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Benedetto F, Spinelli D, Pipitò N, Barillà D, Stilo F, De Caridi G, Barillà C, Spinelli F. Inframalleolar bypass for chronic limb-threatening ischemia. Vasc Med 2021; 26:187-194. [PMID: 33407009 DOI: 10.1177/1358863x20978468] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aims of this study were to analyze the results of inframalleolar bypass for chronic limb-threatening ischemia (CLTI) and to identify outcome-predicting factors. All consecutive patients undergoing inframalleolar bypass for CLTI between 2015 and 2018 were included in this retrospective, single-center study. Outflow artery was the most proximal patent vessel segment in continuity with inframalleolar arteries. Bypasses originating from the popliteal artery were defined as 'short bypasses'. Sixty patients underwent inframalleolar bypass, with four patients undergoing bilateral procedures, making a total of 64 limbs included. The mean age was 73 ± 14 and 52 (81%) were male. The great saphenous vein was the preferred conduit (n = 58, 91%), in a devalvulated fashion (n = 56, 88%). Superficial femoral artery was the most common inflow artery for 'long' grafts (n = 22, 34%), while popliteal artery was the inflow artery for all 'short' grafts (n = 25, 39%). Dorsalis pedis artery was chosen as an outflow artery in 41 patients (63%). Median follow-up was 21 months. Two-year primary and secondary patency, limb salvage, amputation-free survival, and overall survival rates were 67 ± 6%, 88 ± 4%, 84 ± 4%, 72 ± 6%, and 85 ± 4%, respectively. At multivariate analysis, dialysis was an independent predictor for poor primary patency (HR, 4.6; 95% CI, 1.62-13.05; p = 0.004), whereas a short bypass was independently associated with an increased primary patency (HR, 0.3; 95% CI, 0.10-0.89; p = 0.03). In conclusion, bypass grafting to the inframalleolar arteries resulted in good patency rates, limb salvage and overall survival. Dialysis patients had lower primary patency but still had good limb salvage and survival. Short bypass was a predictor of improved primary patency.
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Affiliation(s)
- Filippo Benedetto
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Domenico Spinelli
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Narayana Pipitò
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - David Barillà
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Francesco Stilo
- Vascular Surgery Unit, Campus Bio-Medico of Rome University, Rome, Italy
| | - Giovanni De Caridi
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Chiara Barillà
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Francesco Spinelli
- Vascular Surgery Unit, Campus Bio-Medico of Rome University, Rome, Italy
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Chang H, Rockman CB, Jacobowitz GR, Cayne NS, Veith FJ, Han DK, Patel VI, Kumpfbeck A, Garg K. Interplay of Diabetes Mellitus and End-Stage Renal Disease in Open Revascularization for Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2020; 72:552-562. [PMID: 33227468 DOI: 10.1016/j.avsg.2020.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/15/2020] [Accepted: 10/02/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic limb-threatening ischemia (CLTI) in patients with end-stage renal disease (ESRD) confers a significant survival disadvantage and is associated with a high major amputation rate. Moreover, diabetes mellitus (DM) is an independent risk factor for developing CLTI. However, the interplay between end-stage renal disease (ESRD) and DM on outcomes after peripheral revascularization for CLTI is not well established. Our goal was to assess the effect of DM on outcomes after an infrainguinal bypass for CLTI in patients with ESRD. METHODS Using the Vascular Quality Initiative dataset from January 2003 to March 2020, records for all primary infrainguinal bypasses for CLTI in patients with ESRD were included for analysis. One-year and perioperative outcomes of all-cause mortality, reintervention, amputation-free survival (AFS), and major adverse limb event (MALE) were compared for patients with DM versus those without DM. RESULTS Of a total of 1,058 patients (66% male) with ESRD, 726 (69%) patients had DM, and 332 patients did not have DM. The DM group was younger (median age, 65 years vs. 68 years; P = 0.002), with higher proportions of obesity (body-mass index>30 kg/m2; 34% vs. 19%; P < 0.001) and current smokers (26% vs. 19%; P = 0.013). The DM group presented more frequently with tissue loss (76% vs. 66%; P < 0.001). A distal bypass anastomosis to tibial vessels was more frequently performed in the DM group compared to the non-DM group (57% vs. 45%; P < 0.001). DM was independently associated with higher perioperative MALE (OR 1.34; 95% CI, 1.06-1.68; P = 0.013), without increased risks of loss of primary patency and composite outcomes of amputation or death. On the mean follow-up of 11.4 ± 5.5 months, DM patients had a significantly higher rate of one-year MALEs (43% vs. 32%; P = 0.001). However, the one-year primary patency and AFS did not differ significantly. After adjusting for confounders, the risk-adjusted hazards for MALE (HR 1.34; 95% CI, 1.06-1.68; P = 0.013) were significantly increased in patients with DM. However, DM was not associated with increased risk of AFS (HR 1.16; 95% CI, 0.91-1.47; P = 0.238), or loss of primary patency (HR 1.04; 95% CI, 0.79-1.37; P = 0.767). CONCLUSIONS DM and ESRD each independently predict early and late major adverse limb events after an infrainguinal bypass in patients presenting with CLTI. However, in the presence of ESRD, DM may increase perioperative adverse events but does not influence primary patency and AFS at one year. The risk profile associated with ESRD appears to supersede that of DM, with no additive effect.
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Affiliation(s)
- Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Neal S Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Frank J Veith
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Daniel K Han
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, New York, NY
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New-York Presbyterian / Columbia University Medical Center / Columbia University College of Physicians and Surgeons, New York, NY
| | | | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY; New York University Grossman School of Medicine, New York, NY.
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Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K, Mills JL, Nikol S, Reekers J, Venermo M, Zierler RE, Hinchliffe RJ, Schaper NC. Effectiveness of revascularisation of the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3279. [PMID: 32176439 DOI: 10.1002/dmrr.3279] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 12/16/2022]
Abstract
In patients with diabetes, foot ulceration and peripheral artery disease (PAD), it is often difficult to determine whether, when and how to revascularise the affected lower extremity. The presence of PAD is a major risk factor for non-healing and yet clinical outcomes of revascularisation are not necessarily related to technical success. The International Working Group of the Diabetic Foot updated systematic review on the effectiveness of revascularisation of the ulcerated foot in patients with diabetes and PAD is comprised of 64 studies describing >13 000 patients. Amongst 60 case series and 4 non-randomised controlled studies, we summarised clinically relevant outcomes and found them to be broadly similar between patients treated with open vs endovascular therapy. Following endovascular revascularisation, the 1 year and 2 year limb salvage rates were 80% (IQR 78-82%) and 78% (IQR 75-83%), whereas open therapy was associated with rates of 85% (IQR 80-90%) at 1 year and 87% (IQR 85-88%) at 2 years, however these results were based on a varying combination of studies and cannot therefore be interpreted as cumulative. Overall, wound healing was achieved in a median of 60% of patients (IQR 50-69%) at 1 year in those treated by endovascular or surgical therapy, and the major amputation rate of endovascular vs open therapy was 2% vs 5% at 30 days, 10% vs 9% at 1 year and 13% vs 9% at 2 years. For both strategies, overall mortality was found to be high, with 2% (1-6%) perioperative (or 30 day) mortality, rising sharply to 13% (9-23%) at 1 year, 29% (19-48%) at 2 years and 47% (39-71%) at 5 years. Both the angiosome concept (revascularisation directly to the area of tissue loss via its main feeding artery) or indirect revascularisation through collaterals, appear to be equally effective strategies for restoring perfusion. Overall, the available data do not allow us to recommend one method of revascularisation over the other and more studies are required to determine the best revascularisation approach in diabetic foot ulceration.
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Affiliation(s)
- Rachael O Forsythe
- British Heart Foundation/University of Edinburgh Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland, UK
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Sweden
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Centre-Department of Veterans Affairs, Puget Sound Health Care System, Seattle, Washington
- Department of Veterans Affairs, University of Washington, Seattle, Washington
| | - Robert Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Joon P Hong
- Asan Medical Center, University of Ulsan, Seoul, South Korea
| | | | - Joseph L Mills
- SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | | | - Jim Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, The Netherlands
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Finland
| | - R Eugene Zierler
- Department of Surgery, University of Washington, Washington, Seattle
| | | | - Nicolaas C Schaper
- Div. Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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Sigl M, Noe T, Ruemenapf G, Kraemer BK, Morbach S, Borggrefe M, Amendt K. Outcomes of severe limb ischemia with tissue loss and impact of revascularization in haemodialysis patients with wound, ischemia, and foot infection (WIfI) stage 3 or 4. VASA 2020; 49:63-71. [DOI: 10.1024/0301-1526/a000819] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Summary. Background: With growing prevalence, end-stage renal disease (ESRD) as well as critical limb ischemia (CLI) are both conditions associated with high morbidity and mortality rates. Patients and methods: A retrospective single-centre study provided data of a German interdisciplinary vascular centre. Seventy-seven consecutive haemodialysis (HD) inpatients (median age, 73.6 years) with 91 threatened limbs with Wound, Ischemia, and foot Infection (WIfI) clinical stage 3 or 4 were evaluated for in-hospital treatment of peripheral arterial disease, limb salvage rates, major amputation (MA)-free and overall survival. Results: The 1-year MA-free limb salvage rate was 82 %. On multivariate analysis, a higher WIfI clinical stage (hazard ratio [HR], 7.54; p = 0.008) indicated a higher risk of MA, while at least one-vessel run-off to the foot after revascularization of any kind was associated with a lower risk of MA (HR, 0.17; p = 0.001). In the composite endpoint analysis, the 1-year MA-free overall survival rate was 65 %. Patients with limbs in WIfI clinical stage 4 versus stage 3 carried a more than two-fold increased hazard of death or MA (HR, 2.63; p = 0.028), while revascularization was associated with reduced risk (HR, 0.40; p = 0.021). One-year overall survival (78 %) was not associated with WIfI stage or revascularization but was worse in patients with previous symptomatic coronary artery disease (HR, 3.25; p = 0.039). During long-term follow-up over 12 years, MA-free survival probability was significantly lower in the WIfI stage 4 versus WIfI stage 3 group (HR, 1.58; p = 0.048) without significant differences in overall survival (HR, 1.10; p = 0.696). Conclusions: Lower-extremity CLI with tissue loss in HD patients is associated with high morbidity and mortality rates. WIfI clinical stage was predictive of 1-year MA-free survival, while revascularization significantly reduced MA risk but did not influence overall survival.
