1
|
Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2497-2604. [PMID: 38752899 DOI: 10.1016/j.jacc.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
Collapse
|
2
|
Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
Collapse
|
3
|
Sanin GD, Negmadjanov U, Patterson JW, Hamid RN, Torosian T, Stafford JM, Sheehan MK, Goldman MP, Hurie J, Edwards MS, Velazquez G. Contemporary outcomes for arterial reconstruction with non-saphenous vein cryo-preserved conduits. J Vasc Surg 2024; 79:1457-1465. [PMID: 38286153 DOI: 10.1016/j.jvs.2024.01.201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/06/2023] [Accepted: 01/21/2024] [Indexed: 01/31/2024]
Abstract
OBJECTIVE Cryopreserved (CP) products are utilized during challenging cases when autogenous or prosthetic conduit use is not feasible. Despite decades of experience with cadaveric greater saphenous vein (GSV), there is limited available data regarding the outcomes and patency of other CP products, specifically arterial and deep venous grafts. This study was designed to evaluate outcomes of non-GSV CP conduits in patients undergoing urgent, emergent, and elective arterial reconstruction at our institution. We hypothesized that non-GSV CP allografts have adequate patency and outcomes and are therefore a feasible alternative to GSV in settings where autologous graft is unavailable or prosthetic grafts are contraindicated. METHODS This study was approved by the Institutional Review Board at our institution. We retrospectively reviewed charts of patients undergoing arterial reconstructions using CP conduits from 2010 to 2022. Data collected included demographics, comorbidities, smoking status, indications for surgery, indication for CP conduit use, anatomic reconstruction, urgency of procedure, and blood loss. Time-to-event outcomes included primary and secondary graft patency rates, follow-up amputations, and mortality; other complications included follow-up infection/reinfection and 30-day complications, including return to the operating room and perioperative mortality. Time-to-event analyses were evaluated using product-limit survival estimates. RESULTS Of 96 identified patients receiving CP conduits, 56 patients received non-GSV conduits for 66 arterial reconstructions. The most common type of non-GSV CP product used was femoral artery (31 patients), followed by aorto-iliac artery (22 patients), and femoral vein (19 patients), with some patients receiving more than one reconstruction or CP product. Patients were mostly male (75%), with a mean age of 63.1 years and a mean body mass index of 26.7 kg/m2. Indications for CP conduit use included infection in 53 patients, hostile environment in 36 patients, contaminated field in 30 patients, tissue coverage concerns in 30 patients, inadequate conduit in nine patients, and patient preference in one patient. Notably, multiple patients had more than one indication. Most surgeries (95%) were performed in urgent or emergent settings. Supra-inguinal reconstructions were most common (53%), followed by extra-anatomic bypasses (47%). Thirty-day mortality occurred in 10 patients (19%). Fifteen patients (27%) required return to the operating room for indications related to the vascular reconstructions, with 10 (18%) cases being unplanned and five (9%) cases planned/staged. Overall survival at 6, 12, and 24 months was 80%, 68%, and 59%, respectively. Primary patency at 6, 12, and 24 months was 86%, 70%, and 62%, respectively. Amputation freedom at 6 months, 12 months, and 24 months was 98%, 95%, and 86%, respectively for non-traumatic indications. CONCLUSIONS Non-GSV CP products may be used in complex arterial reconstructions when autogenous or prosthetic options are not feasible or available.
Collapse
Affiliation(s)
- Gloria D Sanin
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC.
| | - Ulugbek Negmadjanov
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - James W Patterson
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Rasikh N Hamid
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Taron Torosian
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Jeanette M Stafford
- Atrium Health Wake Forest Baptist Department of Biostatical Analysis, Winston-Salem, NC
| | - Maureen K Sheehan
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Matthew P Goldman
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Justin Hurie
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Matthew S Edwards
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Gabriela Velazquez
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| |
Collapse
|
4
|
Nwachukwu C, Ratner M, Rockman C, Cayne N, Siracuse JJ, Johnson W, Chang H, Jacobowitz G, Veith F, Shariff S, Garg K. Outcomes and predictors of amputation-free survival in patients undergoing below-knee popliteal-distal bypass. J Vasc Surg 2024; 79:1163-1169.e2. [PMID: 38244642 DOI: 10.1016/j.jvs.2023.12.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/15/2023] [Accepted: 12/17/2023] [Indexed: 01/22/2024]
Abstract
