivariable analysis, intraprocedural tibial vessel angioplasty (HR = 2.3, p = 0.01), distal anastomosis in tibial vessels (HR = 3.6, p = 0.36), and the use of a composite graft (HR = 2.4, p = 0.01) were independently associated with loss of PP.

CONCLUSIONS

The use of CSV in redo bypass is an effective strategy in salvaging threatened lower extremities and in preventing or delaying limb amputation. Our results confirm that further attempts at revascularization are generally appropriate, even in technically changing patients.

Long-Term Outcomes of Vein Adjuncts in Distal Infrainguinal Bypass

BACKGROUND

Autologous vein is recommended for infrainguinal bypass due to improved freedom from occlusion compared to prosthetic graft. In patients without adequate vein, a vein adjunct at the distal anastomosis has been suggested to improve patency in small studies. This study aimed to determine if performance of a distal vein adjunct was associated with improved freedom from occlusion in below-knee popliteal and tibial bypasses compared to prosthetic bypass alone.

METHODS

A retrospective review of the Vascular Quality Initiative Infrainguinal Bypass database was conducted. Patients undergoing prosthetic-only and prosthetic with vein adjuncts were compared. Inclusion criteria included age ≥18 years, and bypass to below-knee popliteal or tibial vessels. Exclusion criteria included autologous vein conduits and prior interventions. Groups were further divided into below-knee popliteal and tibial subgroups.

RESULTS

A cohort of 3,939 patients underwent bypass to the below-knee popliteal artery, with 287 (7.3%) receiving vein adjuncts. More patients were male (68.8 vs. 57.8%, P < 0.001) and had higher rates of congestive heart failure (21.1 vs. 16.0%, P = 0.040) within the below-knee popliteal group. Two-year bypass occlusion was decreased in patients receiving vein adjuncts (11.6 vs. 17.1%, P = 0.004). A cohort of 2,378 patients underwent tibial bypass, with 473 (19.9%) receiving vein adjuncts. Within the tibial group, patients were similar in age, body mass index, race, comorbidities, and indications. Bypass occlusion (24.8 vs. 17.6%, P = 0.005) and amputation (20.5 vs. 15.9%, P = 0.048) rates at 2 years were worse for patients who did not receive a distal vein adjunct to tibial arteries.

CONCLUSIONS

Distal vein adjuncts are associated with improved freedom from occlusion, amputation, major adverse limb events, and overall survival when compared to bypasses performed with prosthetic graft alone for tibial bypasses within the Vascular Quality Initiative. A vein adjunct was not associated with improved freedom from occlusion in below-knee popliteal bypasses. Consideration should be given to utilization of a distal vein adjunct to improve prosthetic bypass longevity and limb salvage for patients requiring tibial bypasses.

Intravascular Lithotripsy and Drug-Coated Balloon Angioplasty for Severely Calcified Common Femoral Artery Atherosclerotic Disease

OBJECTIVES

Intravascular lithotripsy (IVL) followed by drug-coated balloon (DCB) angioplasty might be a valuable alternative to surgery for calcified common femoral artery (CFA) atherosclerotic disease. Nonetheless, the 12 months performance of this treatment strategy remains unknown. This study reports on the 12 months outcomes of IVL with adjunctive DCB angioplasty for calcified CFA lesions.

METHODS

This is a retrospective single-center, single-arm study. Consecutive patients treated by IVL and DCB for calcified CFA disease between February 2017 and September 2020 were evaluated. The primary measure outcome of this analysis was primary patency. Procedural technical success (<30% stenosis), freedom from target lesion revascularization (TLR), secondary patency, and overall mortality were additionally analyzed.

RESULTS

Thirty-three (n=33) patients were included in this study. The majority presented with lifestyle limiting claudication (n=20, 61%), 52% (n=17) of the patients had chronic kidney disease (CKD) and 33% (n=11) had diabetes. The procedural technical success was 97% (n=32). A flow-limiting dissection post IVL was observed in 2 patients (6%) and a peripheral embolization in a single patient (3%), while the bail-out stenting rate amounted to 12% (n=4). No perforation was observed. The median length of hospital stay was 2 days (interquartile range 2-3). At 12 months, the primary patency was 72%. The freedom from TLR and the secondary patency rates were 94% and 88%, respectively. The 12-month survival amounted to 100% and 75% (n=25) of the patients were asymptomatic or presented with mild claudication. The presence of chronic limb-threatening ischemia (CLTI) (hazard ratio [HR], 0.92; confidence interval (CI); 0.18-4.8, p=0.7) or CKD (HR, 1.30; 95% CI, 0.29-5.8; p=0.72), as well as the use of a 7 mm IVL catheter (HR, 0.59; 95% CI, 0.13-2.63; p=0.49) or of high-dose DCB (HR, 0.68; 95% CI, 0.13-3.53; p=0.65) did not influence the primary patency.

CONCLUSIONS

In this study, the combination of IVL and DCB angioplasty for calcified CFA disease was associated with low risk for periprocedural complications, acceptable 12 months clinical outcomes, and low rates of reinterventions.

CLINICAL IMPACT

Intravascular lithotripsy in combination with DCB angioplasty can be an alternative to surgery in highly selected patients with CFA atherosclerotic disease. In this Cohort the combination therapy lead to acceptable clinical results and low reintervention rates at 12 months.

The impact of angiographic pedal circulation status on wound healing in chronic limb-threatening ischemia after bypass surgery

OBJECTIVE

In the treatment of chronic limb-threatening ischemia (CLTI), complete wound healing is an important goal. Although foot perfusion status seems to be important for wound healing, the Global Limb Anatomic Staging System (GLASS) of the Global Vascular Guidelines does not include pedal artery status for the staging process due to the lack of sufficient evidence of its importance. This study aimed to clarify the importance of pedal perfusion status after bypass surgery.

METHODS

Among the 153 CLTI cases that underwent bypass distal to popliteal arteries from 2014 to 2018, 117 CLTI limbs with wounds and with sufficient pedal angiographic data were enrolled. They were classified into two groups, based on the wound status 6 months postoperatively; early wound healing group (EWG; n = 78), which achieved complete wound healing within 6 months postoperatively, and prolonged healing or unhealed wounds group (PWG; n = 39), which failed to achieve wound healing within 6 months. Various factors associated with wound healing, including the wound, ischemia, and foot infection (WIfI) classification, intraoperative graft flow, and pedal angiographic data, were analyzed. Regarding pedal angiographic data, in addition to the GLASS inframalleolar/pedal disease descriptor (IPD), newly formed classification system of the pedal circulation status in association with the location of wounds was included: pedal circulation status was classified into two groups as visualized arterial perfusion towards wounds (visualized perfusion) and non-visualized arterial perfusion towards wounds (non-visualized perfusion).

RESULTS

Univariate analysis showed preoperative albumin (Odds ratio [OR], 0.47; 95% confidence interval [CI], 0.24-0.94; P = .027), higher WIfI clinical stage (OR, 3.88; 95% CI, 1.74-10.1; P = .0005), higher IPD (OR, 2.16; 95% CI, 1.16-4.02; P = .012), and non-visualized perfusion to wounds (OR, 5.74: 95% CI, 2.45-14.0; P < .0001) as significant for prolonged wound healing. Multivariate analysis showed higher WIfI stage (OR, 5.04; 95% CI, 1.74-14.6; P = .0029) and non-visualized perfusion to wounds (OR, 4.34; 95% CI, 1.71-11.0; P = .0021) as significant, whereas IPD was not detected as significant. Regarding blood supply to the foot, although graft flow was significantly lower in IPD-P2 than IPD-P0/P1, graft flow was similar regardless of the status of angiographic circulation to wounds, suggesting that distribution of blood supply to the wound would be more important than total amount of blood supply to the foot for wound healing.

CONCLUSIONS

WIfI clinical stage and pedal circulatory environment were important factors for wound healing after bypass surgery. Pedal anatomical classification system including perfusion status would be important for decision making in CLTI treatment.