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Affiliation(s)
- Martin Sigl
- First Department of Medicine, University Medical Centre Mannheim (UMM), Mannheim, Germany
| | | | - Gerhard Ruemenapf
- Department of Vascular Surgery, Diakonissen-Stiftungs-Krankenhaus Speyer, Gefäßzentrum Oberrhein, Speyer, Germany
| | - Bernhard K. Kraemer
- Vth. Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany
| | - Stephan Morbach
- Department of Diabetology and Angiology, Marienkrankenhaus Soest and Institute for Health Services Research and Health Economics, Research Centre for Health and Society, Heinrich Heine University Düsseldorf, Germany
| | - Martin Borggrefe
- Vth. Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany
| | - Klaus Amendt
- Department of Angiology, Cardiology and Diabetes associated diseases, Diakonissenkrankenhaus Mannheim, Gefäßzentrum Oberrhein, Germany
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Kim J, Park TK, Choi KH, Choi D, Ko YG, Lee JH, Yoon CH, Chae IH, Yu CW, Min PK, Lee SW, Lee SR, Koh YS, Choi SH. Different association between renal dysfunction and clinical outcomes according to the presence of diabetes in patients undergoing endovascular treatment for peripheral artery disease. J Vasc Surg 2019; 71:132-140.e1. [PMID: 31285068 DOI: 10.1016/j.jvs.2019.03.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/30/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Although chronic kidney disease (CKD) and diabetes are important prognostic factors in patients with peripheral artery disease, there are limited data regarding the outcomes of endovascular treatment (EVT) according to the severity of CKD, especially in the presence of diabetes. This study sought to compare clinical outcomes of lower limb EVT between patients with and patients without CKD according to the presence of diabetes. METHODS Patients were enrolled from the Korean multicenter EVT registry and were divided according to the presence of diabetes, then further stratified by CKD (estimated glomerular filtration rate <60 mL/min/1.73 m2). The primary outcome was major adverse limb events (MALEs; a composite of reintervention for target limb, reintervention for target vessel, and unplanned major amputation) at 2 years. RESULTS A total of 3045 patients were eligible for analysis: 1277 nondiabetic patients (944 without CKD, 333 with CKD) and 1768 diabetic patients (951 without CKD, 817 with CKD). CKD was associated with a significantly increased risk of MALEs after EVT in diabetic patients (14.4% vs 9.9%; adjusted hazard ratio, 1.60; 95% confidence interval, 1.28-2.01; P < .001) but not in nondiabetic patients (7.6% vs 9.7%; adjusted hazard ratio, 0.78; 95% confidence interval, 0.53-1.14; P = .203; interaction P = .018). In analysis stratified by the severity of CKD among diabetic patients, end-stage renal disease was significantly associated with an increased risk of MALE. CONCLUSIONS CKD was associated with a significantly higher risk of MALEs after EVT in diabetic patients but not in nondiabetic patients. The increased risk of MALEs was mainly driven by patients with end-stage renal disease.
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Affiliation(s)
- Jihoon Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Donghoon Choi
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Guk Ko
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Hwan Lee
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Chang-Hwan Yoon
- Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - In-Ho Chae
- Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Cheol Woong Yu
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Pil-Ki Min
- Division of Cardiology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung-Whan Lee
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Rok Lee
- Division of Cardiology, Department of Internal Medicine, Chonbuk National University Hospital, Seoul, Republic of Korea
| | - Yoon Seok Koh
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Ramanan B, Jeon-Slaughter H, Chen X, Modrall JG, Tsai S. Comparison of open and endovascular procedures in patients with critical limb ischemia on dialysis. J Vasc Surg 2019; 70:1217-1224. [PMID: 30922740 DOI: 10.1016/j.jvs.2018.12.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/23/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Peripheral artery disease is a common comorbidity in patients with end-stage renal disease (ESRD), but there is a paucity of data comparing outcomes of different interventions in this group of patients. In this study, we examined perioperative outcomes of lower extremity endovascular revascularization (ER) and open revascularization (OR) in dialysis patients with critical limb ischemia (CLI). METHODS Patients on dialysis and undergoing ER and OR for CLI from 2011 to 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program dataset. Patient demographics, comorbidities, anatomic features, and perioperative outcomes were compared between ER and OR procedures. RESULTS From 2011 to 2015, 1021 lower extremity revascularizations were performed in dialysis patients with CLI. In this group, 535 were ER (53%) and 486 were OR (47%) procedures. Although demographic characteristics such as age and gender were similar between the two groups, there was a higher proportion of Caucasians and African Americans in the OR group. Patients undergoing open and endovascular procedures had similar rates of hypertension, congestive heart failure, diabetes, chronic obstructive pulmonary disease, and bleeding disorders. A minority of procedures (4%) were emergencies, which were distributed equally between the two groups. Preoperative aspirin usage was higher in the ER group (84% vs 78%; P = .024), beta-blocker use was higher in the OR group (79% vs 74%; P = .08), and statin use was similar between the two groups (72% in OR and 70% in ER; P = .54). On risk-adjusted multivariate analysis, OR was associated with a lower rate of major amputation (5.97% vs 11.78%; odds ratio, 0.48; 95% confidence interval [CI], 0.26-0.85), but a higher rate of postoperative bleeding (29.6% vs 8.97%; odds ratio, 2.86; 95% CI, 1.8-4.35) and wound complications (15% vs 3%; odds ratio, 4.5; 95% CI, 2.38-8.3). The 30-day mortality and cardiovascular morbidity were similar between the two groups. CONCLUSIONS In patients with ESRD with CLI, OR is associated with a lower risk of major limb amputation but a higher rate of postoperative wound complications and bleeding, compared with ER. Cardiovascular complications, 30-day mortality, reinterventions and readmissions were similar between the two groups. In patients with ESRD with CLI, OR should be considered as an option for limb salvage if feasible. Long-term outcomes comparing the two types of procedures are needed.
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Affiliation(s)
- Bala Ramanan
- Department of Surgery, University of Texas Southwestern Medical Center and VA North Texas Healthcare System, Dallas, Tex.
| | - Haekyung Jeon-Slaughter
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Xiaofei Chen
- Department of Statistical Science, Southern Methodist University, Dallas, Tex
| | - J Gregory Modrall
- Department of Surgery, University of Texas Southwestern Medical Center and VA North Texas Healthcare System, Dallas, Tex
| | - Shirling Tsai
- Department of Surgery, University of Texas Southwestern Medical Center and VA North Texas Healthcare System, Dallas, Tex
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Arhuidese I, Nejim B, Locham S, Malas MB. Infrainguinal bypass surgery outcomes are worse in hemodialysis patients compared with patients with renal transplants. J Vasc Surg 2018; 69:850-856. [PMID: 30583904 DOI: 10.1016/j.jvs.2018.05.252] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 05/31/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Studies of infrainguinal bypass surgery (IBS) in patients with end-stage renal disease have focused on hemodialysis (HD) patients. Little is known of the applicability of their outcomes to patients with renal transplants (RTs). In this study, we sought to compare perioperative and long-term outcomes of IBS in a large population-based cohort of HD and RT patients. METHODS A retrospective review of all HD and RT patients who underwent IBS between January 2007 and December 2011 in the U.S. Renal Data System was performed. Univariable, Kaplan-Meier, multivariable logistic, and Cox regression analyses were employed to evaluate 30-day postoperative (graft failure, limb loss, conduit infection, death) and long-term (primary patency [PP], primary assisted patency [PAP], secondary patency [SP], limb salvage, mortality) outcomes. RESULTS There were 10,787 IBSs performed in 9739 (90%) HD patients and 1048 (10%) RT patients who presented predominantly with critical limb ischemia (72%). Bypass configurations were femoral-popliteal (48%), femoral-tibial (34%), and popliteal-tibial (18%). Comparing HD vs RT patients, PP, PAP, and SP were 18% vs 33%, 23% vs 38%, and 30% vs 48%, respectively, at 5 years among autogenous conduit recipients (all P < .001) and 20% vs 28% (P = .02), 23% vs 31% (P = .02), and 33% vs 53% (P < .001) among prosthetic conduit recipients. Limb salvage and patient survival were 39% vs 56% and 19% vs 48%, respectively, at 5 years (all P < .001). Risk-adjusted analyses demonstrated higher PP (adjusted hazard ratio [aHR], 1.32; 95% confidence interval [CI], 1.20-1.45; P < .001), PAP (aHR, 1.32; 95% CI, 1.19-1.45; P < .001), SP (aHR, 1.47; 95% CI, 1.31-1.65; P < .001), limb salvage (aHR, 1.48; 95% CI, 1.30-1.67; P < .001), and patient survival (aHR, 2.42; 95% CI, 2.17-2.71; P < .001) for RT compared with HD patients. CONCLUSIONS The HD-dependent state is associated with elevated bypass and patient-level risks after IBS compared with patients with RTs. These results show that the benefits of renal transplantation likely extend to infrainguinal bypass-specific outcomes. The estimates of risk reported herein should inform the patient's and provider's expectations at the point of care.
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Affiliation(s)
- Isibor Arhuidese
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md; Division of Vascular Surgery, University of South Florida, Tampa, Fla
| | - Besma Nejim
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md
| | - Satinderjit Locham
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md
| | - Mahmoud B Malas
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, Md.
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Yuo TH, Wallace JR, Fish L, Avgerinos ED, Leers SA, Al-Khoury GE, Makaroun MS, Chaer RA. Editor's Choice - Comparison of Outcomes After Open Surgical and Endovascular Lower Extremity Revascularisation Among End Stage Renal Disease Patients on Dialysis. Eur J Vasc Endovasc Surg 2018; 57:248-257. [PMID: 30385187 DOI: 10.1016/j.ejvs.2018.09.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 09/05/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVES End stage renal disease (ESRD) patients with peripheral arterial disease (PAD) are at high risk of complications following open surgical revascularisation (OSR). Endovascular revascularisation (ER) is an option, but its role is unclear. This study sought to characterise the outcomes of ER and OSR in ESRD patients treated for claudication or critical limb ischaemia (CLI). METHODS The United States Renal Data System was used to investigate outcomes after lower extremity ER and OSR from 2005 to 2011. Primary outcomes were mortality, amputation, and peri-procedural myocardial infarction (MI). Kaplan-Meier (K-M) estimates were generated for mortality and amputation, logistic regression models for 30 day predictors, and proportional hazards models for long-term predictors. RESULTS A total of 20,347 patients underwent OSR and ER (20.3% OSR, 79.7% ER). CLI was the indication in 80.8% of ER and 88.4% of OSR. The unadjusted major amputation rate at 30 days was higher after ER compared with OSR (8.8% vs. 6.4%, p < .001). Conversely, the unadjusted mortality rate at 30 days was lower after ER compared with OSR (8.0% vs. 10.5%, p < .001). Multivariable logistic regression models adjusting for medical covariables and CLI versus claudication status demonstrated increased 30 day mortality risk with OSR compared with ER (OR 2.00, 95% CI 1.43-1.79, p < .001), MI (OR 1.38, 1.23-1.54, p < .001), and the combined endpoint of mortality and major amputation (OR 1.57, 1.16-2.12, p = .004), but lower odds of 30 day major amputation alone (OR 0.67, 0.58-0.77, p < .001). Proportional hazards models demonstrated increased long-term mortality risk with OSR compared with ER (HR 1.05, 1.00-1.09, p = .037), without a difference in major amputation (HR 0.99, 0.93-1.05, p = NS). CONCLUSIONS In this retrospective analysis of an administrative database, ESRD patients suffer from high mortality and amputation rates following lower extremity revascularisation. Compared with ER, OSR is associated with higher mortality. OSR has better 30 day limb salvage, although long-term outcomes are similar.