OBJECTIVE The infrageniculate popliteal artery is a potential source for inflow in lower extremity bypass surgery in patients with isolated tibial artery disease. The objective of our study was to assess the short- and long-term outcomes of popliteal-distal bypasses using data from the Vascular Quality Initiative (VQI). METHODS The VQI registry was queried between 2003 and 2021 for patients undergoing surgical revascularizations with the below-knee popliteal artery serving as inflow. Demographics, comorbidities, intraoperative characteristics, and postoperative complications were analyzed. Kaplan-Meier models were used to estimate amputation-free survival, survival, and freedom from amputation. Cox regression analysis was conducted to determine factors associated with major amputation or death. RESULTS A total of 1884 procedures were analyzed. The mean age of the included patients was 67.7 years. The most frequently observed preoperative comorbidities included insulin-dependent diabetes (52.3%), coronary disease (32.4%), and end-stage renal disease (14.4%). Of all the patients, 670 (35.6%) had a history of ipsilateral endovascular intervention. The procedures were performed for a variety of indications, including tissue loss (84.3%), rest pain (10.9%), and claudication (4.8%). Intraoperatively, the outflow targets were the dorsalis pedis (31.4%), the posterior tibial (24.4%), and the anterior tibial arteries (15.6%). Vein conduit was used in 92.1% of cases. The rate of perioperative myocardial infarction (MI) was 2.4%, and the 30-day mortality was 1.9%. The median length of follow up was 371 days. Amputation-free survival was found to be 85.6% (95% confidence interval [CI], 84.0%-87.2%) at 6 months and 78.6% (95% CI, 76.6%-80.4%) at 12 months. Survival was found to be 93.4% (95% CI, 92.2%-94.5%) at 6 months and 88.6% (95% CI, 87.1%-90.0%) at 12 months. Freedom from amputation was found to be 92.0% (95% CI, 90.7%-93.3%) at 6 months and 89.0% (95% CI, 87.3%-90.4%) at 12 months. Cox regression analysis demonstrated that age greater than 65 years, congestive heart failure, coronary artery disease, and end-stage renal disease were associated with a higher risk of major amputation or death (P < .05). CONCLUSIONS Below-knee popliteal-distal bypass is a safe and effective approach to treat severe tibial vessel occlusive disease in this challenging patient cohort. Patients exhibited low perioperative complication rates and good amputation-free survival at 1 year.
Collapse
Affiliation(s)
- Chukwuma Nwachukwu
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Molly Ratner
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Caron Rockman
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Neal Cayne
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston, MA
| | - William Johnson
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Heepeel Chang
- Division of Vascular Surgery, Department of Surgery, Westchester Medical Center, Valhalla, NY
| | - Glenn Jacobowitz
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Frank Veith
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Saadat Shariff
- Division of Vascular Surgery, Department of Surgery, Montefiore Medical Center, Bronx, NY
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY.
| |
Collapse
|
5
|
Korosoglou G, Torsello G, Saratzis A, Isernia G, Kontopodis N, González TM, Jacobs K, Van Herzeele I, Zayed H, Stavroulakis K. Editor's Choice - Endovascular Versus Surgical Treatment for All Comer Patients With Prosthetic Bypass Graft Occlusion: The Multicentre ENSUPRO Study. Eur J Vasc Endovasc Surg 2024; 67:786-796. [PMID: 37543355 DOI: 10.1016/j.ejvs.2023.07.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 06/10/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE Bypass surgery plays a key role in complex lower limb lesions. However, there is a lack of evidence regarding the management of symptomatic prosthetic bypass graft (PBG) occlusion. This study aimed to report outcomes following open, hybrid, or endovascular management of patients presenting with symptomatic PBG occlusion. METHODS A multicentre, retrospective cohort study was conducted, including patients presenting with PBG occlusion between January 2014 and December 2021 from 18 centres. It assessed the comparative value of treatment strategies, including (1) recanalisation of native vessels, (2) endovascular treatment of the failed PBG, (3) hybrid treatment, and (4) open surgery. The primary outcome measure was amputation free survival (AFS, time to major amputation and or death), whereas all cause mortality, major amputation, PBG re-occlusion, target lesion revascularisation (TLR), and Rutherford category (RC) improvement during follow up were considered as secondary endpoints. RESULTS Of 260 patients with occluded PBGs, 108 (41.5%) were treated endovascularly (24 [22.2%] by recanalisation of native vessels and 84 [77.7%] by PBG re-opening), 57 (21.9%) underwent hybrid revascularisation, and 58 (22.3%) had surgery. In addition, 27 (10.4%) were treated conservatively and 10 (3.8%) received systemic thrombolysis. With a median follow up of 1.4 (0.6 - 3.0) years, AFS was 95.5%, 76.4%, 45.5%, and 37.1%, respectively in Groups 1 - 4 (p = .007). Older age and non-endovascular treatment (HR 1.05 and 1.70; p < .01 for both) were independent predictors of poor AFS. Endovascular treatment was associated with lower rates of major amputation (p = .04), PBG re-occlusion (p < .001), and TLR (p = .037), and higher RC improvements (p < .001), whereas all cause mortality was comparable between treatment groups (p = .21). CONCLUSION Endovascular treatment is associated with higher rates of AFS and RC improvement and lower rates of PBG re-occlusion and TLR in patients with PBG occlusion.