Comparative Efficacy and Safety of Different Balloon Angioplasty Procedures for Infrapopliteal Artery Lesions in Chronic Limb-Threatening Ischemia Patients: A Systematic Review and Network Meta-Analysis

BACKGROUND

The optimal endovascular method to treat infrapopliteal chronic limb-threatening ischemia (CLTI) remains to be determined, given the limitations of stent use in infrapopliteal artery disease. We performed a network meta-analysis (NWM) of randomized controlled trials (RCTs) to simultaneously compare the outcomes of different balloon angioplasty procedures for infrapopliteal artery lesions in CLTI patients.

METHODS

We searched the Cochrane Central Register of Controlled Trials, Embase, and PubMed. 8 eligible RCTs involving 3 endovascular modalities or combinations (plain old balloon angioplasty [POBA], drug-coated balloon [DCB], orbital atherectomy plus plain old balloon angioplasty [OA+POBA]) were included. Primary outcomes were efficacy (12-month clinically driven target lesion revascularization [CDTLR]) and safety (12-month major amputation and all-cause mortality). We used random-effects models based on the frequentist framework.

RESULTS

Plain old balloon angioplasty had a higher 12-month CDTLR rate than DCB (relative risk [RR]: 2.11, confidence interval [CI]: 1.33, 3.34) in the NWM and this result was still statistically significant (RR: 0.47, CI: 0.30, 0.75) in subgroup analyses. According to the SUCRA value, in terms of 12-month CDTLR, OA+POBA was considered the best treatment (SUCRA=72.2), while POBA was considered the worst treatment (SUCRA=8.9). In terms of 12-month all-cause mortality, OA+POBA was considered the best treatment (SUCRA=95.0), while DCB was considered the worst treatment (SUCRA=12.8). In terms of 12-month major amputation, POBA was considered the best treatment (SUCRA=72.0), while DCB was considered the worst treatment (SUCRA=23.0).

CONCLUSIONS

In infrapopliteal CLTI disease, DCB showed a significantly lower 12-month CDTLR in comparison to POBA. There is no statistically significant evidence to suggest that DCB raises safety concerns. The SUCRA values of OA+POBA indicate that it might offer a superior treatment option compared to DCB or POBA in terms of CDTLR and mortality. This advantage, however, was not sustained when major-amputation rates were analyzed. Consequently, further RCTs are required to examine the potential benefits of OA and other forms of atherectomy for managing infrapopliteal CLTI disease.

CLINICAL IMPACT

The findings of this study provide further evidence for the safety of DCB in the application of infrapopliteal CLTI disease and suggest preliminary benefits of atherectomy. These results are likely to encourage further research and application of these treatment modalities in managing infrapopliteal CLTI.POBA has been a traditional approach for treating infrapopliteal artery disease. The current evidence supports clinicians in exploring and utilizing DCB and atherectomy as better treatments.We focused on the performance of different balloon angioplasty procedures in infrapopliteal CLTI, considering the characteristics of infrapopliteal CLTI.

Quality of life and utility of patients with peripheral artery disease (PAD): a systematic review and meta-analysis

Peripheral artery disease (PAD) patients experience low utility, especially those having undergone amputation. Utility is one of the quality weights of health status, converted from quality of life (QOL). This study aimed to systematically review published literature and analyze a pooled estimate of utility in PAD patients. The following databases were queried for articles published from inception up to August 30, 2022: PubMed, ScienceDirect, Scopus, ThaiJo, and the Thai thesis database. Four quality assessment tools were used, tailored to each study's design. A pooled utility was estimated by the random effect and reported using Rutherford and Fontaine classification systems due to their common use in practice. The protocol was registered with the International Prospective Registration of Systematic Reviews (CRD42023392775). Fourteen high-quality studies were included, pooling utility from 3,664 PAD patients. The pooled utility by the Rutherford categories was 0.67, with scores for categories 0, 1-3, 4, and 5 being 0.88, 0.65, 0.68, and 0.58, respectively. The pooled utility by the Fontaine stage was 0.68, with stages 1, 2, 3, and 4 scoring 0.88, 0.65, 0.67, and 0.58, respectively. PAD utility is comparable to that of other chronic diseases. The pooled utility could be a valuable parameter for cost-utility analysis in PAD management.

The Vascular Response After Balloon Angioplasty of Infrapopliteal Intermediate Stenosis Evaluated by Optical Frequency Domain Imaging

BACKGROUND

We often experience worsening of stenosis by balloon angioplasty of infrapopliteal (IP) lesion compared with the initial stenosis. However, reports on this phenomenon are limited.

AIMS

The main purpose of this study is to evaluate vascular response after balloon angioplasty of IP artery stenosis.

METHODS

Thirteen patients (15 arteries) who underwent endovascular treatment (EVT) and follow-up angiography with optical frequency domain imaging (OFDI) of intermediate IP stenosis were included. Serial OFDI images at 3 time points (before and after EVT and at follow-up) were analyzed. Diameter and area of external elastic lamina, internal elastic lamina, and lumen were measured, and plaque area and plaque burden (PB) were calculated. PB before EVT was classified into mild, moderate, and severe by 0%-20%, 21%-40%, and 41%-60%, respectively.

RESULTS

Analyzed were 229 cross sections. External elastic lamina diameter did not change significantly among three time points (3.8 ± 0.5 [95% confidence interval (CI): 3.7 to 3.9] mm, 3.9 ± 0.4 [95% CI: 3.8 to 4.0] mm, 3.9 ± 0.4 [95% CI: 3.8 to 4.0] mm, p = 0.06). Lumen area increased after EVT but became smaller at follow-up than before EVT (4.5 ± 1.5 [95% CI: 4.3 to 4.7] mm2, 5.3 ± 1.3 [95% CI: 5.1 to 5.5] mm2, 3.7 ± 1.2 [95% CI: 3.5 to 3.9] mm2, p < 0.001). Plaque area became smaller after EVT and larger at follow-up than before EVT (3.0 ± 1.7 [95% CI: 2.8 to 3.2] mm2, 2.4 ± 1.5 [95% CI: 2.2 to 2.6] mm2, 4.0 ± 1.6 [95% CI: 3.8 to 4.2] mm2, p < 0.001). Lumen area was significantly smaller at follow-up than before EVT in mild and moderate PB groups, but it was not different in severe PB group (mild PB group: 5.1 ± 1.5 [95% CI: 4.7 to 5.5] mm2 vs. 4.0 ± 1.3 [95% CI: 3.7 to 4.3] mm2, p < 0.001, moderate PB group: 4.6 ± 1.3 [95% CI: 4.4 to 4.8] mm2 vs. 3.6 ± 1.2 [95% CI: 3.4 to 3.8] mm2, p < 0.001, severe PB group: 3.0 ± 1.4 [95% CI: 2.5 to 3.5] mm2 vs. 3.1 ± 1.0 [95% CI: 2.7 to 3.5] mm2, p = 0.93).

CONCLUSIONS

Balloon angioplasty of intermediate IP artery stenosis with mild or moderate PB led to smaller lumen area at follow-up than before EVT.

Association Between Wound Healing and the Japanese Below-the-Knee Chronic Total Occlusion Score in Patients With Chronic Limb-Threatening Ischemia After Endovascular Therapy

INTRODUCTION

In the current study, we hypothesized that the Japanese below-the-knee chronic total occlusion score could be used to stratify the lesion difficulty of endovascular therapy for below-the-knee chronic total occlusion through angiographic evaluation. We thus aimed to evaluate the prognostic impact of the Japanese below-the-knee chronic total occlusion score in patients with chronic limb-threatening ischemia after successful endovascular therapy for below-the-knee chronic total occlusion.

METHODS

This was a retrospective, single-center observational study. We enrolled 139 consecutive patients with chronic limb-threatening ischemia (149 limbs), who underwent successful endovascular therapy for chronic total occlusion between February 2008 and December 2017. The Japanese below-the-knee chronic total occlusion score was assessed based on the definition of the target arterial path. The evaluation items were the rate of amputation-free survival and wound healing at 1 year, and the association between wound healing at 1 year and the Japanese below-the-knee chronic total occlusion score.

RESULTS

The rates of amputation-free survival and wound healing at 1 year were 88.0 and 56.4%, respectively. Multivariate Cox proportional hazard analysis identified direct flow to the wound (hazard ratio: 2.34, 95% confidence interval: 1.28-4.66; p<0.01); Wound, Ischemia, and foot Infection stages 1-3 (hazard ratio: 2.81, 95% confidence interval: 1.63-5.18; p<0.01); and a Japanese below-the-knee chronic total occlusion score ≤1 (hazard ratio: 1.70, 95% confidence interval: 1.02-2.98; p=0.04) to be predictors of wound healing.