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Affiliation(s)
- Theodore H Yuo
- Department of Surgery, University of Pittsburgh School of Medicine, PA, USA.
| | | | - Larry Fish
- Department of Surgery, University of Pittsburgh School of Medicine, PA, USA
| | | | - Steven A Leers
- Department of Surgery, University of Pittsburgh School of Medicine, PA, USA
| | | | - Michel S Makaroun
- Department of Surgery, University of Pittsburgh School of Medicine, PA, USA
| | - Rabih A Chaer
- Department of Surgery, University of Pittsburgh School of Medicine, PA, USA
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9
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Diabetic Foot Limb Salvage—A Series of 809 Attempts and Predictors for Endovascular Limb Salvage Failure. Ann Vasc Surg 2018; 49:9-16. [DOI: 10.1016/j.avsg.2018.01.061] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 09/16/2017] [Accepted: 01/29/2018] [Indexed: 11/23/2022]
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10
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Boufi M, Ghaffari P, Allaire E, Fessi H, Ronco P, Vayssairat M. Foot Gangrene in Patients with End-Stage Renal Disease: A Case Control Study. Angiology 2016; 57:355-61. [PMID: 16703196 DOI: 10.1177/000331970605700312] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The prevalence of peripheral arterial disease (PAD) in patients with end-stage renal disease (ESRD) is high, with an annual risk of amputation estimated at 13%, and indications for limb revascularization in patients combining ESRD with stage IV PAD (foot gangrene) are still controversial. This case-controlled study compared survival, limb salvage, and quality of life in a group of patients hospitalized for foot gangrene according to their renal status (ESRD versus no renal insufficiency). All patients with ESRD hospitalized for foot gangrene (n=16) from 1996 to 2002 were compared with a control group with normal creatininemia (n=24) hospitalized for foot gangrene due to peripheral atherosclerotic arterial disease. The 2 groups were matched for age, sex ratio, and number with diabetes mellitus. After a mean follow-up of 467 ±410 days, patients with ESRD had a more severe prognosis as regards mortality (68.7% vs 12.5%, p=0.0005) and major amputation (31% versus 8%, p=0.09). The ESRD group was characterized by more frequent extensive arterial calcifications (16/16 vs 13/24, p=0.002), owing to a higher level of the calcium phosphorus product (3.54 ±1.2 vs 2.4 ±0.6, p=0.0023), and by impaired microcirculatory perfusion, as indicated by a lower oxygen pressure (TcPO2) (15.6 ±12 mm Hg vs 26 ±16, p=0.07). ESRD implies a poor prognosis in patients with stage IV peripheral arterial disease.
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Affiliation(s)
- Mourad Boufi
- Department of Vascular Surgery and Research Unit of CNRS, UMR 7054, Tenon Hospital (Assistance Publique-Hôpitaux de Paris), University of Paris VI, Saint-Antoine Faculty of Medicine, Paris, France
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11
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Nicholas GG, Bozorgnia M, Nastasee SA, Reed JF. Infrainguinal Bypass in Patients with End-stage Renal Disease: Survival and Ambulation. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857440003400206] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to evaluate the outcomes of infrainguinal bypass surgery and ambulatory status in patients with end-stage renal disease (ESRD). Vascular registry data and the medical records of patients requiring infrainguinal bypass surgery from 1985 through 1995 were reviewed retrospectively. Patients with chronic limb-threatening ischemia requiring maintenance hemodialysis or peritoneal dialysis for ≥ 6 months were compared to a randomly selected group of patients under going foot salvage infrainguinal bypass in the absence of ESRD. Primary outcomes were mortality, amputation, and ambulatory status at 30 days and 1 year. Data were analyzed using Pearson's chi-square methods, Fisher's Exact test, Mann-Whitney U, life table analyses, and Quality of Life-Class (QL-Class) ranking. There were 57 patients with ESRD who underwent 66 infrainguinal bypass proce dures. Mean age was 65.8 ±9.8 years (41-85 years). The 30-day operative mortality rate was 12.3% (7 patients). The cumulative survival at 1 year was 51.8% ±0.9%, and at 2 years it was 32.8% ± 1.3%. The cumulative limb loss was 29.7% ± 1.1% at 1 year and 36.7% ±2.6% at 2 years. In the comparison group, 46 patients without ESRD underwent 50 infrainguinal bypass procedures. The mean age of these patients was 72.3 ±9.1 years (36-90 years). The cumulative survival for the patients without ESRD was significantly higher (p < 0.001) both at 1 year (91.1% ±0.6%) and 2 years (88.8% ±0.8%). The cumulative limb loss for the comparison group was significantly lower (p < 0.001) at 1 year (4.1% ±0.4%) and at 2 years (6.3% ±0.5%). At both 30 days and 1 year, the QL- Class walking status rating was lower for the group with ESRD compared to patients without ESRD (p < 0.001). Patients with ESRD have a high mortality rate in the first 24 months after infrain guinal bypass grafting for foot salvage surgery compared with a similar group of patients without ESRD. Although foot salvage can be achieved in some survivors with ESRD, the ambulatory rate is low. These results support a very conservative approach when recom mending infrainguinal bypass grafting for foot salvage surgery for patients with ESRD.
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Affiliation(s)
| | | | | | - James F. Reed
- Health Studies Services, Lehigh Valley Hospital, Allentown, Pennsylvania
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12
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Meloni M, Giurato L, Izzo V, Stefanini M, Pampana E, Gandini R, Uccioli L. Long term outcomes of diabetic haemodialysis patients with critical limb ischemia and foot ulcer. Diabetes Res Clin Pract 2016; 116:117-22. [PMID: 27321326 DOI: 10.1016/j.diabres.2016.04.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 03/23/2016] [Accepted: 04/18/2016] [Indexed: 01/28/2023]
Abstract
AIM To evaluate the outcomes of diabetic dialysis patients with critical limb ischemia and foot ulcer. METHODS The study group included 599 diabetic, 99 dialyzed (Ds) (16.5%) and 500 not dialyzed (NDs) (83%) patients with critical limb ischemia and foot ulcers identified as stage C (ischemia) or D (ischemia plus infection) of Texas Wound Classification. All patients were treated by endovascular revascularization. Outcomes were expressed as healing, major amputation, death and non healing after 12months. The mean follow-up was 15±13months. RESULTS The outcomes of the whole population were: 48.9% healing, 11.3% major amputation, 12.7% death, 27.1 non healing. At the multivariate analysis dialysis was a negative predictor of healing and a positive predictor of major amputation. Outcomes for Ds and NDs were respectively: healing (30.3 vs 52.6%), major amputation (14.4 vs 10.8%), death (21.1 vs 11%) and non-healing (34.2 vs 25.6%) (X=0.0004). Amputation occurred earlier in Ds than in NDs. According to the multivariate analysis in Ds ischemic heart disease and lower ΔTcPO2 were negative predictors for healing. Successful revascularization was a negative predictor for major amputation. HDL and carotid artery disease were predictive factors of death among NDs. Among Ds high blood pressure values were the only predictor of amputation while no variable resulted predictive of healing or death. CONCLUSIONS Our study shows that our limb salvage protocol ensures a good rate of limb salvage in Ds even if they have a higher risk of amputation and death compared to NDs.
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Affiliation(s)
- Marco Meloni
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy.
| | - Laura Giurato
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Valentina Izzo
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | | | - Enrico Pampana
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Roberto Gandini
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Luigi Uccioli
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy
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13
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Meyer A, Schinz K, Lang W, Schmid A, Regus S, Rother U. Outcomes and Influence of the Pedal Arch in Below-the-Knee Angioplasty in Patients with End-Stage Renal Disease and Critical Limb Ischemia. Ann Vasc Surg 2016; 35:121-9. [PMID: 27238998 DOI: 10.1016/j.avsg.2016.01.039] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 01/17/2016] [Accepted: 01/18/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Management of dialysis patients with critical limb ischemia (CLI) still represents a challenge to vascular medicine, whereas the effects of the pedal arch quality in these patients with predominant affection of the infrapopliteal vessels have rarely been evaluated. Therefore, our aim was to analyze the outcomes of infrapopliteal angioplasty in the setting of chronic renal failure (end-stage renal disease) and evaluate the influence of the pedal arch involvement on clinical success. METHODS Prospective follow-up of 32 ERSD patients on hemodialysis (mean age, 72 years) with CLI and consecutive infrapopliteal angioplasty over a 5-year period 2010-2014 was performed. Mean follow-up was 10 months (range, 0-51 months). Statistical end points were defined for amputation-free survival, overall survival, and wound healing. Each patient's pedal arch was classified in 4 categories according to patency on completion angiography and the influence of the pedal arch quality on end points was assessed. RESULTS A total of 44 vessels in 32 ischemic legs were treated. Technical success was achieved in 96% of patients, no major complications were observed. A 30-day mortality rate amounted 6% with no procedure-related deaths. The 1-year amputation-free survival rate was 56% and 34% at 2 years. Two major amputations were required. Subsequent revascularization procedures were necessary in 11 patients (10 redo angioplasty, 1 pedal bypass graft). The pedal arch was classified as category I in 1 patient (3%), category IIa in 12 (38%), IIb in 3 (9%), and III in 16 patients (50%). No statistical significant differences in terms of survival or wound-healing rate were observed between those groups, and the pedal arch quality had no impact on predefined end points. CONCLUSIONS End-stage renal disease patients represent a subgroup with poor prognosis of limb salvage in CLI. Amputation-free survival remains poor and based on these data, an endovascular therapy is feasible and safe in these highly multimorbid patients. The quality of the pedal arch was not found to have any impact on wound healing or survival in the present study.