Collapse
Affiliation(s)
| | - Giovanni Torsello
- University Hospital Münster, Institute for Vascular Research, Franziskus Hospital, Münster, Germany
| | - Athanasios Saratzis
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Giacomo Isernia
- Department of Vascular and Endovascular Surgery, University Hospital of Perugia, Perugia, Italy
| | | | | | - Karen Jacobs
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Hany Zayed
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | |
Collapse
|
6
|
Huang H, Zhang X, Wang Y, Tang H, Huang X, Zhang H, Li D. Popliteal artery pseudoaneurysm and secondary ipsilateral deep vein thrombosis caused by an exostosis in a mature adult. J Vasc Surg Cases Innov Tech 2024; 10:101375. [PMID: 38130363 PMCID: PMC10731611 DOI: 10.1016/j.jvscit.2023.101375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/06/2023] [Indexed: 12/23/2023] Open
Abstract
Exostosis (also known as osteochondroma) is the most common benign bony lump of young people, usually arising at the distal femur. Vascular complications associated with exostoses are rare and include true aneurysm or pseudoaneurysm formation, deep vein thrombosis, arteriovenous fistula, and arterial insufficiency of the limbs. Few case reports describe pseudoaneurysms resulting from exostoses in mature adults, and no consensus has been reached regarding the optimal therapy. We report the case of a 51-year-old male patient complaining of persistent right thigh pain with a pulsatile mass and right calf swelling, without a history of trauma or hereditary multiple exostoses. The diagnosis was confirmed by computed tomography angiography, which showed a pseudoaneurysm of the popliteal artery resulting from an exostosis on the lateral aspect of the distal femur. A Doppler ultrasound examination confirmed popliteal vein thrombosis caused by the compression of the pseudoaneurysm. Surgical treatment consisted of removing the exostosis, excision of the pseudoaneurysm, and an end-to-end anastomosis. The deep vein thrombosis was treated with rivaroxaban for 3 months. The patient was discharged after 6 days and followed up for 6 months with satisfactory results.
Collapse
Affiliation(s)
- He Huang
- Department of Vascular Surgery, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Xiaosong Zhang
- Department of Vascular Surgery, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Yusheng Wang
- Department of Vascular Surgery, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Hao Tang
- Department of Vascular Surgery, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Xiaoming Huang
- Department of Vascular Surgery, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Honggang Zhang
- Department of Vascular Surgery, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Da Li
- Department of Vascular Surgery, The First People's Hospital of Lianyungang, Lianyungang, China
| |
Collapse
|
7
|
Parker M, Penton A, McDonnell S, Kolde G, Babrowski T, Blecha M. Investigation of center-specific saphenous vein utilization rates in femoral popliteal artery bypass and associated impact of conduit on outcomes. J Vasc Surg 2023; 78:1497-1512.e3. [PMID: 37648090 PMCID: PMC10756644 DOI: 10.1016/j.jvs.2023.08.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/14/2023] [Accepted: 08/19/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE The purpose of this study is to investigate variation in great saphenous vein (GSV) use among the various centers participating in the Vascular Quality Initiative infrainguinal bypass modules. Further, differences in outcomes in femoral-popliteal artery bypass with single segment GSV conduit vs prosthetic conduit will be documented. Center GSV use rate impact on outcomes will be investigated. METHODS Primary exclusions were patients undergoing redo bypass, urgent or emergent bypass, and those in whom prosthetic graft was used while having undergone prior coronary artery bypass grafting. The distribution of GSV use across the 260 centers participating in Vascular Quality Initiative infrainguinal bypass module was placed into histogram and variance in mean GSV use evaluated with analysis of variance analysis. Centers that used GSV in >50% of bypasses were categorized as high use centers and centers that used the GSV in <30% of cases were categorized as low use centers. Baseline differences in patient characteristics and comorbidities in those undergoing bypass with GSV vs prosthetic conduit were analyzed with χ2 testing and the Student t test, as were those undergoing treatment in high vs low use centers. Multivariable time-dependent Cox regression analyses were then performed for the primary outcomes of major amputation ipsilateral to the operative side and mortality in long-term follow-up. High vs low use center was a dichotomous variable in these regressions. Secondary outcomes of freedom from graft infection and freedom from loss of primary patency were performed with Kaplan-Meier analysis. RESULTS Among centers with >50 patients meeting inclusion criteria for this study, GSV use ranged from 15% to 93% (analysis of variance P < .001). When considering all centers irrespective of number of patients, the range was 0% to 100%. On Kaplan-Meier analysis, GSV conduit use was associated with improved freedom from loss of primary or primary assisted patency, improved freedom from major amputation after index hospitalization, improved freedom from graft infection after the index hospitalization, and improved freedom from mortality in long-term follow-up (log-rank P < .001 for all four outcomes). Both low use center (hazard ratio, 1.35; P < .001) and prosthetic graft use (hazard ratio, 1.24; P < .001) achieved multivariable significance as risks for mortality in long-term follow-up. Other variables with a multivariable mortality association are presented in the manuscript. Low use center and prosthetic bypass were significant univariable but not multivariable risks for major amputation after index hospitalization. CONCLUSIONS There is remarkably wide variation in GSV use for femoral popliteal artery bypass among various medical centers. GSV use is associated with enhanced long-term survival as well as freedom from loss of bypass patency and graft infection. The data herein indicate institutional patterns of prosthetic conduit choice, which has the potential to be altered to enhance outcomes.