CONCLUSIONS

A Japanese below-the-knee chronic total occlusion score ≤1, direct flow to the wound, and Wound, Ischemia, and foot Infection stages 1-3 were found to be associated with wound healing after successful endovascular therapy for below-the-knee chronic total occlusion in patients with chronic limb-threatening ischemia.

CLINICAL IMPACT

This study was conducted to evaluate the prognostic impact of the Japanese below-the-knee chronic total occlusion (J-BTK CTO) score in patients with chronic limb-threatening ischemia (CLTI) after successful endovascular treatment (EVT). The results showed that the J-BTK CTO score not only evaluates the difficulty of EVT but also can predict limb prognosis. Using the J-BTK CTO score, it seems possible to predict the limb prognosis and make it useful in clinical practice.

Incidence of Angiographic Deterioration Following Inframalleolar Angioplasty and Its Impact on Outcomes in Patients With Chronic Limb-Threatening Ischemia Requiring Repeat Intervention

Background

Clinical impact of inframalleolar (IM) angioplasty in patients with chronic limb-threatening ischemia (CLTI) is still controversial.

Methods and Results

This single-center, retrospective study included 168 patients with CLTI and tissue loss who underwent angioplasty for IM lesions. Angiographic follow up was performed at reintervention between April 2010 and December 2020. The outcome measure was the incidence of angiographic deterioration characterized by severe restenosis or occlusion of mildly stenotic lesions, occlusion of severely stenotic lesions, or extension of the occlusion length at reintervention. Angiographic deterioration was observed in 47.7% of patients, with the majority attributed to occlusion in severely stenotic lesions. Multivariate analysis revealed that a distal reference vessel diameter ≤1.0 mm in the initial angioplasty (hazard ratio 1.91 [95% confidence interval 1.20-3.04]; P=0.006) was significantly associated with angiographic deterioration of IM lesions at reintervention.

Conclusions

Angiographic deterioration occurred in approximately half of the patients with CLTI who underwent IM angioplasty and reintervention.

Prognostic Value of Hospital Frailty Risk Score and Clinical Outcomes in Critical Limb-Threatening Ischemia and End-Stage Kidney Disease

BACKGROUND

End-stage kidney disease (ESKD) is commonly associated with critical limb-threatening ischemia (CLTI) and frailty. Yet there are no specific tools to predict outcomes of CLTI in ESKD, particularly those that incorporate frailty. We aimed to assess the utility of the medical record-based Hospital Frailty Risk (HFR) score in predicting outcomes of CLTI in ESKD.

METHODS AND RESULTS

We identified patients with ESKD diagnosed with CLTI from the US Renal Data System from 2015 to 2018. These patients were categorized into 3 frailty risk groups on the basis of their HFR scores: low (<5), intermediate (5-10), high-risk (>10), and on the basis of whether they underwent revascularization (endovascular revascularization [ER]/surgical revascularization [SR]) or not (no revascularization). Primary outcomes of interest included in-hospital composite of death or major amputation and in-hospital death. We included 49 454 eligible patients, with ER/SR cohort including 19.8% (n=9777). A total of 88.4% (ER/SR) and 90.0% (no revascularization) were frail on the HFR scale. We found a nonlinear association between HFR score and in-hospital adverse outcomes. In both cohorts, intermediate and high-risk HFR scores were associated with greater risk of in-hospital death (high-risk, ER/SR: odds ratio, 2.7 [95% CI, 1.6-4.8]; P<0.0001; no revascularization: odds ratio, 7.8 [95% CI, 5.3-11.6]; P<0.01) and composite of in-hospital major amputation or death (high-risk, ER/SR: odds ratio, 2.4 [95% CI, 1.9-3.1]; P<0.0001; no revascularization: odds ratio, 1.7 [95% CI, 1.5-1.9]; P<0.0001).

CONCLUSIONS

The HFR score can predict risk of in-hospital death and composite of death or major amputation in patients with ESKD and CLTI. Further data are needed to determine the utility of the HFR score in this population.

Primary Limb-Based Patency for Chronic Limb-Threatening Ischemia Treated with Endovascular Therapy Based on the Global Limb Anatomic Staging System

PURPOSE

To validate the correlation between the Global Limb Anatomic Staging System (GLASS) and primary limb-based patency (LBP) and to identify the risk factors associated with LBP loss.

MATERIALS AND METHODS

A single-center retrospective analysis was performed on patients with chronic limb-threatening ischemia (CLTI) who underwent endovascular therapy (EVT) between January 2018 and May 2022. All lesions were categorized into 3 groups (GLASS Stages I, II, and III). The primary LBP rates were analyzed and compared across the GLASS stages. The risk factors for the loss of primary LBP were identified using Cox regression analysis.

RESULTS

In total, 236 limbs from 231 patients were included, with 52 (22%) limbs stratified as GLASS Stage I, 59 (25%) limbs as GLASS Stage II, and 125 (53%) limbs as GLASS Stage III. The 1-year LBP rates for limbs classified as GLASS Stages I, II, and III were 78.8%, 69.5%, and 41.6%, respectively (P < .001). The long-term LBP rate was 54.2% in GLASS Stage I, 38.6% in GLASS Stage II, and 10.5% in GLASS Stage III (P < .001). Multivariate analysis revealed that GLASS stages (GLASS Stage Ⅰ vs Ⅲ, hazard ratio [HR], 0.36; 95% CI, 0.18-0.72; P = .004; GLASS Stage Ⅱ vs Ⅲ, HR, 0.47; 95% CI, 0.25-0.86; P = .02), diabetes, smoking, and sex were independently associated with LBP.

CONCLUSIONS

GLASS Stage III was associated with lower LBP rates in patients with CLTI who underwent EVT. The GLASS stages may serve as prognostic indicators for patients with CLTI after intervention.

Risk score for one-year mortality following emergent infra-inguinal bypass

OBJECTIVE

The purpose of this study is to identify variables that place patients at higher risk for mortality following emergent infra-inguinal bypass. Further, this study will create a risk score for mortality following emergent infra-inguinal bypass to help tailor postoperative and long-term patient management.

METHODS

In the Vascular Quality Initiative, we identified 2126 patients who underwent emergent infra-inguinal artery bypass. Two primary outcomes were investigated: 30 day mortality following emergent infra-inguinal bypass; and 1-year mortality following emergent infra-inguinal bypass. The first step in analysis was univariable analysis for each outcome with χ2 analysis for categorical variables and Student t-test for comparison of means of ordinal variables. Next, binary logistic regression analysis was performed for each outcome utilizing variables that achieved a univariable P value ≤ .10. Factors with a multivariable P value ≤ .05 were included in the risk score, and points were weighted and assigned based on the respective regression beta-coefficient in the multivariable regression.

RESULTS

Variables with a significant multivariable association (P < .05) with 1-year mortality were: increasing age; body mass index less than 20 kg/m2; coronary artery disease; active hemodialysis at time of presentation; anemia at admission; prosthetic conduit for emergent bypass; postoperative myocardial infarction; postoperative acute renal insufficiency; perioperative stroke; baseline non-ambulatory status; new onset hemodialysis requirement perioperatively; need for bypass revision or thrombectomy during index admission; lack of statin prescription at discharge; lack of antiplatelet medication at discharge; and, lack of anticoagulation at time of hospital discharge. Pertinent negatives included all sociodemographic variables including rural living status, insurance status, and Area Deprivation Index home area. The risk score achieved an area under the curve of 0.820, and regression analysis of the risk score achieved an overall accuracy of 87.9% with 97.7% accuracy in predicting survival, indicating the model performs better in determining which patients will survive rather than precisely determining who will experience 1-year mortality.

CONCLUSIONS

Discharge medications are the primary modifiable variable impacting survival after emergent infra-inguinal bypass surgery. In the absence of contraindication, all these patients should be discharged on antiplatelet, statin, and anticoagulant medications after emergent infra-inguinal bypass as they significantly enhance survival. Social determinants of health do not impact survival among patients treated with emergent infra-inguinal bypass at Vascular Quality Initiative centers. A risk score for mortality at 1 year after emergent infra-inguinal bypass has been created that has excellent accuracy.