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Affiliation(s)
- Alexander Meyer
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Katharina Schinz
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Werner Lang
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Axel Schmid
- Institute of Radiology, University Hospital Erlangen, Erlangen, Germany
| | - Susanne Regus
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, University Hospital Erlangen, Erlangen, Germany.
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14
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Kobayashi S. [CKD and Progression of PAD.]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2016; 105:842-849. [PMID: 29182836 DOI: 10.2169/naika.105.842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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15
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[Long-term results after balloon angioplasty of crural arteries. Which factors influence leg salvage and survival rates?]. Radiologe 2016; 56:254-65. [PMID: 26924155 DOI: 10.1007/s00117-016-0079-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIM Clinical and statistical study analysing factors with influence on success rates, procedure-related complications, and long-term results for patients who underwent angioplasty of the crural arteries. MATERIAL AND METHODS Retrospectively we evaluated all patients who underwent angioplasty of the crural arteries due to critical chronic limb ischemia or severe claudication in the time period from 1/2002 to 12/2005. These patients were contacted in the time period from 1/2009 to 12/2010, and a follow-up examination including angiography was performed or telephone interviews were conducted with patients, relatives and referring physicians for follow-up. 212 patients with a mean age of 77.8 years (99 women and 113 men) underwent crural angioplasty on 239 limbs. The primary end points were the limb salvage rate and patient survival rate. The secondary end points included the complication rate, technical success rate, and patency rate. The prognostic relevance of treatment and selected variables with respect to limb salvage and patient survival were analysed with multiple logistic regression. RESULTS The technical success rate was 98.4%. Between 1/2009 and 12/2010, 49.5% of the patients died. An angiographic follow-up study was performed in 49.9% of the treated legs. The primary patency-rate (72% after 6 months and 62.8% after 12 months) was significant, influenced only by the riskfactor dialysis (p = 0.0207). After a mean follow-up of 3.7 years, 48 patients (22.6%) experienced minor- or major-amputation on 53 legs (22.2%). The limb salvage rate (Kaplan-Maier estimation) was 85.4% after 5 years. The mean survival rate according to Kaplan-Meier was 79.7, 72.2, 67.3 and 51.4% after 1, 2, 3 and 5 years, respectively. Results of multiple logistic regression analysis showed that negative prognostic variables with respect to patient survival were amputation (p = 0.0017) and dialysis (p = 0.0011) and with respect to limb salvage dialysis (p < 0.0001) and non-patent peroneal artery (p < 0.0001). CONCLUSION Balloon angioplasty of the crural arteries shows a high technical success rate with an acceptable complication rate. Dialysis and non-patent peroneal artery are negative prognostic variables for the clinical long-term success.
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16
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Hinchliffe RJ, Brownrigg JRW, Andros G, Apelqvist J, Boyko EJ, Fitridge R, Mills JL, Reekers J, Shearman CP, Zierler RE, Schaper NC. Effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral artery disease: a systematic review. Diabetes Metab Res Rev 2016; 32 Suppl 1:136-44. [PMID: 26342204 DOI: 10.1002/dmrr.2705] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Symptoms or signs of peripheral artery disease (PAD) can be observed in up to 50% of the patients with a diabetic foot ulcer and is a risk factor for poor healing and amputation. In 2012, a multidisciplinary working group of the International Working Group on the Diabetic Foot published a systematic review on the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. This publication is an update of this review and now includes the results of a systematic search for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980 to June 2014. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 56 articles were eligible for full-text review. There were no randomized controlled trials, but there were four nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 80-90%), and following endovascular revascularization, these rates were 78% (70-89%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular techniques. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of conservatively treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients.
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Affiliation(s)
- R J Hinchliffe
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK
| | - J R W Brownrigg
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK
| | - G Andros
- Amputation Prevention Center, Valley Presbyterian Hospital, Los Angeles, CA, USA
| | - J Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - E J Boyko
- Seattle Epidemiologic Research and Information Centre, Department of Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, WA, USA
| | - R Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - J L Mills
- Michael E. Debakey Department of Surgery, Baylor College of Medicine, Houston, USA
| | - J Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - C P Shearman
- Department of Vascular Surgery, Southampton University Hospitals NHS Trust, Southampton, UK
| | - R E Zierler
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - N C Schaper
- Division Endocrinology, MUMC+, CARIM Institute, Maastricht, The Netherlands
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17
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Fallon JM, Goodney PP, Stone DH, Patel VI, Nolan BW, Kalish JA, Zhao Y, Hamdan AD. Outcomes of lower extremity revascularization among the hemodialysis-dependent. J Vasc Surg 2015; 62:1183-91.e1. [PMID: 26254454 DOI: 10.1016/j.jvs.2015.06.203] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 06/02/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Optimal patient selection for lower extremity revascularization remains a clinical challenge among the hemodialysis-dependent (HD). The purpose of this study was to examine contemporary real world open and endovascular outcomes of HD patients to better facilitate patient selection for intervention. METHODS A regional multicenter registry was queried between 2003 and 2013 for HD patients (N = 689) undergoing open surgical bypass (n = 295) or endovascular intervention (n = 394) for lower extremity revascularization. Patient demographics and comorbidities were recorded. The primary outcome was overall survival. Secondary outcomes included graft patency, freedom from major adverse limb events, and amputation-free survival (AFS). Multivariate analysis was performed to identify independent risk factors for death and amputation. RESULTS Among the 689 HD patients undergoing lower extremity revascularization, 66% were male, and 83% were white. Ninety percent of revascularizations were performed for critical limb ischemia and 8% for claudication. Overall survival at 1, 2, and 5 years survival remained low at 60%, 43%, and 21%, respectively. Overall 1- and 2-year AFS was 40% and 17%. Mortality accounted for the primary mode of failure for both open bypass (78%) and endovascular interventions (80%) at two years. Survival, AFS, and freedom from major adverse limb event outcomes did not differ significantly between revascularization techniques. At 2 years, endovascular patency was higher than open bypass (76% vs 26%; 95% confidence interval [CI], 0.28-0.71; P = .02). Multivariate analysis identified age ≥80 years (hazard ratio [HR], 1.9; 95% CI, 1.4-2.5; P < .01), indication of rest pain or tissue loss (HR, 1.8; 95% CI, 1.3-2.6; P < .01), preoperative wheelchair/bedridden status (HR, 1.5; 95% CI, 1.1-2.1; P < .01), coronary artery disease (HR, 1.5; 95% CI, 1.2-1.9; P < .01), and chronic obstructive pulmonary disease (HR, 1.4; 95% CI, 1.1-1.8; P = .01) as independent predictors of death. The presence of three or more risk factors resulted in predicted 1-year mortality of 64%. CONCLUSIONS Overall survival and AFS among HD patients remains poor, irrespective of revascularization strategy. Mortality remains the primary driver for these findings and justifies a prudent approach to patient selection. Focus for improved results should emphasize predictors of survival to better identify those most likely to benefit from revascularization.
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Affiliation(s)
- John M Fallon
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David H Stone
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Virendra I Patel
- Division of Vascular Surgery, The Massachusetts General Hospital, Boston, Mass
| | - Brian W Nolan
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jeffrey A Kalish
- Division of Vascular Surgery, Boston University Medical Center, Boston, Mass
| | - Yuanyuan Zhao
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Allen D Hamdan
- Division of Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
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Meyer A, Goller K, Horch RE, Beier JP, Taeger CD, Arkudas A, Lang W. Results of combined vascular reconstruction and free flap transfer for limb salvage in patients with critical limb ischemia. J Vasc Surg 2015; 61:1239-48. [DOI: 10.1016/j.jvs.2014.12.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 12/08/2014] [Indexed: 12/17/2022]
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19
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Comprehensive Approach to Management of Critical Limb Ischemia. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:332. [DOI: 10.1007/s11936-014-0332-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Friedell ML, Stark KR, Kujath SW, Carter RR. Current status of lower-extremity revascularization. Curr Probl Surg 2014; 51:254-90. [DOI: 10.1067/j.cpsurg.2014.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 02/25/2014] [Indexed: 11/22/2022]
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21
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Aiello A, Anichini R, Brocco E, Caravaggi C, Chiavetta A, Cioni R, Da Ros R, De Feo ME, Ferraresi R, Florio F, Gargiulo M, Galzerano G, Gandini R, Giurato L, Graziani L, Mancini L, Manzi M, Modugno P, Setacci C, Uccioli L. Treatment of peripheral arterial disease in diabetes: a consensus of the Italian Societies of Diabetes (SID, AMD), Radiology (SIRM) and Vascular Endovascular Surgery (SICVE). Nutr Metab Cardiovasc Dis 2014; 24:355-369. [PMID: 24486336 DOI: 10.1016/j.numecd.2013.12.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 10/31/2013] [Accepted: 12/01/2013] [Indexed: 02/07/2023]
Abstract
Diabetic foot (DF) is a chronic and highly disabling complication of diabetes. The prevalence of peripheral arterial disease (PAD) is high in diabetic patients and, associated or not with peripheral neuropathy (PN), can be found in 50% of cases of DF. It is worth pointing out that the number of major amputations in diabetic patients is still very high. Many PAD diabetic patients are not revascularised due to lack of technical expertise or, even worse, negative beliefs because of poor experience. This despite the progress obtained in the techniques of distal revascularisation that nowadays allow to reopen distal arteries of the leg and foot. Italy has one of the lowest prevalence rates of major amputations in Europe, and has a long tradition in the field of limb salvage by means of an aggressive approach in debridement, antibiotic therapy and distal revascularisation. Therefore, we believe it is appropriate to produce a consensus document concerning the treatment of PAD and limb salvage in diabetic patients, based on the Italian experience in this field, to share with the scientific community.