Collapse
Affiliation(s)
- Michael Parker
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy, Chicago, IL
| | - Ashley Penton
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy, Chicago, IL
| | - Shannon McDonnell
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy, Chicago, IL
| | - Grant Kolde
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy, Chicago, IL
| | - Trissa Babrowski
- University of Chicago Medical Center, Pritzker School of Medicine, Section of Vascular Surgery and Endovascular Therapy, Chicago, IL
| | - Matthew Blecha
- Loyola University Chicago, Stritch School of Medicine, Loyola University Health System, Division of Vascular Surgery and Endovascular Therapy, Chicago, IL.
| |
Collapse
|
8
|
Kluckner M, Gruber L, Wippel D, Lobenwein D, Westreicher W, Pilz M, Enzmann FK. Long-Term Outcome of Bypass Surgery versus Endovascular Revascularization in Long Femoropopliteal Lesions. J Clin Med 2023; 12:jcm12103507. [PMID: 37240613 DOI: 10.3390/jcm12103507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/30/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
Long-term follow-up data comparing surgical and endovascular revascularization of femoropopliteal lesions is rarely reported. This study presents 4-year results of revascularization for long femoropopliteal lesions (Trans-Atlantic Inter-Society Consensus Types C and D) with vein bypass (VBP), polytetrafluorethylene bypass (PTFE), and endovascular intervention with a nitinol stent (NS). Data from a randomized-controlled trial on VBP and NS was compared with a retrospective patient cohort using PTFE with the same inclusion and exclusion criteria. Primary, primary assisted, and secondary patency, as well as changes in Rutherford categories and limb salvage rates, are reported. Between 2016 and 2020, 332 femoropopliteal lesions underwent revascularization. The lesion lengths and basic patient characteristics were similar between the groups. 49% of the patients presented with chronic limb threatening ischemia at the time of revascularization. During the four-year follow-up, primary patency was comparable for all three groups. Primary assisted and secondary patency were significantly higher after VBP, while PTFE and NS had similar results. Clinical improvement was also significantly superior after VBP. After four years of follow-up, patency rates as well as the clinical outcome clearly favor VBP. If no vein is available, NS is as effective as PTFE bypass with regard to patency and clinical outcome.
Collapse
Affiliation(s)
- Michaela Kluckner
- Department of Vascular Surgery, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Leonhard Gruber
- Department of Radiology, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - David Wippel
- Department of Vascular Surgery, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Daniela Lobenwein
- Department of Vascular Surgery, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Werner Westreicher
- Department of Vascular Surgery, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Manuela Pilz
- Department of Cardiac, Vascular and Endovascular Surgery, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
| | - Florian K Enzmann
- Department of Vascular Surgery, Medical University Innsbruck, 6020 Innsbruck, Austria
| |
Collapse
|
9
|
Sirignano P, Margheritini C, Ruggiero F, Panzano C, Filippi F, Rizzo L, Taurino M. The Ability to Look Beyond: The Treatment of Peripheral Arterial Disease. J Clin Med 2023; 12:jcm12093073. [PMID: 37176513 PMCID: PMC10179057 DOI: 10.3390/jcm12093073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
This paper offers a practical overview of the contemporary management of patients with peripheral arterial disease presenting intermittent claudication (IC), including clinical and instrumental diagnosis, risk factors modification, medical management, and evidence-based revascularization indications and techniques. Decision making represents a crucial element in the management of the patient with IC; for this, we think a review of this type could be very useful, especially for non-vascular specialists.