The natural history of isolated common femoral endarterectomy for chronic limb-threatening ischemia

OBJECTIVE

Occlusive disease of the common femoral artery can generate profound lower extremity ischemia as the normal collateral pathways from the profunda to the superficial femoral artery cannot adequately develop. In patients with lifestyle-limiting claudication, isolated common femoral endarterectomy (CFE) is highly effective. Because CFE does not provide direct, in-line flow to the plantar arch, it has been felt to provide inadequate revascularization to patients with chronic limb-threatening ischemia (CLTI). The purpose of this retrospective clinical study was to report and assess the natural history of selected patients with CLTI treated with isolated CFE (without concomitant infrainguinal revascularization).

METHODS

Consecutive CFEs performed in a large, urban hospital for CLTI between 2014 and 2021 were reviewed. Patient characteristics, limb, and anatomical stages using the Wound, Ischemia, foot Infection (WIfI) and Global Limb Anatomic Staging System were tabulated. Limb-specific and survival-related end points were analyzed.

RESULTS

Fifty-eight patients presenting with CLTI underwent isolated CFE (mean age, 74 ± 10 years; 62% male, 90% current or prior smoker). Comorbidities included diabetes (52%), coronary artery disease (55%), congestive heart failure (22%), and end-stage renal failure on hemodialysis (5%). Patients presented with either rest pain (36%) or tissue loss (64%); the latter group exhibited advanced limb threat (68% in WIfI stage 3 or 4). The majority of patients had associated severe infrainguinal disease (50% Global Limb Anatomic Staging Systems 3). After a median follow-up of 17 months (range, 10-29 months), vascular reintervention was required in 7 patients (12%). One patient (2%) required major limb amputation after presentation in WIfI stage 4 (W3I3fI0). Indeed, WIfI stage 4 was a significant univariate predictor of the need for subsequent infrainguinal bypass (P = .034).

CONCLUSIONS

Isolated CFE as primary therapy in highly selected patients with CLTI was safe and effective. Index limb stage is predictive of the need for associated infrainguinal revascularization in this complex population.

Practice patterns of peripheral vascular interventions for peripheral artery disease in the office-based laboratory setting versus outpatient hospital

OBJECTIVE

Controversy exists regarding the value and limitations of different sites of service for peripheral artery disease treatment. We aimed to examine practice patterns associated with peripheral vascular interventions (PVIs) performed in the office-based laboratory (OBL) vs outpatient hospital site of service using a nationally representative database.

METHODS

Using 100% Medicare fee-for-service claims data, we identified all patients undergoing PVI for claudication or chronic limb-threatening ischemia (CLTI) between January 2017 and December 2022. We evaluated the associations of patient and procedure characteristics with site of service using multivariable hierarchical logistic regression. We used multinomial regression models to estimate the relative risk ratios (RRRs) of site of service and intervention type (angioplasty, stent, or atherectomy) and intervention anatomic level (iliac, femoropopliteal, or tibial) after adjusting for baseline patient characteristics and clustering by physician.

RESULTS

Of 848,526 PVI, 485,942 (57.3%) were performed in an OBL. OBL use increased significantly over time from 48.3% in 2017 to 65.5% in 2022 (P < .001). Patients treated in OBLs were more likely to be Black (adjusted odds ratio [aOR], 1.14; 95% confidence interval [CI], 1.11-1.18) or other non-White race (aOR, 1.13; 95% CI, 1.08-1.18), have fewer comorbidities, and undergo treatment for claudication vs CLTI (aOR, 1.30; 95% CI, 1.26-1.33) compared with patients treated in outpatient hospital settings. Physicians with majority practice (>50% procedures) in an OBL were more likely to practice in urban settings (aOR, 21.58; 95% CI, 9.31-50.02), specialize in radiology (aOR, 18.15; 95% CI, 8.92- 36.92), and have high-volume PVI practices (aOR, 2.15; 95% CI, 2.10-2.29). The median time from diagnosis to treatment was shorter in OBLs, particularly for patients with CLTI (29 vs 39 days; P < .001). The OBL setting was the strongest predictor of patients receiving an atherectomy alone (adjusted RRR [aRRR] 6.67; 95% CI, 6.59-6.76) or atherectomy + stent (aRRR, 10.84; 95% CI, 10.64-11.05), and these findings were consistent in subgroup analyses stratified by PVI indication. The OBL setting was also associated with higher risk of tibial interventions for both claudication (aRRR, 3.18; 95% CI, 3.11-3.25) and CLTI (aRRR, 1.89; 95% CI, 1.86-1.92). The average reimbursement (including professional and facility fees) was slightly higher for OBLs compared with the hospital ($8742/case vs $8459/case; P < .001). However, in a simulated cohort resetting the OBL's intervention type distribution to that of the hospital, OBLs were associated with a hypothetical cost savings of $221,219,803 overall and $2602 per case.

CONCLUSIONS

The OBL site of service was associated with greater access to care for non-White patients and a shorter time from diagnosis to treatment, but more frequently performed high-cost interventions compared with the outpatient hospital setting. The benefit to patients from improved access to peripheral artery disease care in OBL settings must be balanced with the potential limitations of receiving differential care.

Predictors of recurrent restenosis after repeat drug-coated balloon therapy for drug-coated balloon restenosis in femoropopliteal lesions: Results of the RECURRENCE study

BACKGROUND

Despite the widespread use of drug-coated balloons (DCBs) for femoropopliteal (FP) lesions, there is still no consensus on treatment strategies for DCB restenosis. This study aimed to determine the risk factors for recurrent restenosis after repeat DCB therapy for DCB restenosis in FP lesions.

METHODS

This multicenter retrospective study assessed 1176 consecutive limbs in 860 patients who successfully received initial DCB therapy for FP lesions at four cardiovascular centers between May 2018 and December 2022. Among these patients, 118 consecutive limbs of 104 patients treated via repeat DCB for primary DCB restenosis were enrolled.

RESULTS

The Kaplan-Meier estimate of freedom from recurrent restenosis was 74.6% at 1 year. Cox proportional hazard multivariate analysis revealed that recurrent restenosis was independently associated with the time from initial DCB to primary restenosis (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.79-0.92; p < 0.001), history of ≥2 endovascular therapies (EVTs) (HR, 3.11; 95%CI, 1.36-7.12; p = 0.007), and PACSS grade 3 or 4 (HR, 2.76; 95%CI, 1.15-6.63; p = 0.023). Furthermore, receiver operating characteristic curve analysis showed that the cutoff value of the time from initial DCB to primary restenosis to prevent recurrent restenosis was 12.6 months, with an area under the curve of 0.841 (p < 0.001).

CONCLUSION

Repeat DCB therapy for DCB restenosis might be an acceptable strategy, particularly for restenosis that occurred more than 12.6 months after initial DCB, given the rate of freedom from recurrent restenosis.

Surgery With Peripheral Nerve Block Under Dexmedetomidine Sedation for Foot Ulcer

Background

Patients who require surgical treatment for diabetic foot ulcer (DFU) or chronic limb-threatening ischemia (CLTI) are often in generally poor condition and have complications. General anesthesia may be risky in surgery for such patients. Thus, the authors perform surgery using peripheral nerve block under dexmedetomidine sedation for patients with DFU and CLTI.

Methods

This study evaluated intraoperative stress, anxiety, and safety in 18 patients undergoing peripheral nerve block with dexmedetomidine. Sedation levels were assessed using the observer's assessment of alertness/sedation (OAA/S) score on a 5-point scale from 5 (awake) to 1 (deeply sedated). Postoperatively, a questionnaire was administered to assess intraoperative stress and memory. Intraoperative stress was assessed using a 6-point face scale (0 to 6: not at all to unbearably high), and intraoperative memory was rated on a 5-point numeric scale (1 to 5: no memory to everything).

Results

The intraoperative OAA/S score was 3-5, indicating that appropriate sedation was obtained. The mean intraoperative stress score was 0.72 (range: 0-3), and the mean intraoperative memory score was 2.44 (range: 1-4). One patient had bradycardia and 9 had hypoxemia. All of these cases were improved by decreasing the dose of dexmedetomidine and encouraging deep breathing on call.