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Affiliation(s)
- A Aiello
- P.O. Campobasso - ASReM, Campobasso, Italy
| | - R Anichini
- Servizi di Diabetologia, USL 3, Pistoia, Italy
| | - E Brocco
- Policlinico Abano Terme, Presidio Ospedaliero ULSS 16, Veneto, Italy
| | - C Caravaggi
- Istituto Clinico "Città Studi", Milan, Italy
| | | | - R Cioni
- Dipartimento Radiologia Diagnostica, interventistica e medicina nucleare, Azienda Ospedaliera Universitaria Pisana, Pisa, italy
| | - R Da Ros
- Centro Diabetologico Monfalcone (GO) - Ass2, Gorizia, Italy
| | - M E De Feo
- U.O.S. Diabetologia A.O.R.N. "A. Cardarelli", Naples, Italy
| | - R Ferraresi
- Emodinamica Interventistica Cardiovascolare, Istituto Clinico Città Studi, Milan, Italy
| | - F Florio
- IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - M Gargiulo
- Chirurgia Vascolare, Azienda Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - G Galzerano
- Department of Surgery Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy
| | - R Gandini
- Dipartimento Diagnostica per immagini, Imaging molecolare, radioterapia e radiologia interventistica, Policlinico Universitario Tor Vergata, Rome, Italy
| | - L Giurato
- Diabetic Foot Unit, Dept of Internal Medicine, Policlinico Universitario Tor Vergata, Rome, Italy
| | - L Graziani
- Unità Operativa di Cardiologia Invasiva, Istituto Clinico "Città di Brescia", Brescia, Italy
| | - L Mancini
- Istituto Dermatologico Immacolata IRCCS, Rome, Italy
| | - M Manzi
- Radiologia Interventistica, Policlinico Abano Terme, Presidio Ospedaliero ULSS 16, Veneto, Italy
| | - P Modugno
- Dipartimento Malattie Cardiovascolari Fondazione Giovanni Paolo II, Università Cattolica Sacro Cuore, Campobasso, Italy
| | - C Setacci
- Department of Surgery Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy
| | - L Uccioli
- Diabetic Foot Unit, Dept of Internal Medicine, Policlinico Universitario Tor Vergata, Rome, Italy.
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Rashid H, Slim H, Zayed H, Huang DY, Wilkins CJ, Evans DR, Sidhu PS, Edmonds M. The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome. J Vasc Surg 2013; 57:1219-26. [DOI: 10.1016/j.jvs.2012.10.129] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 10/11/2012] [Accepted: 10/17/2012] [Indexed: 11/25/2022]
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23
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Garimella PS, Hart PD, O'Hare A, DeLoach S, Herzog CA, Hirsch AT. Peripheral Artery Disease and CKD: A Focus on Peripheral Artery Disease as a Critical Component of CKD Care. Am J Kidney Dis 2012; 60:641-54. [DOI: 10.1053/j.ajkd.2012.02.340] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2011] [Accepted: 02/29/2012] [Indexed: 11/11/2022]
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Hinchliffe RJ, Andros G, Apelqvist J, Bakker K, Friederichs S, Lammer J, Lepantalo M, Mills JL, Reekers J, Shearman CP, Valk G, Zierler RE, Schaper NC. A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metab Res Rev 2012; 28 Suppl 1:179-217. [PMID: 22271740 DOI: 10.1002/dmrr.2249] [Citation(s) in RCA: 145] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In several large recent observational studies, peripheral arterial disease (PAD) was present in up to 50% of the patients with a diabetic foot ulcer and was an independent risk factor for amputation. The International Working Group on the Diabetic Foot therefore established a multidisciplinary working group to evaluate the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. A systematic search was performed for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980-June 2010. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 49 papers were eligible for full text review. There were no randomized controlled trials, but there were three nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 80-90%), and following endovascular revascularization, these rates were 78% (70.5-85.5%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular revascularization. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of medically treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients.
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Affiliation(s)
- R J Hinchliffe
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK.
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Lepäntalo M, Fiengo L, Biancari F. Peripheral arterial disease in diabetic patients with renal insufficiency: a review. Diabetes Metab Res Rev 2012; 28 Suppl 1:40-5. [PMID: 22271722 DOI: 10.1002/dmrr.2233] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Peripheral arterial disease is common among diabetic patients with renal insufficiency, and most of the diabetic patients with end-stage renal disease (ESRD) have peripheral arterial disease. Ischaemia is probably overrepresented as an etiological factor for a diabetic foot ulcer in this group of patients compared with other diabetic patients. ESRD is a strong risk factor for both ulceration and amputation in diabetic patients. It increases the risk of nonhealing of ulcers and major amputation with an OR of 2.5-3. Renal disease is a more important predictor of poor outcome after revascularizations than commonly expected. Preoperative vascular imaging is also affected by a number of limitations, mostly related to side effects of contrast agents poorly eliminated because of kidney dysfunction. Patients with renal failure have high perioperative morbidity and mortality. Persistent ischaemia, extensive infection, forefoot and heel gangrene, poor run-off, poor cardiac function, and the length of dialysis-dependent renal failure all affect the outcome adversely. Despite dismal overall outcome, recent data indicate that by proper selection, favourable results can be obtained even in ESRD patients, with the majority of studies reporting 1-year limb salvage rates of 65-75% after revascularization among survivors. High 1-year mortality of 38% reported in a recent review has to be taken into consideration, though. The preferential use of endovascular-first approach is attractive in this vulnerable multimorbid group of patients, but the evidence for endovascular treatment is very scarce. The need for complete revascularization of the foot may be even more important than in other patients with ischaemic ulcerated diabetic foot because there are a number of factors counteracting healing in these patients. Typically, half of the patients are reported to lose their legs despite open bypass. To control tissue damage and improve chances of ulcer healing, one should understand that early referral to vascular consultation is necessary.
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Affiliation(s)
- Mauri Lepäntalo
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland.
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Grisafi JL, Dadachanji C, Rahbar R, Detschelt E, Benckart DH, Muluk SC. The Effect of Immunosuppression on Lower Extremity Arterial Bypass Outcomes. Ann Vasc Surg 2011; 25:165-8. [DOI: 10.1016/j.avsg.2010.07.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Revised: 04/16/2010] [Accepted: 07/19/2010] [Indexed: 10/19/2022]
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Khan MUN, Lall P, Harris LM, Dryjski ML, Dosluoglu HH. Predictors of limb loss despite a patent endovascular-treated arterial segment. J Vasc Surg 2009; 49:1440-5; discussion 1445-6. [DOI: 10.1016/j.jvs.2009.02.226] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2008] [Revised: 02/03/2009] [Accepted: 02/03/2009] [Indexed: 11/29/2022]
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Jeffcoate WJ, Lipsky BA, Berendt AR, Cavanagh PR, Bus SA, Peters EJG, van Houtum WH, Valk GD, Bakker K. Unresolved issues in the management of ulcers of the foot in diabetes. Diabet Med 2008; 25:1380-9. [PMID: 19046235 DOI: 10.1111/j.1464-5491.2008.02573.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Management of diabetic foot ulcers presents a major clinical challenge. The response to treatment is often poor and the outcome disappointing, while the costs are high for both healthcare providers and the patient. In such circumstances, it is essential that management should be based on firm evidence and follow consensus. In the case of the diabetic foot, however, clinical practice can vary widely. It is for these reasons that the International Working Group on the Diabetic Foot has published guidelines for adoption worldwide. The Group has now also completed a series of non-systematic and systematic reviews on the subjects of soft tissue infection, osteomyelitis, offloading and other interventions designed to promote ulcer healing. The current article collates the results of this work in order to demonstrate the extent and quality of the evidence which is available in these areas. In general, the available scientific evidence is thin, leaving many issues unresolved. Although the complex nature of diabetic foot disease presents particular difficulties in the design of robust clinical trials, and the absence of published evidence to support the use of an intervention does not always mean that the intervention is ineffective, there is a clear need for more research in the area. Evidence from sound clinical studies is urgently needed to guide consensus and to underpin clinical practice. It is only in this way that patients suffering with these frequently neglected complications of diabetes can be offered the best hope for a favourable outcome, at the least cost.
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Affiliation(s)
- W J Jeffcoate
- Foot Ulcer Trials Unit, Nottingham University Hospitals Trust, Nottingham, UK.
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Dosluoglu HH, Cherr GS, Lall P, Harris LM, Dryjski ML. Peroneal artery-only runoff following endovascular revascularizations is effective for limb salvage in patients with tissue loss. J Vasc Surg 2008; 48:137-43. [DOI: 10.1016/j.jvs.2008.02.070] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Revised: 02/26/2008] [Accepted: 02/29/2008] [Indexed: 10/22/2022]
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The management of ischemic heel ulcers and gangrene in the endovascular era. Am J Surg 2007; 194:600-5. [DOI: 10.1016/j.amjsurg.2007.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2007] [Revised: 07/08/2007] [Accepted: 08/09/2007] [Indexed: 11/19/2022]
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Steel MW, DeOrio JK. Forefoot amputation with limb revascularization: the effects of amputation, timing, and wound closure on the peripheral vascular bypass graft site. Foot Ankle Int 2007; 28:690-4. [PMID: 17592699 DOI: 10.3113/fai.2007.0690] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Much has been written about the effects of successful arterial bypass on forefoot surgery for ulceration and gangrene. This study examined the effects of the amputation site and timing on the arterial bypass graft site. METHODS We reviewed the records of all patients who had successful vascular bypass graft surgery and amputation at our institution, between October, 1995 and May, 2002. Thirty-eight procedures in 35 patients fit the criteria and were included in the study. RESULTS Thirty-five patients had successful vascular bypass graft surgery and forefoot amputation for gangrene or nonhealing ulceration. Three of these patients developed gangrene on the contralateral side and received similar treatment for that side. All of the wounds eventually healed. Healing time, rate of graft infection, and rate of wound dehiscence did not differ noticeably between patients with amputation immediately after arterial bypass and patients with amputation one or more days after arterial bypass. Infection at the bypass site occurred in two patients; their amputation sites were closed primarily. Wound dehiscence developed at the bypass site in one patient whose amputation site was closed by secondary intention. Although not statistically significant, the median healing time in patients treated with primary closure (37 days) was less than that in patients treated with closure by secondary intention (61 days; p = 0.09), and rates of graft infection and wound dehiscence did not differ between these two groups of patients. CONCLUSIONS Amputation site wound closure may adversely affect the bypass graft, but results were not statistically significant. Treatment requires a closely coordinated team approach between the vascular surgeon and the orthopedic surgeon.