Collapse
Affiliation(s)
- Pasqualino Sirignano
- Vascular and Endovascular Surgery Unit, Sant'Andrea Hospital of Rome, Department of General and Specialistic Surgery, "Sapienza" University of Rome, 00189 Rome, Italy
| | - Costanza Margheritini
- Vascular and Endovascular Surgery Unit, Sant'Andrea Hospital of Rome, Department of Molecular and Clinical Medicine, "Sapienza" University of Rome, 00189 Rome, Italy
| | - Federica Ruggiero
- Vascular and Endovascular Surgery Unit, Sant'Andrea Hospital of Rome, Department of Molecular and Clinical Medicine, "Sapienza" University of Rome, 00189 Rome, Italy
| | - Claudia Panzano
- Vascular and Endovascular Surgery Unit, Misericordia Hospital, 58100 Grosseto, Italy
| | - Federico Filippi
- Vascular and Endovascular Surgery Unit, Misericordia Hospital, 58100 Grosseto, Italy
| | - Luigi Rizzo
- Vascular and Endovascular Surgery Unit, Sant'Andrea Hospital of Rome, Department of Molecular and Clinical Medicine, "Sapienza" University of Rome, 00189 Rome, Italy
| | - Maurizio Taurino
- Vascular and Endovascular Surgery Unit, Sant'Andrea Hospital of Rome, Department of Molecular and Clinical Medicine, "Sapienza" University of Rome, 00189 Rome, Italy
| |
Collapse
|
10
|
Gutowski P, Guziewicz M, Ilzecki M, Kazimierczak A, Lawson JH, Prichard HL, Przywara S, Samad R, Tente W, Turek J, Witkiewicz W, Zapotoczny N, Zubilewicz T, Niklason LE. Six-year outcomes of a phase II study of human-tissue engineered blood vessels for peripheral arterial bypass. JVS Vasc Sci 2023; 4:100092. [PMID: 36874956 PMCID: PMC9976461 DOI: 10.1016/j.jvssci.2022.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 11/08/2022] [Indexed: 12/05/2022] Open
Abstract
Objective The human acellular vessel (HAV) was evaluated for surgical bypass in a phase II study. The primary results at 24 months after implantation have been reported, and the patients will be evaluated for ≤10 years. Methods In the present report, we have described the 6-year results of a prospective, open-label, single-treatment arm, multicenter study. Patients with advanced peripheral artery disease (PAD) requiring above-the-knee femoropopliteal bypass surgery without available autologous graft options had undergone implantation with the HAV, a bioengineered human tissue replacement blood vessel. The patients who completed the 24-month primary portion of the study will be evaluated for ≤10 years after implantation. The present mid-term analysis was performed at the 6-year milestone (72 months) for patients followed up for 24 to 72 months. Results HAVs were implanted in 20 patients at three sites in Poland. Seven patients had discontinued the study before completing the 2-year portion of the study: four after graft occlusion had occurred and three who had died of causes deemed unrelated to the conduit, with the HAV reported as functional at their last visit. The primary results at 24 months showed primary, primary assisted, and secondary patency rates of 58%, 58%, and 74%, respectively. One vessel had developed a pseudoaneurysm deemed possibly iatrogenic; no other signs of structural failure were reported. No rejections or infections of the HAV occurred, and no patient had required amputation of the implanted limb. Of the 20 patients, 13 had completed the primary portion of the study; however, 1 patient had died shortly after 24 months. Of the remaining 12 patients, 3 died of causes unrelated to the HAV. One patient had required thrombectomy twice, with secondary patency achieved. No other interventions were recorded between 24 and 72 months. At 72 months, five patients had a patent HAV, including four patients with primary patency. For the entire study population from day 1 to month 72, the overall primary, primary assisted, and secondary patency rate estimated using Kaplan-Meier analysis was 44%, 45%, and 60% respectively, with censoring for death. No patient had experienced rejection or infection of the HAV, and no patient had required amputation of the implanted limb. Conclusions The infection-resistant, off-the-shelf HAV could provide a durable alternative conduit in the arterial circuit setting to restore the lower extremity blood supply in patients with PAD, with remodeling into the recipient's own vessel over time. The HAV is currently being evaluated in seven clinical trials to treat PAD, vascular trauma, and as a hemodialysis access conduit.
Collapse
Affiliation(s)
- Piotr Gutowski
- Department of Vascular Surgery and Angiology, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Malgorzata Guziewicz
- Research and Development Centre, Department of Vascular Surgery, General Hospital, Wroclaw, Poland
| | - Marek Ilzecki
- Clinic of Vascular Surgery and Angiology, Medical University of Lublin, Lublin, Poland
| | - Arkadiusz Kazimierczak
- Department of Vascular Surgery and Angiology, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Jeffrey H. Lawson
- Humacyte, Inc, Durham, NC
- Department of Surgery, Duke University, Durham, NC
| | | | - Stanislaw Przywara
- Clinic of Vascular Surgery and Angiology, Medical University of Lublin, Lublin, Poland
| | - Rabih Samad
- Department of Vascular Surgery and Angiology, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | | | - Jakub Turek