Conclusions

These results suggest that this procedure is a useful method to reduce patient burden and alleviate stress and anxiety during surgery. However, dexmedetomidine may cause hypoxemia in patients with DFU or CLTI; thus, attention should be paid to hypoxemia and countermeasures should be taken against this adverse effect.

Recombinant Human Hepatocyte Growth Factor Plasmids for Treating Patients with Chronic Limb Threatening Ischaemia: A Systematic Review and Meta-analysis

OBJECTIVE

Recombinant human hepatocyte growth factor (HGF) plasmids are novel alternatives to salvage limbs in patients with chronic limb threatening ischaemia (CLTI). A systematic review and meta-analysis of data was conducted to assess the therapeutic efficacy of HGF plasmids in patients with CLTI.

DATA SOURCES

Randomised controlled studies evaluating HGF plasmid efficacy in patients with CLTI were identified using MEDLINE, Embase, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov databases.

REVIEW METHODS

Meta-analyses of the reported relative risk (RR) or mean difference (MD) were conducted. Subgroup analyses were performed to determine the efficacy of HGF plasmids in cohorts excluding Buerger's disease. Certainty of evidence for each outcome was assessed.

RESULTS

Seven studies (n = 655 participants) were included. Based on low certainty evidence, patients treated with HGF had a significantly higher complete ulcer healing rate (RR 1.99, 95% confidence interval [CI] 1.30 - 3.04; p = .002) than patients treated with placebo. HGF treatment was associated with reduced visual analogue scale (VAS) scores of pain severity (MD -1.56, 95% CI -2.12 - -1.00; p < .001) vs. placebo in patients with CLTI assessed at three month follow up (low certainty evidence); no significant differences were observed in major amputation (RR 0.91, 95% CI 0.48 - 1.73; p = .77) (low certainty evidence) or all cause mortality rate (RR 0.93, 95% CI 0.38 - 2.27; p = .87) (low certainty evidence) between patients treated with HGF and placebo. Low certainty evidence suggested no significant differences in change in ankle brachial index at six months (MD 0.00, 95% CI -0.09 - 0.09; p = 1.0) between patients treated with HGF and placebo. The complete ulcer healing rate and improved three month VAS scores of pain severity benefits persisted in subgroup analyses (low certainty evidence).

CONCLUSION

Low certainty evidence suggested that HGF treatment is associated with an increased complete ulcer healing rate and reduced ischaemic pain in patients with CLTI.

Patients with Acute Lower Limb Ischemia Continue to Have Significant Morbidity and Mortality

BACKGROUND

The treatment of acute lower limb ischemia (ALLI) has evolved over the last several decades with the availability of several new treatment modalities. This study was undertaken to evaluate the contemporary presentation and outcomes of ALLI patients.

METHODS

We retrospectively analyzed data from a prospectively collected database of all patients who presented to our tertiary referral hospital with acute ischemia of the lower extremity between May 2016 and October 2020. The cause of death was obtained from the Michigan State Death Registry.

RESULTS

During the study period, 233 patients (251 lower limbs) were evaluated for ALLI. Seventy-three percent had thrombotic occlusion, 24% had embolic occlusion, and 3% due to a low flow state. Rutherford classification of ischemia severity was 7%, 49%, 40%, and 4% for Rutherford grade I, IIA, IIB, and III, respectively. Five percent underwent primary amputations, and 6% received medical therapy only. The mean length of stay was 11 ± 9 days. Nineteen percent of patients were readmitted within 30 days of discharge. At 30 days postoperatively, mortality was 9% and limb loss was 19%. On multivariate analysis, 1 or no vessel runoff to the foot postoperatively was associated with higher 30-day limb loss. Patients with no run-off vessels postoperatively had significantly higher 30-day mortality. Cardiovascular complications accounted for most deaths (48%). At 1-year postoperatively, mortality and limb loss reached 17% and 34%, respectively.

CONCLUSIONS

Despite advances in treatment modalities and cardiovascular care, patients presenting with ALLI continue to have high mortality, limb loss, and readmission rates at 30 days.

Clinical outcomes and risk factors associated with drug-coated balloon treatment for femoropopliteal artery disease in patients on maintenance hemodialysis

The effect of drug-coated balloons (DCB) on hemodialysis (HD) in patients with femoropopliteal (FP) disease remains uncertain. This study aimed to investigate the outcomes of DCB therapy in patients with FP artery disease on HD. A total of 185 patients with FP lesions (140 HD patients) who underwent DCB treatment were included in the study. The incidence of restenosis and target lesion revascularization (TLR) at 12 months were measured. Risk factors for TLR were also investigated. The mean age was 71.7 years, and diabetes was observed in 82.3% of patients. The mean duration of receiving dialysis was 8.8 years. The mean lesion length was 11.0 cm, and approximately half of the lesions were severely calcified. Severe dissection after DCB therapy was observed in 19.5% of patients. During the follow-up period, 74 restenosis, 68 TLRs, 8 major amputations, and 28 deaths were observed. The freedom rates from restenosis and TLR at 12 months were 63.8% and 71.3%, respectively. The freedom rates after low- and high-dose DCB at 12 months were 61.9% and 70.6% for restenosis (P = 0.49) and 66.4% and 79.4% for TLR (P = 0.095), respectively. Independent risk factors for TLR at 12 months of age were diabetes, chronic limb-threatening ischemia, and severe calcification. When patients were divided into four groups according to the number of these three risk factors, the rates of freedom from TLR at 12 months were 100%, 94.8%, 76.7%, and 30.3% in the groups with no risk factors, any one risk factor, any two risk factors, and all risk factors, respectively (P < 0.0001). Clinical outcomes after endovascular therapy in HD patients with FP disease remain unsatisfactory, even if they are treated with DCB. In particular, patients on HD with diabetes, chronic limb-threatening ischemia, and severe calcification have poor outcomes.

Brazilian Society of Angiology and Vascular Surgery guidelines on peripheral artery disease

Patients with peripheral artery disease and generalized atherosclerosis are at high risk of cardiovascular and limb complications, affecting both quality of life and longevity. Lower limb atherosclerotic disease is associated with high cardiovascular morbidity and mortality and adequate management is founded on treatments involving patient-dependent factors, such as lifestyle changes, and physician-dependent factors, such as clinical treatment, endovascular treatment, or conventional surgery. Medical management of peripheral artery disease is multifaceted, and its most important elements are reduction of cholesterol level, antithrombotic therapy, control of arterial blood pressure, control of diabetes, and smoking cessation. Adhesion to this regime can reduce complications related to the limbs, such as chronic limb-threatening ischemia, that can result in amputation, and the systemic complications of atherosclerosis, such as stroke and myocardial infarction.

Outcomes of prosthetic and biological grafts compared to arm vein grafts in patients with chronic limb-threatening ischemia

OBJECTIVE

The optimal conduit for infrainguinal bypass (IIB) is single-segment great saphenous vein (GSV). Unfortunately, GSV is not always available in patients with chronic limb-threatening ischemia (CLTI). Other graft choices include arm vein grafts (AVs), prosthetic grafts (PGs), or biologic grafts (BGs). Current data regarding the durability and limb salvage rates of those options is scarce; hence, we aimed to investigate the impact of alternative graft types on postoperative and long-term outcomes on IIB in patients with CLTI.

METHODS

The Vascular Quality Initiative (VQI) database was queried for patients undergoing IIB from January 2003 to April 2024. Patients were stratified into three groups: AVs (cephalic, basilic), PGs (Dacron, polytetrafluoroethylene [PTFE]), and BGs (cadaveric, homograft, or xenograft). Saphenous vein grafts (greater and lesser saphenous) were excluded. Multivariate logistic regression analyzed postoperative outcomes: 30-day mortality, major adverse cardiovascular events, graft occlusion, prolonged length of stay >7 days, packed red blood cell transfusion >2 units, and infection. Cox regression was used to report 1-year outcomes: mortality, major amputation (above-ankle), and major adverse limb events (defined as major amputation, thrombectomy, or reintervention).