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Owens CD, Ho KJ, Kim S, Schanzer A, Lin J, Matros E, Belkin M, Conte MS. Refinement of survival prediction in patients undergoing lower extremity bypass surgery: stratification by chronic kidney disease classification. J Vasc Surg 2007; 45:944-52. [PMID: 17391900 DOI: 10.1016/j.jvs.2007.01.025] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Accepted: 01/05/2007] [Indexed: 01/28/2023]
Abstract
OBJECTIVE End-stage renal disease (ESRD) imparts a significant survival disadvantage to individuals undergoing lower extremity revascularization; however, the influence of lesser degrees of renal impairment remains unclear. This study examined the prognostic significance of the chronic kidney disease (CKD) classification on survival, limb salvage, and graft patency in patients undergoing lower extremity arterial reconstruction. METHODS A prospective registry was evaluated for consecutive patients between January 31, 1995, and December 21, 2004, undergoing first-time, lower extremity vein bypass surgery. Glomerular filtration rate (GFR) was estimated with the Modification of Diet in Renal Disease equation using each patient's preoperative creatinine concentration. CKD categories were taken from current National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria. RESULTS The cohort included 456 subjects, with a mean (+/- SD) age of 68.1 +/- 10.8 years. There were 274 men (60%) and 378 Caucasians (82.5%). Comorbidities included diabetes mellitus in 270 (59.0%), hypertension in 333 (72.7%), coronary artery disease in 242 (52.8%), and dyslipidemia in 203 (44.5%). The surgical indication was critical limb ischemia in 384 (83.8%). Among the variables examined, diabetes and critical ischemia as the indication for bypass were significantly skewed toward higher CKD classifications (P < .001). The 5-year survival rates by CKD class were, CKD 1 and 2, 57%; CKD 3, 46%; CKD 4, 23%; and CKD 5, 9.5%. On univariate analysis, age, coronary artery disease, diabetes mellitus, hypertension, critical ischemia, and CKD were significant predictors of mortality. After adjustment, however, only age (hazard ratio [HR], 1.05, 95% confidence interval [CI], 1.03 to 1.06) and CKD stages 4 (HR, 4.23; 95% CI, 2.04 to 8.75) and 5 (HR, 3.27; 95% CI, 1.96 to 5.45) retained significance. Subjects within the CKD 5 classification were more likely to have a major amputation (P = .018) compared with all other CKD classes. Notably, no relationship was detected between CKD category and graft patency. CONCLUSION CKD staging adequately differentiates survival curves and risk for major amputation among patients with renal impairment who are undergoing lower extremity bypass surgery. This may help in clinical decision analysis as well as in the refinement of stratification in future clinical trial design where survival is an end point.
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Affiliation(s)
- Christopher D Owens
- Division of Vascular Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
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Albers M, Romiti M, De Luccia N, Brochado-Neto FC, Nishimoto I, Pereira CAB. An updated meta-analysis of infrainguinal arterial reconstruction in patients with end-stage renal disease. J Vasc Surg 2007; 45:536-42. [PMID: 17257801 DOI: 10.1016/j.jvs.2006.11.036] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2006] [Accepted: 11/13/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND A previous meta-analysis reported on the mid-term outcomes of infrainguinal bypass grafts in patients with critical limb ischemia and end-stage renal disease. Given the competing interest in endovascular procedures, the results of bypass surgery must be assessed as precisely as possible for future comparison. In this study, the original meta-analysis was refined and updated by increasing the number of studies reviewed, estimating primary graft patency, extending follow-up time, and investigating the problem of early amputation despite a patent graft. METHODS Studies published from 1987 through 2005 were identified from two electronic databases. Two investigators independently extracted the survival data from life tables, survival curves, and texts. Pooled survival curves were then constructed for graft patency, limb salvage, and patient survival according to a random-effects protocol for meta-analysis. RESULTS Of 28 articles included, 18 reported amputation despite a patent graft in 84 (10%) out of 844 limbs, and 25 described a perioperative mortality of 88 (8.8%) out of 996 patients. The 5-year pooled estimate (SE) was 50.4% (15.4%) for primary patency, 50.8% (19.0%) for secondary patency, 66.6% (11.2%) for limb salvage, and 23.0% (11.7%) for patient survival. No publication bias was detected. CONCLUSIONS Limb salvage can be achieved in most end-stage renal disease patients who undergo bypass surgery for critical ischemia, but survival is poor. To avoid early amputation despite a patent graft, bypass grafting should not be offered to patients with a great amount of tissue loss or extensive infection.
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Affiliation(s)
- Maximiano Albers
- Vascular Surgery Section, Department of Surgery, Health and Medical Sciences Sector, Lusiada Foundation (UNILUS), Santos, SP, Brazil.
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Goulet S, Trepman E, Mmath MC, Koulack J, Fong H, Duerksen F, Martin B, Simonsen JN, Nicolle L, Embil J. Revascularization for peripheral vascular disease in Aboriginal and non-Aboriginal patients. J Vasc Surg 2006; 43:735-41. [PMID: 16616229 DOI: 10.1016/j.jvs.2005.11.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2005] [Accepted: 11/29/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND Canadian Aboriginal subjects have a higher prevalence of diabetes, renal disease, and lower extremity amputation than non-Aboriginal subjects. However, limited information is available about patient outcomes for arterial bypass surgery in Canadian Aboriginal compared with non-Aboriginal subjects. METHODS A retrospective study of all patients undergoing revascularization for peripheral vascular disease at a tertiary care referral center was performed. RESULTS A total of 828 procedures were performed on 678 patients between 1995 and 2002: 108 (13%) procedures on 84 (12%) Aboriginal patients and 720 (87%) procedures on 594 (88%) non-Aboriginal patients. Aboriginal patients had a higher prevalence of diabetes, chronic renal failure, and end-stage renal disease than non-Aboriginal patients. Aboriginal patients presented with more serious complications (gangrene [Aboriginal, 63 [58%] of 108 patients; non-Aboriginal, 112 [16%] of 720 patients; P < .0001] and nonhealing ulcer [Aboriginal, 29 [27%] of 108 patients; non-Aboriginal, 131 [18%] of 720 patients; P < .05]) and required urgent or emergency revascularization (Aboriginal, 47 [49%] of 95 patients; non-Aboriginal, 228 [36%] of 634 patients; P < .02) more frequently than non-Aboriginal patients. The 60-month patient mortality was similar for both groups (Aboriginal, 20 [24%] of 84 patients; non-Aboriginal, 160 [27%] of 594 patients; not significant), but Aboriginal patients had loss of limb more frequently (Aboriginal, 19 [18%] of 108 patients; non-Aboriginal, 62 [9%] of 720 patients; P < .0001) and had loss of primary graft patency more frequently (Aboriginal, 39 [36%] of 108 patients; non-Aboriginal, 155 [22%] of 720 patients; P < .0001) than non-Aboriginal patients. CONCLUSIONS Canadian Aboriginal subjects had worse outcomes with revascularization than non-Aboriginal subjects, but ethnicity and diabetes were not independent risk factors for poor outcome. Multivariate analysis showed that the poor outcomes in mortality, limb salvage, and primary graft patency among Aboriginal patients undergoing revascularization may be attributed to renal disease and a more advanced mode of presentation of peripheral vascular disease complications at the time of intervention.
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Affiliation(s)
- Stephen Goulet
- Department of Medicine, University of Manitoba, Winnipeg, Canada
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Miyajima S, Shirai A, Yamamoto S, Okada N, Matsushita T. Risk factors for major limb amputations in diabetic foot gangrene patients. Diabetes Res Clin Pract 2006; 71:272-9. [PMID: 16139385 DOI: 10.1016/j.diabres.2005.07.005] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2004] [Revised: 05/06/2005] [Accepted: 07/05/2005] [Indexed: 11/25/2022]
Abstract
We analyzed the clinical picture of diabetic foot lesion patients to investigate the risk factors for major limb amputations. The subjects were 210 diabetic foot lesion patients treated at our department over the past 9 years. The mean follow-up period was 604.5 [standard deviation (S.D.) 451.2] days with a median value of 492 days. There were 113 men and 97 women. By the final follow-up day, 18 underwent bypass surgeries (9%) and 13 skin grafts (6%), while 110 patients (52%) finally required limb amputation. The breakdown was 45 major amputations above or below the knee and 65 minor amputations of the toes or metatarsals. The outcomes of the major amputations were retrospectively analyzed by group. The blood glucose control was poor in all 45 major amputees, and their mean HbA1c (8.80%) was higher than that in the minor or non-amputation group (7.79%, P = 0.035). In the major amputation group, two patients had loss of vision due to retinopathy, and 30 patients received long-term hemodialysis due to nephropathy. The rate of arteriosclerosis obliterans (ASO) was higher in the major amputation group than in the minor or non-amputation group, and arteriography showed significantly high rates of multiple stenosis. Multivariate analysis of these results by the proportional hazard model showed that ASO with multiple stenosis (hazard ratio 3.23, 95% CI: 1.12-5.10), hemodialysis (2.14, 95% CI: 1.17-3.44), and HbA1c (1.20, 95% CI: 1.03-1.41) were independent risk factors for major amputation. The 3-year survival rate was 24.1% in the major amputation group and 93.0% in the minor or non-amputation group, and the life expectancy was significantly lower for the major amputees than the minor or non-amputees (P<0.0001). Together with early detection and treatment of foot lesions, good blood glucose control and early management of systemic complications such as nephropathy and arteriosclerosis are considered important to avoid major amputations.
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Affiliation(s)
- Susumu Miyajima
- Department of Dermatology, Osaka Koseinenkin Hospital, 4-2-78, Fukushima-ku, Fukushima, Osaka 553-0003, Japan.
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Derivaciones femorodistales perimaleolares en pacientes en hemodiálisis. ANGIOLOGIA 2006. [DOI: 10.1016/s0003-3170(06)74995-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Brosi P, Baumgartner I, Silvestro A, Do DD, Mahler F, Triller J, Diehm N. Below-the-Knee Angioplasty in Patients With End‐Stage Renal Disease. J Endovasc Ther 2005; 12:704-13. [PMID: 16363900 DOI: 10.1583/05-1638mr.1] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To determine clinical efficacy of below-the-knee (BTK) angioplasty in patients with end-stage renal disease (ESRD). METHODS Interrogation of a prospectively maintained database containing 2,659 patients treated at a tertiary referral hospital between February 1995 and June 2004 identified 29 ESRD patients (21 men; median age 69 years, IQR 10.12) who had 73 infrapopliteal atherosclerotic lesions treated in 38 ischemic limbs. The indication for treatment was intermittent claudication in 13 (34%) and critical limb ischemia in 25 (66%) limbs. BTK angioplasty was attempted either alone (n=18) or combined with an endovascular inflow procedure (n=20). Primary clinical success was defined as hemodynamic improvement (ABI increase >or=0.1) and/or symptomatic improvement (at least one clinical category). Cumulative rates were calculated according to the Kaplan-Meier estimate. RESULTS Primary technical success reached 97%, whereas hemodynamic improvement was obtained in only 50% (19/38) of the limbs treated. The pedal arteries were severely diseased in all, and complete occlusion of the pedal arch was found in 58% (18/31) of limbs on completion angiography. Median follow-up was 5.9 months (IQR 11.5). Primary clinical success was 17%, 11%, 11%, and 11% in patients with BTK angioplasty alone and 53%, 45%, 45%, and 45% in patients with inflow procedures after 3, 6, 9, and 12 months, respectively (p=0.017). Limb salvage was 73% at 12 months. Subgroup analyses showed significantly better clinical results in men (p=0.003) and in patients on hemodialysis compared to peritoneal dialysis (p=0.037). CONCLUSIONS Clinical efficacy of BTK angioplasty is limited in patients with ESRD because of the severely diseased pedal arteries. Further studies are warranted to define subgroups of patients likely to experience a more favorable outcome.