- Research and Development Centre, Department of Vascular Surgery, General Hospital, Wroclaw, Poland
| | - Wojcieh Witkiewicz
- Research and Development Centre, Department of Vascular Surgery, General Hospital, Wroclaw, Poland
| | - Norbert Zapotoczny
- Research and Development Centre, Department of Vascular Surgery, General Hospital, Wroclaw, Poland
| | - Tomaz Zubilewicz
- Clinic of Vascular Surgery and Angiology, Medical University of Lublin, Lublin, Poland
| | - Laura E. Niklason
- Humacyte, Inc, Durham, NC
- Department of Anesthesia and Biomedical Engineering, Yale University, New Haven
- Department of Biomedical Engineering, Yale University, New Haven, CT
- Correspondence: Laura E. Niklason, MD, PhD, Humacyte, Inc, 2525 NC-54, Durham, NC 27713
| |
Collapse
|
11
|
Horie K, Takahara M, Nakama T, Tanaka A, Tobita K, Hayakawa N, Mori S, Iwata Y, Suzuki K. Retrospective multicenter registry for endovascular treatment with newer devices in over 25-cm femoropopliteal artery disease: A retrospective observational study. Health Sci Rep 2022; 6:e1003. [PMID: 36544617 PMCID: PMC9764405 DOI: 10.1002/hsr2.1003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/10/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Background and Aims Endovascular therapy (EVT) is recommended in femoropopliteal (FP) lesions shorter than 25 cm by current guidelines; however, diffuse FP lesions remains challenging for EVT. The aim of this study was to investigate the efficacy of EVT with the latest devices for FP lesions longer than 25 cm. Methods This retrospective multicenter registry analyzed patients presented peripheral artery disease (PAD) having FP lesions longer than 25 cm who underwent EVT using the latest devices between 2017 and 2021. The primary outcome was restenosis 1 year after EVT. Results The present study enrolled a total of 504 PAD patients with 614 lesions undergoing EVT for diffuse FP lesions. The Kaplan-Meier analysis showed that the rates of freedom from restenosis and clinically-driven target lesion revascularization were 79.3% and 82.4% 1 year after EVT, respectively. The multivariate Cox proportional hazards regression analysis showed that clinical features associated independently with restenosis risk were cilostazol use (adjusted hazard ratio, 0.49 [0.32-0.74]; p = 0.001), reference vessel diameter (RVD) (0.72 [0.58-0.89] per 1-mm increase; p = 0.002), and P3 segment involvement (2.08 [1.33-3.26]; p = 0.001). The Kaplan-Meier analysis was conducted to compare the primary patency between cases with and without a small RVD, P3 involvement, and/or lack of cilostazol; any risk factors were related to a worse primary patency rate, compared with cases without risk factors. Conclusion In the current EVT era, the primary patency at 1 year was acceptable at 79.3% in patients with FP lesions longer than 25 cm. A small vessel and P3 segment involvement might be associated with a poor 1-year patency rate after EVT, whereas cilostazol administration might contribute to reducing restenosis.
Collapse
Affiliation(s)
- Kazunori Horie
- Department of Cardiovascular MedicineSendai Kousei HospitalMiyagiJapan
| | - Mitsuyoshi Takahara
- Department of Metabolic MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Tatsuya Nakama
- Department of CardiologyTokyobay UrayasuIchikawa Medical CenterChibaJapan
| | - Akiko Tanaka
- Department of Cardiovascular MedicineSendai Kousei HospitalMiyagiJapan
| | - Kazuki Tobita
- Department of CardiologyShonan Kamakura General HospitalKanagawaJapan
| | - Naoki Hayakawa
- Department of Cardiovascular MedicineAsahi General HospitalChibaJapan
| | - Shinsuke Mori
- Department of CardiologySaiseikai Yokohama City Eastern HospitalKanagawaJapan
| | - Yo Iwata
- Department of CardiologyFunabashi Municipal Medical CenterChibaJapan
| | - Kenji Suzuki
- Department of CardiologyTokyo Saiseikai Central HospitalTokyoJapan
| |
Collapse
|
12
|
Thomas JP, So KL, Turner JT, Malanowski AJ, Colvard BD. Optimal conduit choice for open lower extremity bypass in critical limb threatening ischemia. Semin Vasc Surg 2022; 35:172-179. [DOI: 10.1053/j.semvascsurg.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/02/2022] [Accepted: 05/02/2022] [Indexed: 11/11/2022]
|
13
|
Gensicke N, Nicholson R, Sharp W. Lower extremity aneurysmal degeneration of great saphenous venous allograft bypass in an adolescent boy. J Vasc Surg Cases Innov Tech 2022; 8:5-8. [PMID: 35024522 PMCID: PMC8731692 DOI: 10.1016/j.jvscit.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 10/10/2021] [Indexed: 12/05/2022] Open
Abstract
Chronic limb-threatening ischemia in the pediatric population is a rare phenomenon. When open repair is necessitated, an autogenous conduit is preferred. However, venous grafts are prone to their own long-term complications. We have presented the case of a 10-year-old boy with chronic limb-threatening ischemia due to popliteal artery thrombosis that was treated with an ipsilateral great saphenous vein bypass. Seven years after the initial procedure, the venous graft had developed aneurysmal degeneration with acute thrombosis, necessitating bypass revision. Through the present case, we have discussed the surgical approach and highlighted the importance of long-term postoperative surveillance after open repair in the pediatric population.