RESULTS

A total of 9165 IIB procedures have been analyzed: AV, 417 (4.55%); PG, 7520 (82.05%); and BG, 1228 (13.40%). Compared with AVs, patients receiving PGs had higher odds of infection (adjusted odds ratio [aOR], 2.89; P = .045) and higher hazard of 1-year mortality (adjusted hazard ratio [aHR], 1.51; P = .035). On the other hand, patients receiving BGs had higher risk of graft occlusion (aOR, 4.55; P = .040) and infection (aOR, 2.78; P = .046), as well as higher hazard of 1-year mortality (aHR, 1.53; P = .040), amputation (aHR, 1.72; P = .019), and amputation or death (aHR, 1.52; P = .005) compared with patients receiving AVs. After stratifying by bypass configuration, patients with AVs had the highest overall survival and amputation-free survival among the three alternative conduits in below-knee popliteal and tibial bypass targets.

CONCLUSIONS

In this large multi-institutional study investigating alternative conduits to GSV, AVs are found to be the most resistant to infections and are associated with the best overall survival and limb salvage outcomes compared with PGs and BGs, particularly in below-knee distal targets. In cases where no GSV is available, AVs and PGs are acceptable alternatives with comparable 1-year amputation-free survival and major adverse limb events-free survival rates. On the other hand, BGs are associated with higher risk of graft occlusion and lower freedom from major amputation and death compared with AVs.

Foot Sole Temperature Correlates with Ankle-Brachial Index, Pulse Wave Velocity, and Arterial Age in Diabetic Patients Without Diagnosis of Peripheral Arterial Disease

Background/Objectives: Some vascular alterations such as peripheral arterial disease (PAD) or arterial stiffness can alter perfusion of the limbs, so we wondered if this is reflected in the temperature of the soles of the feet of diabetic patients who did not have a diagnosis of peripheral arterial disease. Foot sole temperature was correlated with the ankle-brachial index (ABI), carotid-femoral pulse wave velocity (cfPWV), brachial-ankle pulse wave velocity (baPWV), and arterial age. Methods: A total of 175 patients with type 2 diabetes mellitus, without a previous diagnosis of PAD, were recruited. Comorbidities, anthropometry, biochemical analysis results, temperature, ABI, cfPWV, baPWV, and arterial age were recorded. Forty-two temperature records were obtained from the sole of the foot with an FLIR T865 thermal imaging camera. ABI, cfPWV, baPWV, and arterial age were obtained using plethysmographic and oscillometric methods. Statistical analysis was performed with SPSS v.29.0 (correlations and multiple linear regression models). Results: All temperature points analyzed correlated negatively with ABI (p < 0.001) and rho values ranged from -0.168 to -0.210. Likewise, cfPWV, baPWV, and arterial age had similar results, since most temperature records showed low rho values and a negative correlation with these parameters. Four models were developed to explain the variables of interest. Temperature was involved in all of them. The temperature of the first toe was included in the prediction of cfPWV, baPWV, and arterial age. Conclusions: There is an inversely proportional relationship between temperature and ABI, cfPWV, baPWV, and arterial age in diabetic patients without a previous diagnosis of arterial disease. Temperature can be a predictor of these hemodynamic variables.

Atherectomy Followed by Drug-Coated Balloon Angioplasty Versus Surgery for Symptomatic Deep Femoral Artery Arteriosclerotic Disease

PURPOSE

Limited data are available regarding endovascular therapy of arteriosclerotic lesions of the deep femoral artery (DFA). In this study, we compare the outcomes of atherectomy combined with drug-coated balloon (DCB) angioplasty and open repair of DFA lesions.

METHODS

This is a multicenter retrospective registry of patients with peripheral artery occlusive disease Rutherford categories 2 to 5 treated by surgical profundaplasty (SP) or atherectomy followed by DCB for DFA lesions (symptomatic DFA). The primary endpoint was clinically driven target lesion revascularization (CD-TLR). Overall mortality, target limb reinterventions, major amputation, and major adverse limb events (MALEs) were additionally analyzed.

RESULTS

A total of 373 patients treated for an arteriosclerotic lesion of the DFA between February 2015 and August 2021 were included, 301 treated by SP and 72 with atherectomy and DCB. The rates of chronic limb threatening ischemia (CLTI) were 42.2% and 22.2% (p<0.002) for the surgical and endovascular groups, respectively. A previous DFA intervention was more frequent in the endovascular group (30.6% vs 15.3%; p<0.003). Patients who had an open repair were more likely to have an occlusion of the profunda (34.9% vs 19.7%, p=0.014), severe calcified lesions (26.5% vs 5.6%, p=0.001), and lesions longer than 20 mm (95.7% vs 88.7%, p=0.024). After propensity score matching, no significant differences were found with regard to technical and hemodynamic success. At 24 months, no difference was found in terms of freedom from CD-TLR (95.7% vs 96.8%), freedom from all-cause mortality (94.2% vs 98.5%), freedom from MALE (90.4% vs 93.9%), and amputation-free survival (93.8% vs 97%). Following endovascular therapy, length of stay was significantly lower (p<0.001) and any reintervention on the index limb was more frequent (p=0.039).

CONCLUSION

Patients with CLTI, occlusion of profunda, severe calcified lesions, and longer lesions are more frequently treated by open surgery, while reinterventions are more commonly treated by atherectomy and DCB. In patients with comparable clinical and lesion characteristics after matching, endovascular and surgical reconstruction of DFA lesions showed similar mid-term clinical outcomes. However, the risk of reintervention at the index limb is higher after endovascular treatment. Randomized studies are now warranted to compare both techniques in terms of medical and financial aspects.

CLINICAL IMPACT

Atherectomy followed by DCB of symptomatic DFA is safe and effective. In patients with comparable clinical and lesion characteristics, outcomes are comparable with surgery. However, the risk of reintervention at the index limb is higher after endovascular treatment. Therefore, whenever possible an additional outflow vessel revascularization should be performed by the time of the primary intervention. Randomized studies are warranted to compare endovascular techniques and open surgery also under economic aspects.

Multifactorial analysis of risk factors for foot ulcers in patients with neurovascular complications of diabetes

Background

Diabetic foot ulcers (DFU) are a major complication associated with significant morbidity and mortality. While numerous studies have investigated risk factors for these ulcers in general, few have focused specifically on patients with Neurovascular Complications of Diabetes. This study aimed to evaluate the prevalence and risk factors for DFU in this specific population.

Methods

We analyzed data from the National Institutes of Health (NIS) database for the years 2017-2019, involving a cohort of 161,834 patients aged over 18 who were diagnosed with neurovascular complications of diabetes. Demographic characteristics (age, gender, ethnicity), hospital characteristics, comorbidities, and other relevant data were included for analysis. A binary logistic regression model was generated to identify independent risk factors for DFU.

Results

The prevalence of DFU among patients with neurovascular complications of diabetes was 29.4% during the period from 2017 to 2019. Compared to patients without DFU, those with DFU had longer hospitalization times and higher costs. The multiple regression analysis revealed that Iron-deficiency anemia (OR, 1.10; 95% CI, 1.01-1.11; P=0.019), Hypertension (OR, 1.07; 95% CI, 1.03-1.11; P=0.001), Obesity (OR, 1.08; 95% CI, 1.06-1.11; P<0.001), Peripheral vascular disorders (PVD) (OR, 1.69; 95% CI, 1.65-1.74; P<0.001), Osteomyelitis (OR, 7.10; 95% CI, 6.89-7.31; P<0.001), Tinea pedis (OR, 1.89; 95% CI, 1.59-2.26; P<0.001), Sepsis (OR, 1.24; 95% CI, 1.20-1.28; P<0.001), and onychomycosis (OR, 1.26; 95% CI, 1.13-1.42; P<0.001) were independent predictors for DFU in this population.

Conclusion

The study found a high prevalence of DFU in patients with neurovascular complications of diabetes. Identifying and addressing risk factors such as deficiency anemia, hypertension, obesity, PVD, infections, and foot conditions may contribute to reducing the prevalence of DFU in this vulnerable population.