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Affiliation(s)
- Philippe Brosi
- Swiss Cardiovascular Center, Division of Angiology, Inselspital, University of Bern, Switzerland
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Aulivola B, Gargiulo M, Bessoni M, Rumolo A, Stella A. Infrapopliteal Angioplasty for Limb Salvage in the Setting of Renal Failure: Do Results Justify Its Use? Ann Vasc Surg 2005; 19:762-8. [PMID: 16228808 DOI: 10.1007/s10016-005-7970-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Multiple reports advocate the use of infrapopliteal angioplasty for limb salvage; however, its utility in the setting of renal failure is unclear. We performed angioplasty, rather than bypass, for tibial stenoses or occlusions <3 cm on 90 limbs of 79 patients (64.4% male, mean age 67.2 years), all with ischemic ulcer. Seventy (77.8%) had diabetes mellitus and 16 (17.8%) had end-stage renal disease (ESRD). Mean follow-up was 14.3 months (range 0.3-45). Associated femoropopliteal revascularization was required in 28 (31.0%) limbs. Primary angiographic success was achieved in 83 (92.2%) limbs. Residual stenosis or thrombosis occurred in two and five limbs, respectively. Dissection occurred in six limbs, all successfully treated with stent placement. Ulcer healing occurred after initial angioplasty in 41 (55.4%) non-ESRD and four (25%) ESRD limbs. Subsequent revascularization procedures were required in 21 (23.3%) limbs, including six bypasses and 15 repeat angioplasties, of which three underwent subsequent bypasses. Major amputation was required in 11 (14.9%) non-ESRD and seven (43.7%) ESRD limbs. Limb salvage was 84.4% and 80.2% in those without and 52.5% and 52.5% in those with ESRD at 1 and 3 years, respectively (p = 0.01). Thirty-day mortality was 2.2%. Overall actuarial survival was 82.2% and 62.1% at 1 and 3 years, respectively, and did not differ significantly between patients with and without ESRD (p = 0.66). Infrapopliteal angioplasty is a safe technique with low procedural morbidity and mortality. However, the inferior wound-healing and limb-salvage rates observed in patients with renal failure bring to question the utility of infrapopliteal angioplasty in this population.
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Affiliation(s)
- Bernadette Aulivola
- Division of Vascular Surgery, Department of Surgery, Loyola University Medical Center, 2160 South First Avenue, EMS Building 110, Room 3216, Maywood, IL 60153, USA.
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Chambon J, Alarcon B, N’Guyen H, Gaillard R, Pagniez D, Dumont A. Résultats des revascularisations sous-inguinales chez les malades en insuffisance rénale terminale. ACTA ACUST UNITED AC 2005; 130:26-31. [DOI: 10.1016/j.anchir.2004.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Georgopoulos S, Filis K, Vourliotakis G, Bakoyannis C, Papapetrou A, Klonaris C, Papalambros E, Bastounis E. Lower Extremity Bypass Procedures in Diabetic Patients with End-Stage Renal Disease: Is It Worthwhile? ACTA ACUST UNITED AC 2004; 99:c37-41. [PMID: 15627791 DOI: 10.1159/000082865] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2003] [Accepted: 07/08/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Limb-threatening ischemia in patients with end-stage renal disease (ESRD) represents a challenging therapeutic problem. Furthermore, diabetes mellitus is frequently associated with ischemic gangrene, persistent infection and impaired wound healing. The present study was undertaken to examine graft patency, limb salvage and survival in patients with ESRD and diabetes following bypass grafting to treat lower limb critical ischemia. METHODS A retrospective analysis of 56 arterial reconstructions performed in 39 patients with diabetes mellitus and ESRD during a period of 8 years. The indications for bypass grafting were: ischemic rest pain (n = 13), non-healing ulcer (n = 18) or foot gangrene (n = 25). Risk factors in association with surgical morbidity and mortality, limb loss and graft patency were evaluated. RESULTS Thirty-four patients were on hemodialysis and 5 on peritoneal dialysis. Forty-nine infrainguinal reconstructions were performed; the site of distal anastomosis was the below knee popliteal artery (n = 22), the anterior tibial artery (n = 12), the posterior tibial artery (n = 8), and the peroneal artery (n = 7). Seven axillofemoral reconstructions were also performed; the site of distal anastomosis was the common femoral artery (n = 5) and the above knee popliteal artery (n = 2). The 30-day operative mortality rate was 18% (7 patients). The mean follow-up was 11.5 (range 1-93) months. Patient survival rate at 1 and 2 years was 63 and 45%, respectively. Primary patency rate was 64% at 1 year and 58% at 2 years. The limb salvage rate was 65% in the first year. CONCLUSION Limb salvage rate in patients with ESRD and diabetes justifies an aggressive policy of revascularization, despite decreased survival of this population.
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Affiliation(s)
- S Georgopoulos
- Division of Vascular Surgery, First Department of Surgery, University of Athens Medical School, Athens, Greece
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Jaar BG, Astor BC, Berns JS, Powe NR. Predictors of amputation and survival following lower extremity revascularization in hemodialysis patients. Kidney Int 2004; 65:613-20. [PMID: 14717932 DOI: 10.1111/j.1523-1755.2004.00420.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Peripheral vascular disease (PVD) has become increasingly common in end-stage renal disease (ESRD) patients, leading to an increase in the rate of revascularization and amputation. We studied the prognosis of ESRD patients undergoing their first revascularization procedure. METHODS We conducted a longitudinal cohort study of hemodialysis patients enrolled in special studies of the United States Renal Data System. Cox proportional hazards analysis was used to assess the independent effect of type of initial revascularization procedure on lower extremity amputation and all-cause, cardiac, and infectious mortality over 3 years, after adjustment for sociodemographic, clinical, and biologic baseline characteristics. RESULTS Eight hundred patients underwent an initial revascularization procedure by surgical bypass or angioplasty. The overall incidence of subsequent amputation was 16.3/100 person-years, 22.6 for bypass, and 5.7 for angioplasty. After adjustment for patient characteristics, the risk of amputation was higher for bypass versus angioplasty [relative hazard (RH) 4.00; 95% CI 2.46 to 6.57], for black versus white patients (RH 1.49; 95% CI 1.04 to 2.15), for uninsured or patients on Medicaid versus patients with private insurance or on Medicare (RH 1.65; 95% CI 1.12 to 2.72), and for patients with diabetes versus no diabetes (RH 2.51; 95% CI 1.67 to 3.76). Compared with patients who underwent angioplasty, the risk of all-cause (RH 1.37; 95% CI 1.10 to 1.70), cardiac (RH 1.50; 95% CI 1.08 to 2.09), and infectious (RH 2.17; 95% CI 1.10 to 4.29) mortality was greater among patients who underwent bypass. CONCLUSION Risk of amputation following revascularization procedures was positively associated with type of procedure, black race, uninsured/Medicaid, and diabetes status. Risk of death was also higher following bypass. While this might reflect underlying severity of disease, patient education, screening, and optimal care of lower extremities should be emphasized to detect PVD at an early stage of the disease process.
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Affiliation(s)
- Bernard G Jaar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA.
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Van Damme H, Zhang L, Baguet E, Creemers E, Albert A, Limet R. Crural Artery Bypass with the Autogenous Greater Saphenous Vein. Eur J Vasc Endovasc Surg 2003; 26:635-42. [PMID: 14603424 DOI: 10.1016/s1078-5884(03)00345-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the long-term outcome of greater saphenous vein (GSV) infrapopliteal revascularisation in a single centre over a 10 year period. MATERIAL AND METHODS Fourty-one variables relating to a consecutive series of 90 crural artery GSV(76% in situ) bypasses in 81 patients (1990-2000) were analysed. The mean age of the 47 men and 34 women was 70 years. Limb-threatening ischaemia was present in 96% of cases, claudication in four patients. In 18 patients, surgery was 'redo'. RESULTS The perioperative mortality was 3% (n=3). Patient survival was 54% at 4 years. Independent risk factors affecting survival were chronic renal insufficiency (p=0.04), hypertension (p=0.02), and ischaemic heart disease (p=0.01). Four bypasses thrombosed within 30 days. Three of them could be successfully reopened. Mean follow-up was 39 months. The primary patency rate at 4 years was 80%. Chronic renal insufficiency revealed to be the single independent risk factor for graft thrombosis (p=0.03, RR=12.4). The 4-year limb salvage rate was 88%. No independent risk factor affecting the limb salvage could be identified. CONCLUSION Crural artery revascularisation is a valuable option for the management of limb threatening infrapopliteal arterial occlusive disease.
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Affiliation(s)
- H Van Damme
- Department of Cardiovascular and Thoracic Surgery, University Hospital of Liège, CHU du Sart-Tilman, Belgium
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Abou-Zamzam AM, Teruya TH, Killeen JD, Ballard JL. Major lower extremity amputation in an academic vascular center. Ann Vasc Surg 2003; 17:86-90. [PMID: 12522704 DOI: 10.1007/s10016-001-0340-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Major lower extremity amputations continue to be performed despite an aggressive policy of revascularization. Factors leading to amputation were analyzed to determine whether a reduction in the limb loss rate is possible. A retrospective analysis of a prospectively maintained vascular registry was performed to identify patients undergoing above-knee amputation (AKA), below-knee amputation (BKA), and lower extremity revascularization (LER) for limb salvage between January 1, 1999 and January 1, 2002. Patient demographics, comorbidities, insurance carriers, and indications for operative intervention were analyzed. Greater than one-half of all major lower extremity amputations are performed in patients who have failed attempts at revascularization or who are not candidates for LER due to anatomic factors. However, one-quarter of eventual amputees present very late to the vascular surgeon with extensive gangrene or infection that precludes limb salvage. Prompt patient referral and treatment may improve outcome in this group of patients. In our study, insurance issues did not appear to affect treatment. Renal failure continues to play a major role in limb loss.