Collapse
Affiliation(s)
- Nicole Gensicke
- Department of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Rachael Nicholson
- Department of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - William Sharp
- Department of Vascular Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| |
Collapse
|
14
|
Zhao AH, Kwok CHR, Jansen SJ. How to Prevent Surgical Site Infection in Vascular Surgery: A Review of the Evidence. Ann Vasc Surg 2021; 78:336-361. [PMID: 34543711 DOI: 10.1016/j.avsg.2021.06.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 06/16/2021] [Accepted: 06/20/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND This review aims to identify and review the current evidence for preventing postoperative surgical site infections in abdominal aortic aneurysm surgery or infrainguinal arterial surgery. METHODS Extended literature review of clinical trials that examined the prevention of postoperative surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. Searches were conducted on Ovid MEDLINE (1950 - 13 March 2020) using key terms for vascular surgery, surgical site infections and specific preventative techniques. Articles were included if they discussed a relationship between a preventative technique and surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. The GRADE guidelines were used to assess the quality of evidence. RESULTS 21 techniques and 81 studies were included. Prophylactic antibiotics and negative pressure wound therapy have a high quality of evidence for the prevention of surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. A moderate quality evidence base was identified for gentamicin containing collagen implant (confined to high surgical site infection risk centers). Currently, there is a low or very low quality of evidence to suggest a reduction in the surgical site infection rate for combination therapy, glycaemic control, Methicillin-resistant Staphylococcus aureus screening and absorbable suture. Evidence suggests no beneficial effect for nutritional supplementation, chlorhexidine bath, hair removal therapy, Staphylococcus aureus nasal eradication, cyanoacrylate microsealant, silver grafts, rifampicin bonded grafts, triclosan coated suture and postoperative wound drains. Endoscopic saphenous vein harvest may reduce surgical site infection rate (very low quality of evidence) but may lower long-term patency. Autologous vein grafts may increase surgical site infections (very low quality of evidence) but may provide better long-term patency rates in above-knee infrainguinal bypass surgery. There was no identified evidence for perioperative normothermia, electrosurgical bipolar vessel sealer or Dermabond and Tegaderm for surgical site infection prevention in vascular surgery. CONCLUSIONS Prophylactic antibiotics and postoperative negative pressure wound therapy are effective in the prevention of postoperative surgical site infection in abdominal aortic aneurysm or infrainguinal arterial surgery. There exists a significant risk of bias in the literature for many preventative techniques and further studies are required to investigate the efficacy of gentamicin containing collagen implant, and specific combination therapies.
Collapse
Affiliation(s)
- Adam Hanting Zhao
- School of Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, Western Australia, Australia; Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Western Australia, Nedlands, Western Australia, Australia.
| | - Chi Ho Ricky Kwok
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Western Australia, Nedlands, Western Australia, Australia
| | - Shirley Jane Jansen
- School of Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, Western Australia, Australia; Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Western Australia, Nedlands, Western Australia, Australia; Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia; Heart and Vascular Research Institute, Harry Perkins Institute for Medical Research, Nedlands, Western Australia, Australia
| |
Collapse
|
15
|
Cheng TW, Raulli SJ, Farber A, Levin SR, Kalish JA, Jones DW, Rybin D, Doros G, Siracuse JJ. The Association of the Day of the Week with Outcomes of Infrainguinal Lower Extremity Bypass. Ann Vasc Surg 2020; 73:43-50. [PMID: 33370572 DOI: 10.1016/j.avsg.2020.11.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The day of the week (DOW) for performing procedures and operations has been shown to affect clinical and resource utilization outcomes. Limited published data are available on vascular surgery operations. Our primary objective was to assess outcomes by DOW for infrainguinal lower extremity bypass (LEB) performed for claudication or rest pain. The secondary objective was to assess outcomes by DOW for LEBs performed for tissue loss. METHODS The Vascular Quality Initiative was queried from 2003 to 2018 for all elective index infrainguinal LEBs performed for claudication or rest pain. Cases performed for acute limb ischemia as well as concomitant peripheral vascular intervention, nonelective LEBs, sequential grafts, and weekend cases were excluded. LEBs were grouped by DOW: Monday-Tuesday (early weekdays) versus Wednesday-Friday (later weekdays). Baseline data, operative details, and outcomes were collected. Univariate and multivariable analyses were performed. LEBs performed for claudication/rest pain were analyzed together while tissue loss was assessed separately. RESULTS There were 12,084 LEBs identified-44.5% performed on Monday-Tuesday and 55.5% on Wednesday-Friday. Overall, the mean age was 65.6 years, 68.6% were male, and 82.8% were Caucasian. LEBs were performed for claudication in 57.4% of cases. An autogenous great saphenous vein was used in 58.8% of cases, whereas a prosthetic graft was used in 35.1% of cases. The most common bypass origin was the femoral artery (94.1%), and target was the popliteal artery (70.1%). Significant differences between Monday-Tuesday versus Wednesday-Friday, respectively, were mean body mass index (27.8 kg/m2 vs. 28 kg/m2), preoperative aspirin use (74.2% vs. 72.5%), continuous vein harvest technique (41.9% vs. 44%), and mean operative time (mins) (216.2 vs. 222.6) (all P < 0.05). Univariate postoperative outcomes were significantly different between Monday-Tuesday versus Wednesday-Friday, respectively, for mean length of stay (LOS) (days) (3.9 vs. 4.3), cardiac complications (myocardial infarction/dysrhythmia/congestive heart failure) (3.5% vs. 4.9%), stroke (0.3% vs. 0.6%), and respiratory complications (0.8% vs. 1.3%) (all P < 0.05). Multivariable analysis demonstrated that LEBs performed on Wednesday-Friday versus Monday-Tuesday for claudication/rest pain were independently associated with cardiac complications and prolonged LOS. There were also 8,491 LEBs performed for tissue loss which overall had similar findings to LEBs performed for claudication/rest pain such as increased LOS for LEBs performed for tissue loss on Wednesday-Friday (P < 0.001) and similar likeliness for respiratory complication, wound complication, return to the operating room, and mortality (all P > 0.05). However, LEBs performed for tissue loss on Wednesday-Friday versus Monday-Tuesday had similar cardiac complications (P > 0.05). CONCLUSIONS Elective LEBs performed on later weekdays for claudication/rest pain were associated with cardiac complications and prolonged LOS, whereas tissue loss confirmed association with prolonged LOS. Further investigations are needed to identify whether increased resources or allocation of resources should be focused on later weekdays to optimize patient outcomes.