Graduating vascular surgery trainee proficiency in endovascular and open peripheral revascularization procedures

BACKGROUND

Endovascular interventions for peripheral artery disease have increased in prevalence over time given the inherent benefits of minimally invasive approaches. Although it is essential that vascular surgery graduates are facile with endovascular techniques, the results of the BEST-CLI (Best Endovascular vs. Best Surgical Therapy in Patients With Critical Limb Ischemia) trial highlight the equivalent importance of ensuring trainee competence in open skills. Recent studies demonstrate increasing case volume of both endovascular and open procedures during vascular surgery training. Case volume is merely a surrogate marker for competence, however, and the objective competence attained by trainees at the time of graduation is unknown. We sought to investigate operative autonomy and competence of graduating vascular surgery trainees performing endovascular as compared with open peripheral vascular revascularization procedures.

METHODS

Operative performance and autonomy ratings for infrainguinal endovascular and open revascularizations from the Society for Improving Professional Learning Operative application database were collected for all vascular surgery participating institutions from 2018 to 2023. The distribution for autonomy and performance ratings were determined by training level for endovascular and open procedures, respectively. Mixed effects logistic regressions were conducted to estimate the predictive association between procedure type and autonomy and performance assessment, adjusting for training level and case complexity. Subsequently, the estimated model was applied to predict the probability of a graduating trainee being rated as meaningfully autonomous or competent while performing endovascular and open procedures across various case complexities.

RESULTS

Sixty-nine residents from 23 programs (12 fellowship, 11 residency) were assessed on 706 revascularization procedures (n = 383 endovascular; n = 323 open). When controlling for training level and case complexity, there were no differences in autonomy (odds ratio [OR], 1.11; 95% confidence interval [CI], 0.62-1.99) or competency assessment (OR, 0.86; 95% CI, 0.46-1.59) for endovascular, as compared with open, peripheral revascularization procedures. For average complexity procedures, the predicted probability of a trainee being assessed as competent and autonomous at the time of graduation was high (competent: 88% endovascular, 86% open; autonomous: 96% endovascular, 97% open). The predicted probability of competence and autonomy for complex procedures was lower, but remained similar between groups (competent: 73% endovascular, 70% open; autonomous: 92% endovascular, 92% open).

CONCLUSIONS

There is no difference in the graduating level of autonomy and competence of endovascular as compared with open peripheral revascularization procedures for vascular surgery trainees. These findings suggest that vascular surgery trainees enter independent practice with adequate proficiency to use the full scope of techniques to care for patients requiring peripheral revascularization procedures.

Percutaneous Deep Venous Arterialization by Balloon Angioplasty without Stent Implantation for Patients with Chronic Limb-Threatening Ischemia Undergoing Hemodialysis: A Retrospective Cohort, Single-Center, Single-Arm Study

PURPOSE

This retrospective, single-center study aimed to determine the efficacy of percutaneous deep venous arterialization in patients on hemodialysis with chronic limb-threatening ischemia.

MATERIALS AND METHODS

Twenty-one consecutive limbs on hemodialysis with chronic limb-threatening ischemia were treated with percutaneous deep venous arterialization using balloon angioplasty following a failed pedal arterial reconstruction between May 2021 and June 2022. An arteriovenous fistula near the ankle joint was created to ensure sufficient venous flow reversal to the pedal veins. In case of occlusion of the tibial artery, a guidewire was advanced (subintimal) to the ankle joint vicinity was technically important. The primary outcome measures were the 6-month complete wound healing and freedom from major amputation rates; the secondary outcome measure was the 6-month amputation-free survival.

RESULTS

Occlusion of all pedal arteries was observed in 17 limbs (81.0%). Arteriovenous fistulas were predominantly created at the distal portions of the posterior tibial artery and vein in 18 limbs (85.7%). No extravasation at the fistulas was observed. Re-intervention was required in 16 limbs (76.2%) due to tibial artery or deep vein occlusion. The 6-month complete wound healing rate was 42.9% (nine limbs), with a median healing time of 85 days (interquartile range: 58-151 days). The 6-month freedom from major amputation and amputation-free survival rates were 90.5% (19 limbs) and 61.9% (13 limbs), respectively.

CONCLUSION

Balloon angioplasty without stent implantation for percutaneous deep venous arterialization is promising for improving the complete wound healing and amputation-free survival rates after pedal artery reconstruction failure.

LEVEL OF EVIDENCE

Level 3b, retrospective cohort study.

Clinical Outcomes After Distal Bypass in Patients With Chronic Limb-Threatening Ischemia due to Connective Tissue Disease

OBJECTIVES

Chronic limb-threatening ischemia (CLTI) is mostly caused by arteriosclerosis, but is sometimes due to connective tissue disease. However, there is a limited knowledge of clinical outcomes of patients with CLTI with connective tissue disease. The objective of the study was to assess outcomes after distal bypass in these patients using global vascular guidelines.

MATERIAL AND METHODS

Data from distal bypasses performed for CLTI at a single center from 2014 to 2023 were evaluated retrospectively. Clinical outcomes after distal bypass were compared for patients with CLTI with arteriosclerosis (AS group) and those with connective tissue disease (CD group). The primary endpoints were limb salvage and wound healing.

RESULTS

Of the 282 distal bypasses performed for 222 patients with CLTI, 22 were conducted for 21 patients with connective tissue disease (CD group). The connective tissue disease was progressive systemic scleroderma (n = 11 patients), pemphigoid diseases (n = 2), polyarteritis nodosa (n = 2), rheumatoid arthritis (n = 2), and others (n = 4). Compared with the AS group, the CD group included more females (P = .007) and had greater oral steroid use (P < .001) and a higher Global Limb Anatomical Staging System (GLASS) inframalleolar (IM) modifier P2 (P < .001). The mean follow-up period of the whole cohort was 27 ± 22 months with no significant difference between the groups (P = .25), and 22 limbs required major amputation during this period. The 2-year limb salvage rate was significantly lower in the CD group compared to the AS group (75% vs 94%, P = .020). Wound healing was achieved in 220 (78%) limbs, and the 12-month wound healing rate was significantly lower in the CD group (52% vs 86%, P = .006).

CONCLUSION

The low 2-year limb salvage and 12-month wound healing rates in patients with CLTI with connective tissue disease indicate that distal bypass may be challenging in these patients.

Outcomes after endovascular revascularization for chronic limb-threatening ischemia from the only Vascular Quality Initiative (VQI) center in Asia

OBJECTIVE

This study compares chronic limb-threatening ischemia disease characteristics and endovascular revascularization outcomes in a multi-ethnic Asian cohort vs their North American counterparts.

METHODS

The Society for Vascular Surgery Vascular Quality Initiative (VQI) registry database from the first and currently the only VQI center in Asia was reviewed to identify patients with chronic limb-threatening ischemia who underwent endovascular revascularization between July 2019 and April 2024. Standardized VQI reporting variables were compared against benchmarks derived from all participating centers in North America.

RESULTS

A total of 2862 endovascular revascularization procedures from our center were benchmarked against 129,347 procedures from 406 North American centers. Our cohort had a higher burden of comorbidities (diabetes mellitus, end-stage renal disease, cardiac disease) and presented with more advanced Wound, Ischemia, and foot Infection stages. Our patients had more heavily calcified and longer (14.8 cm vs 6.0 cm) diseased vessels with higher prevalence of multi-level (87% vs 54.6%), infrapopliteal (52.6% vs 38.9%), and inframalleolar (9.6% vs 2.4%) disease. Rates of technical success (92.7% vs 93%) and symptom improvement (39.1% vs 40.4%) were comparable between cohorts. However, 1-year mortality rates (28.9% vs 25.1%) and major amputation rates (13.3% vs 7.8%) were significantly higher.

CONCLUSIONS

Short-term outcomes of technical success and symptom relief in our center were comparable to benchmarked North American outcomes despite having a cohort with more diseased vessels, higher Wound, Ischemia, and foot Infection stages, and more comorbidities. However, this cohort fared worse in longer term outcomes of 1-year mortality and major amputation rates. Further studies are required to elucidate the causes to improve these outcomes.

Outcomes of revascularization of stenotic inframalleolar lesions in chronic limb-threatening ischemia

BACKGROUND

For chronic limb-threatening ischemia, revascularization has been reported for occlusions but not for stenosis in the inframalleolar (IM) lesions. We investigated the clinical outcomes of balloon dilation for stenotic IM lesions distal to the treatment target in the infrapopliteal (IP) legion.

METHODS

We conducted a retrospective analysis of patients who had chronic limb-threatening ischemia and underwent revascularization of stenotic IM lesions distal to the target IP lesions between January 2015 and August 2022. The outcome measures were amputation-free survival, wound healing rate, and freedom from target IM reintervention.