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Affiliation(s)
- Ahmed M Abou-Zamzam
- Department of Surgery, Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
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Yasuhara H, Naka S, Yanagie H, Nagawa H. Influence of diabetes on persistent nonhealing ischemic foot ulcer in end-stage renal disease. World J Surg 2002; 26:1360-4. [PMID: 12447564 DOI: 10.1007/s00268-002-6335-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The aim of this study was to identify important atherosclerotic risk factors for characteristic nonhealing ischemic foot ulcers in patients with end-stage renal failure. We retrospectively studied 534 consecutive hemodialysis patients in five dialysis units of the Tokyo metropolitan area between 1980 and 1999. The influence of risk factors for ischemic foot ulcers in hemodialysis patients was determined using a multivariate logistic model. The characteristic features were also evaluated with further comparison of the prevalence of risk factors between hemodialyzed diabetic patients with ischemic foot ulcers and another 61 age- and gender-matched nonhemodialyzed diabetic patients with ischemic foot ulcers. In the logistic model, two factors emerged as important risk factors for ischemic foot ulcers: renal failure due to diabetes [odds ratio 21.580 (95% CI 4.838-96.251); p = 0.0001] and a history of cerebrovascular disease [odds ratio 2.782 (1.015-7.624); p = 0.0467]. On the basis of a comparison of age- and gender-matched control patients, associated diabetic triopathy, a history of cerebrovascular disease, and hypertension were more frequent in the hemodialysis patients. The development of ischemic foot ulcers in those with end-stage renal failure is strongly influenced by underlying advanced diabetic microangiopathy and such other factors as sequelae of cerebrovascular disease and patient debilitation.
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Affiliation(s)
- Hiroshi Yasuhara
- Department of Surgery, Teikyo University Ichihara Hospital, 3426-3 Anesaki, Ichihara City, Chiba 299-0111, Japan.
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Dorweiler B, Neufang A, Schmiedt W, Oelert H. Pedal arterial bypass for limb salvage in patients with diabetes mellitus. Eur J Vasc Endovasc Surg 2002; 24:309-13. [PMID: 12323173 DOI: 10.1053/ejvs.2002.1735] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE to evaluate pedal bypass grafting in patients with diabetes mellitus with critical limb ischaemia. PATIENTS AND METHOD from 1994 to 1999, 49 consecutive pedal bypass grafts were performed in 46 patients with a median age of 69 years (range 37-85 years). The incidence of insulin-dependent diabetes mellitus was 87%. The distal anastomosis was located at the dorsalis pedis artery in 36, at the inframalleolar posterior tibial artery in 9 and at the plantar artery in 4 cases, respectively. RESULTS one patient died perioperatively. Two bypass occlusions and one major amputation accounted for a primary patency rate of 96% and a limb salvage rate of 98% at 30 days, respectively. During a median follow-up of 28 months (range 1-70 months), 21 patients died of nonrelated causes. Three additional graft occlusions and 4 major amputations were noted resulting in a primary patency rate of 89% and a limb salvage rate of 87% at 48 months, respectively. CONCLUSION Pedal bypass grafting utilising the greater saphenous vein with in-situ technique is a reliable and effective procedure to achieve durable limb salvage in patients with diabetes mellitus.
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Affiliation(s)
- B Dorweiler
- Department of Cardiothoracic and Vascular Surgery, University Hospital, Johannes-Gutenberg Medical School, Langenbeckstrasse 1, 55101 Mainz, Germany
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Gerrard DJ, Ray SA, Barrio EA, Wood CH, Scoble JE, Taylor PR. Effect of chronic renal failure on mortality rate following arterial reconstruction. Br J Surg 2002; 89:70-3. [PMID: 11851666 DOI: 10.1046/j.0007-1323.2001.01961.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is some evidence that patients with renal failure who have arterial procedures may have a poor outcome. This study compared the hospital mortality rate of arterial surgery in patients with chronic renal failure and those with normal renal function. METHODS A consecutive series of 1718 patients undergoing arterial reconstructive surgery (excluding amputation) was entered prospectively on to a computerized database. Chronic renal failure was defined as a serum creatinine level over 400 micromol/l, or dialysis (either peritoneal or haemodialysis), or a successful renal transplant. Mortality was assessed at 30 days or in hospital. RESULTS There were 69 patients (4.0 per cent) who were defined as having chronic renal failure. The mortality rate in this group was 23 per cent (16 patients) compared with 7.3 per cent (120 patients) of the 1649 patients without renal failure. The mortality rate was highest in patients undergoing urgent or emergency surgery and in those undergoing reconstruction for lower limb occlusive disease. The main causes of death were related to the cardiovascular system. CONCLUSION Patients with chronic renal failure undergoing arterial surgery have a poor outcome compared with those with normal renal function.
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Affiliation(s)
- D J Gerrard
- Department of Surgery, Guy's and St Thomas' Hospital, London SE1 7EH, UK
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O'Hare A, Johansen K. Lower-extremity peripheral arterial disease among patients with end-stage renal disease. J Am Soc Nephrol 2001; 12:2838-2847. [PMID: 11729255 DOI: 10.1681/asn.v12122838] [Citation(s) in RCA: 189] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Peripheral arterial occlusive disease (PAOD) accounts for significant morbidity and mortality among end-stage renal disease (ESRD) patients but has not been as extensively studied as other kinds of atherosclerotic disease in this population. The current epidemiology and management of PAOD in ESRD patients is here reviewed and target areas for future research are identified. The prevalence of PAOD appears to be much higher among ESRD patients than in the general population. Risk factors for disease among ESRD patients are not well understood but probably include both conventional and dialysis or uremia-associated risk factors. Standard diagnostic techniques used to identify PAOD in the general population may not be as helpful in ESRD patients because many of these tests are inaccurate in the settings of vascular calcification and small-vessel disease. Despite the fact that this is a common disease in ESRD patients, most of these patients are not screened for PAOD. Interventions that have proven effective in the prevention and treatment of PAOD in the general population, such as smoking cessation, preventive foot care, and exercise, have not been systematically applied to ESRD patients. Furthermore, the optimal management of ischemic ulceration and gangrene in ESRD patients is quite controversial, and better algorithms for the prevention and management of PAOD in ESRD patients are needed. In conclusion, PAOD is common in ESRD patients. Future research should identify risk factors for disease in this population, and efforts should be made to develop strategies for the effective prevention and management of limb ischemia in this population.
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Affiliation(s)
- Ann O'Hare
- Departments of *Medicine and Biostatistics and Epidemiology, University of California, San Francisco, California; and Department of Medicine, Veterans Affairs Medical Center, San Francisco, California
| | - Kirsten Johansen
- Departments of *Medicine and Biostatistics and Epidemiology, University of California, San Francisco, California; and Department of Medicine, Veterans Affairs Medical Center, San Francisco, California
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Albers M, Romiti M, Bragança Pereira CA, Fonseca RL, da Silva Júnior M. A meta-analysis of infrainguinal arterial reconstruction in patients with end-stage renal disease. Eur J Vasc Endovasc Surg 2001; 22:294-300. [PMID: 11563886 DOI: 10.1053/ejvs.2001.1469] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES to determine graft patency, limb salvage, and patient survival following infrainguinal bypass grafting in patients with end-stage renal disease (ESRD). METHODS studies published from 1987 through 2000 were identified from the PUBMED database and pertinent original articles. Sixteen studies were found that used survival analysis to report the outcomes of interest. Two investigators independently extracted the data from standard life-tables, survival curves and texts. A new method was developed for meta-analysis of uncontrolled studies that use survival analysis with different follow-up intervals. RESULTS random-effects modelling yielded the following summary estimates at one- and two-year follow-up: 79% (95% CI, 70-87%) and 74% (63-85%) for graft patency; 77% (69-84%) and 73% (64-81%) for limb salvage; and 59% and 42% for patient survival. CONCLUSION despite a severely limited life span, infrainguinal bypass grafting for the treatment of critical ischaemia is worthwhile in selected patients with ESRD.
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Affiliation(s)
- M Albers
- Vascular Surgery Section, Department of Surgery, Fundação Lusíada, Santos-SP, Brazil
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Morbach S, Quante C, Ochs HR, Gaschler F, Pallast JM, Knevels U. Increased risk of lower-extremity amputation among Caucasian diabetic patients on dialysis. Diabetes Care 2001; 24:1689-90. [PMID: 11522723 DOI: 10.2337/diacare.24.9.1689] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- S Morbach
- Marienkrankenhaus Department of Internal Medicine, Diabetic Foot Clinic, Widumgasse 5, 59494 Soest, Germany.
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Meyerson SL, Skelly CL, Curi MA, Desai TR, Katz D, Bassiouny HS, McKinsey JF, Gewertz BL, Schwartz LB. Long-term results justify autogenous infrainguinal bypass grafting in patients with end-stage renal failure. J Vasc Surg 2001; 34:27-33. [PMID: 11436071 DOI: 10.1067/mva.2001.116350] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Infrainguinal bypass grafting for limb-threatening ischemia in patients with end-stage renal disease is generally thought to be associated with increased operative risk and poor long-term outcome. This retrospective study was undertaken to examine the modern-era, long-term results of infrainguinal bypass grafting in dialysis-dependent patients. METHODS Over the past 5 years in a single institution, 425 lower extremities (368 consecutive patients) were revascularized for the indication of limb salvage. Sixty-four patients (82 limbs) were dialysis-dependent at the time of revascularization, and this group was analyzed separately. They exhibited statistically significant higher incidences of diabetes (83% vs 56%; P <.001), hypertension (91% vs 74%; P <.001), and more distal vascular disease, which required a greater proportion of proximal anastomoses at the popliteal level (24% vs 11%; P <.01) and distal anastomoses at the infrapopliteal level (75% vs 65%; P <.05). RESULTS Despite the higher prevalence of comorbid conditions and distal disease in patients with renal failure, their perioperative 30-day mortality rate remained low (4.9%) and was not significantly different from that in patients with functioning kidneys (2.9%; P = not significant). After a median follow-up of 11 months (range, 0-60 months), the 3-year autogenous conduit secondary graft patency in patients with renal failure was no different than in patients with functioning kidneys (67% +/- 9% vs 64% +/- 5%; P = not significant). Nonautogenous conduits in dialysis-dependent patients exhibited a significantly poorer outcome with only 27% +/- 12% remaining secondarily patent at 2 years. As expected, both limb salvage and patient survival were significantly less in patients with renal faiture, although both exceeded 50% at 3 years (limb salvage 59% +/- 8% vs 68% +/- 5%; P <.05; patient survival 60% +/- 8% vs 86% +/- 4%; P <.001). The often-quoted phenomenon of limb loss, despite a patent bypass graft, occurred infrequently in this study (n = 3 of 82 limbs). CONCLUSION Infrainguinal revascularization can be performed in dialysis-dependent patients with acceptable perioperative and long-term results, especially in patients in whom adequate autologous conduit is available.
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Affiliation(s)
- S L Meyerson
- Department of Surgery, Section of Vascular Surgery, University of Chicago, Ill., USA
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