Collapse
Affiliation(s)
- Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Stephen J Raulli
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Denis Rybin
- Department of Biostatistics, Boston University, School of Public Health, Boston, MA
| | - Gheorghe Doros
- Department of Biostatistics, Boston University, School of Public Health, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
| |
Collapse
|
16
|
Levin SR, Farber A, Osborne NH, Beck AW, McFarland GE, Rybin D, Cheng TW, Siracuse JJ. Tibial bypass in patients with intermittent claudication is associated with poor outcomes. J Vasc Surg 2020; 73:564-571.e1. [PMID: 32707381 DOI: 10.1016/j.jvs.2020.06.118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/19/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Given that intermittent claudication (IC) rarely progresses to chronic limb-threatening ischemia and limb loss, safety and durability of elective interventions for IC are essential. Whether patients with IC benefit from tibial intervention is controversial, and data supporting its utility are limited. Despite endovascular therapy expansion, surgical bypass is still commonly performed. We sought to assess outcomes of bypass to tibial arteries for IC. METHODS The Vascular Quality Initiative (2003-2018) was queried for infrainguinal bypasses performed for IC. Perioperative and 1-year outcomes were compared between bypasses constructed to tibial and popliteal arteries. RESULTS Of 5347 infrainguinal bypasses, 1173 (22%) and 4184 (78%) were tibial and popliteal bypasses, respectively. Overall, mean age was 65 ± 10 years, and patients were often men (72%) and current smokers (42%). Tibial bypasses commonly targeted posterior tibial (40%), tibioperoneal trunk (23%), and anterior tibial (19%) arteries. Great saphenous vein was more often used for tibial bypass than for popliteal bypass (78% vs 54%; P < .001). Patients undergoing tibial compared with popliteal bypass more often had impaired ambulation and prior ipsilateral bypasses and were less often taking antiplatelets and statins (all P < .05). In the perioperative period, tibial bypass patients had longer postoperative length of stay (4.5 ± 3.5 vs 3.5 ± 2.8 days), more pulmonary complications (1.3% vs 0.6%), and higher return to the operating room (7% vs 4%; all P < .05). Perioperative myocardial infarction (1.2% vs 0.8%; P = .19), stroke (0.4% vs 0.4%; P = .91), and mortality (0.3 vs 0.3%; P = .86) rates were similar between the cohorts. At 1 year, tibial compared with popliteal bypasses exhibited lower freedom from occlusion/death (81% vs 89%; P < .001), ipsilateral major amputation/death (90% vs 94%; P < .001), and reintervention/amputation/death (73% vs 80%; P < .001), but patient survival was similar (96% vs 97%; P = .07). On multivariable analysis, tibial compared with popliteal bypass was independently associated with increased occlusion/death (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.28-2.11; P < .001), major ipsilateral amputation/death (HR, 1.6; 95% CI, 1.12-2.19; P = .003), and ipsilateral reintervention/amputation/death (HR, 1.51; 95% CI, 1.28-1.79; P < .001), with similar patient survival. CONCLUSIONS In patients with IC, tibial bypass was associated with poor outcomes, including major amputation. Surgeons should exhaust nonoperative therapies and present realistic outcome expectations to their patients before offering such intervention.
Collapse
Affiliation(s)
- Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | | | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Denis Rybin
- Department of Biostatistics, Boston University School of Public Health, Boston, Mass
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
| |
Collapse
|
17
|
Samson RH. Big data concerning polytetrafluoroethylene above- and below-knee bypass grafts provide more questions than answers. J Vasc Surg 2020; 71:1818. [DOI: 10.1016/j.jvs.2019.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 12/03/2019] [Indexed: 11/26/2022]
|
18
|
Humbarger O, Jones DW. Reply. J Vasc Surg 2020; 71:1818-1819. [PMID: 32334737 DOI: 10.1016/j.jvs.2019.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 12/19/2019] [Indexed: 10/24/2022]
Affiliation(s)
- Olivia Humbarger
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| |
Collapse
|