RESULTS

The 87 patients had a mean age of 72.7 ± 10.7 years and comprised 67.8% men, 74.7% with diabetes mellitus, 55.2% on dialysis, 33.3% who had Rutherford six classification. The amputation-free survival (AFS), wound healing, and freedom from target IM reintervention rates at 1 year were 82.9%, 53.3%, and 58.4%, respectively. On Cox proportional multivariate analysis, the predictors were Wound, Ischemia, and foot Infection (WIfI) ≥3 and diffuse stenosis in the target IM vessels for delayed wound healing and Global Limb Anatomic Staging System stage Ⅲ and ≥3 diseased IM vessels before endovascular therapy for target IM reintervention. At the time of reintervention, the lesion morphology had progressed from stenosis to occlusion in 50% of cases.

CONCLUSIONS

In patients with chronic limb-threatening ischemia, revascularization of stenosis in IM lesions showed a high reintervention rate and progression of lesion morphology, although AFS and wound-healing rates were acceptable.

Outcomes and Patency of Endovascular Infrapopliteal Reinterventions in Patients With Chronic Limb-Threatening Ischemia

PURPOSE

Endovascular revascularization is the preferred treatment to improve perfusion of the lower extremity in patients with chronic limb-threatening ischemia (CLTI). Patients with CLTI often present with stenotic-occlusive lesions involving the infrapopliteal arteries. Although the frequency of treating infrapopliteal lesions is increasing, the reintervention rates remain high. This study aimed to determine the outcomes and patency of infrapopliteal endovascular reinterventions.

METHODS

This retrospective, multicenter cohort study of 3 Dutch hospitals included patients who underwent an endovascular infrapopliteal reintervention in 2015 up to 2021 after a primary infrapopliteal intervention for CLTI. The outcome measures after the reintervention procedures included technical success rate, the mortality rate and complication rate (any deviation from the normal postinterventional course) at 30 days, overall survival, amputation-free survival (AFS), freedom from major amputation, major adverse limb event (MALE), and recurrent reinterventions (a reintervention following the infrapopliteal reintervention). Cox proportional hazard models were used to determine risk factors for AFS and freedom from major amputation or recurrent reintervention.

RESULTS

Eighty-one patients with CLTI were included. A total of 87 limbs underwent an infrapopliteal reintervention in which 122 lesions were treated. Technical success was achieved in 99 lesions (81%). The 30-day mortality rate was 1%, and the complication rate was 13%. Overall survival and AFS at 1 year were 69% (95% confidence interval [CI], 55%-79%) and 54% (95% CI, 37%-67%), respectively, and those at 2.5 years were 45% (95% CI, 33%-56%) and 21% (95% CI, 11%-33%), respectively. Freedom from major amputation, MALE, and recurrent reinterventions at 1 year and 2.5 years were 59% (95% CI, 46%-70%) and 41% (95% CI, 25%-56%); 54% (95% CI, 41%-65%) and 36% (95% CI, 21%-51%); and 68% (95% CI, 55%-78%) and 51% (95% CI, 33%-66%), respectively. A Global Limb Anatomic Staging System score of III showed an increased hazard ratio of 2.559 (95% CI, 1.078-6.072; p=0.033) for freedom of major amputation or recurrent reintervention.

CONCLUSIONS

The results of this study indicate that endovascular infrapopliteal reinterventions can be performed with acceptable 30-day mortality and complication rates. However, outcomes and patency were moderate to poor, with low AFS, high rates of major amputations, and recurrent reinterventions.

CLINICAL IMPACT

This multicenter retrospective study evaluating outcome and patency of endovascular infrapopliteal reinterventions for CLTI, shows that endovascular infrapopliteal reinterventions can be performed with acceptable 30-day mortality and complication rates. However, the short- and mid-term outcomes of the infrapopliteal reinterventions were moderate to poor, with low rates of AFS and a high need for recurrent reinterventions. While the frequency of performing infrapopliteal reinterventions is increasing with additional growing complexity of the disease, alternative treatment options such as venous bypass grafting or deep venous arterialization may be considered and should be studied in randomized controlled trials.

Common Criticisms and Rebuttals of the Best Endovascular Versus Best Surgical Therapy in Patients with Chronic Limb-Threatening Ischemia (BEST-CLI) Trial

The Best Endovascular Versus Best Surgical Therapy in Patients With Chronic Limb-Threatening Ischemia trial was a landmark trial which provides high-quality data for the decision-making regarding the treatment of chronic-limb threatening ischemia. Overall, the trial suggests that in patients with adequate greater saphenous vein conduit, bypass surgery should be offered as a first line treatment given superior outcomes. In this article, we outline the common critiques of the trial, followed by responses to provide a deeper understanding of the strengths and limitations of this important trial.

Distal Adjuncts for High-Risk Lower Extremity Bypasses

BACKGROUND

This review will discuss the use of distal adjuncts for improving graft patency in high-risk lower extremity bypasses.

METHODS

Factors that contribute to the increased risk of failure in high-risk lower extremity bypasses, such as the use of nonautogenous conduits, the creation of bypasses to very distal arterial targets, and bypasses in patients with significant tibial arterial disease, will be discussed.

RESULTS

The use of surgical techniques such as creating venous cuffs, venous patches, and arteriovenous fistulas have been shown to improve the patency of high-risk bypasses.

CONCLUSIONS

Despite the increased risk of failure, the use of surgical adjuncts such as cuffs, patches, and arteriovenous fistulas can improve the patency rates of high-risk lower extremity bypasses.

Near-Infrared Fluorescence Imaging With Indocyanine Green to Predict Clinical Outcome After Revascularization in Lower Extremity Arterial Disease

Contemporary quality control methods are often insufficient in predicting clinical outcomes after revascularization in lower extremity arterial disease (LEAD) patients. This study evaluates the potential of near-infrared fluorescence imaging with indocyanine green to predict the clinical outcome following revascularization. Near-infrared fluorescence imaging was performed before and within 5 days following the revascularization procedure. Clinical improvement was defined as substantial improvement of pain free walking distance, reduction of rest- and/or nocturnal pain, or tendency toward wound healing. Time-intensity curves and 8 perfusion parameters were extracted from the dorsum of the treated foot. The quantified postinterventional perfusion improvement was compared within the clinical outcome groups. Successful near-infrared fluorescence imaging was performed in 72 patients (76 limbs, 52.6% claudication, 47.4% chronic limb-threatening ischemia) including 40 endovascular- and 36 surgical/hybrid revascularizations. Clinical improvement was observed in 61 patients. All perfusion parameters showed a significant postinterventional difference in the clinical improvement group (P-values <.001), while no significant differences were seen in the group without clinical improvement (P-values .168-.929). Four parameters demonstrated significant differences in percentage improvement comparing the outcome groups (P-values within .002-.006). Near-infrared fluorescence imaging has promising additional value besides clinical parameters for predicting the clinical outcome of revascularized LEAD patients.

Intravascular lithotripsy in infra-popliteal peripheral artery disease

Chronic limb-threatening ischemia (CLTI) carries a significant risk of limb loss and thus demands urgent attention. Calcified atherosclerotic disease affecting the infra-popliteal (IP) arteries poses a formidable challenge for effective revascularization due to the narrow vessel diameter and the common presence of extensively calcified, long occlusive lesions. Intravascular lithotripsy (IVL) is an endovascular treatment that induces microfractures in the medial calcifications of blood vessels, thereby facilitating the clearance of calcified obstructive arterial lesions. This review assesses the growing body of evidence from multiple prospective studies that have investigated the role of IVL in the treatment of peripheral arterial disease (PAD) involving the IP segment. The clinical efficacy of IVL has been extensively studied and validated in various trials and real-world experiences. These studies consistently demonstrate IVL's ability to achieve vessel preparation, with excellent procedural success rates and low rates of major adverse events. Moreover, IVL has shown remarkable versatility, proving effective across a wide spectrum of PAD, including iliac artery disease, femoropopliteal disease and IP calcified disease. The available results from existing literature are encouraging and demonstrates safety and efficacy of the technology in treating calcified PAD. Additional studies on a larger scale are needed to better understand its long-term effects.