Chapter VI: Follow-up after revascularisation

Surveillance After Surgical and Endovascular Treatment for Peripheral Artery Disease: a Dutch Survey

OBJECTIVE

At present, there is no clear, optimal approach to surveillance after invasive treatment of peripheral artery disease (PAD) in terms of modality, duration, clinical benefit, and cost effectiveness. The ongoing debate on the clinical benefit and cost effectiveness of standard surveillance creates a clear knowledge gap and may result in overtreatment or undertreatment. In this study, a survey was conducted among vascular surgeons in the Netherlands to assess the currently applied surveillance programmes.

METHODS

All vascular surgeons from the Dutch Society for Vascular Surgery received an online survey on follow up after open and endovascular revascularisation in patients with PAD. Surveillance was defined as at least one follow up visit after intervention with or without additional imaging or ankle brachial index (ABI) measurement. Ten types of PAD intervention were surveyed.

RESULTS

Surveys were returned by 97 (46.2%) of 210 vascular surgeons, and 76% reported using a routine follow up protocol after an invasive intervention. Clinical follow up only is most commonly performed after femoral endarterectomy (53%). After peripheral bypass surgery, clinical follow up only is applied rarely (4 - 8%). In six of the 10 interventions surveyed, duplex ultrasound (DUS) was the most used imaging modality for follow up. After bypass surgery, 76 - 86% of vascular surgeons perform DUS with or without ABI measurement. After endovascular interventions, 21 - 60% performed DUS surveillance. Lifelong surveillance is most often applied after aortobifemoral bypass (57%). Surveillance frequency and duration vary greatly within the same intervention. Frequencies range from every three or six months to annually. Duration ranges from one time surveillance to lifelong follow up.

CONCLUSION

There is significant practice variation in surveillance after surgical and endovascular treatment of patients with PAD in the Netherlands. Prospective studies to evaluate treatment outcomes and to define the clinical need and cost effectiveness of standardised surveillance programmes for patients with PAD are recommended.

Editor's Choice - Quality Assessment of European Society for Vascular Surgery Clinical Practice Guidelines

OBJECTIVE

An increasing number of clinical practice guidelines (CPGs) have emerged over recent years. To have clinical utility, they need to be rigorously developed and scientifically robust. Instruments have been developed to assess the quality of clinical guideline development and reporting. The aim of this study was to evaluate CPGs from the European Society for Vascular Surgery (ESVS) using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

METHODS

CPGs published by the ESVS during the period January 2011 to January 2023 were included. Two independent reviewers assessed the guidelines after receiving training in the use and application of the AGREE II instrument. Inter-reviewer reliability was assessed with the intraclass correlation coefficient. Maximum scaled scores were 100. Statistical analysis was performed using SPSS Statistics v.26.

RESULTS

Sixteen guidelines were included in the study. Good inter-reviewer score reliability was found on statistical analysis (> 0.9). The mean ± standard deviation domain scores were 68.1 ± 20.3% for scope and purpose, 57.1 ± 21.1% for stakeholder involvement, 67.8 ± 19.5% for rigour of development, 78.1 ± 20.6% for clarity of presentation, 50.3 ± 15.4% for applicability, 77.6 ± 17.6% for editorial independence, and 69.8 ± 20.1% for overall quality. Stakeholder involvement and applicability have improved in quality over time but are still the lowest scoring domains.

CONCLUSION

Most ESVS clinical guidelines are of high quality and reporting. There is scope for improvement, specifically by addressing the domains of stakeholder involvement and clinical applicability.

Routinely ultrasound surveillance improves outcome after endovascular treatment of peripheral arterial disease: propensity-matched comparisons of clinical outcomes after ultrasound or clinical-hemodynamic based surveillance programs

BACKGROUND

Endovascular treatment (EVT) has replaced open repair as the first option in intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI) in several centers. However, evidence of the most optimal post-procedural surveillance strategy is sparse. This study aimed to compare two routine surveillance programs after EVT of IC/CLTI: clinical and hemodynamic assessment (CHA) vs. duplex ultrasound (DUS) and clinical/hemodynamic assessment in combination.

METHODS

Between February 2012 and December 2015, all patients with EVT of IC/CLTI were allocated to either CHA or DUS-based routine surveillance programs. The allocation-ratio was 1:2 (CHA:DUS), and propensity score matching (PSM) was used to control baseline differences between the groups. Follow-up visits in the CHA group consisted of clinical assessment and ABI at 3, 6, 12 and 24 months. Follow-up visits in DUS group consisted of clinical assessment, ABI, and target vessel DUS at 1, 3, 6, 12, 18 and 24 months.

RESULTS

In total, 340 legs in 305 patients suffering from IC/CLTI were included; 111 (33%) in the CHA-group and 229 (67%) in the DUS group. The two groups were identical except for a significantly lower incidence of diabetes mellitus in the CHA group than the DUS group, 55% vs. 72%, respectively (P=006). Based on PSM, the CHA-group vs. the DUS-group was burdened of an increased risk of amputation (12.5% vs. 8.27%, HR=0.41 [95% CI: 0.17-0.96]), and a higher mortality (21.2% vs. 12.8%, HR=0.37 [95% CI: 0.19-0.72]). The reported differences in reintervention rate (7.5% vs. 12.8%, HR=1.12 [95% CI: 0.44-2.84]) were insignificant. The mean follow-up was 317 days (SD=0.214) in the CHA group and 611 days (SD=0.298) in the DUS group.

CONCLUSIONS

Our results suggest that DUS-based routine surveillance after EVT of IC/CLTI is superior to CHA-based routine surveillance in improved amputation rate and mortality.

Clinical considerations after endovascular therapy of peripheral artery disease

Introduction: Patients with peripheral artery disease (PAD) are at higher risk for all-cause mortality, driven by increased cardiovascular mortality rates. In this manuscript we review the literature on guideline-recommended therapies and discuss the major clinical considerations after endovascular therapy of PAD.Areas covered: Current guidelines recommend smoking cessation, aspirin, statin, and renin-angiotensin system inhibitors in order to reduce the risk of cardiovascular and limb-related adverse events. Nonetheless, studies have shown that patients with PAD are undertreated with these important medical therapies. Additionally, there is lack in evidence regarding the most optimal follow up imaging approach for early detection of disease recurrence and re-intervention among patients undergoing endovascular therapy for PAD. We also describe the benefits of supervised walking exercise for patients with PAD that undergo revascularization procedures and are fit for such interventions.Expert opinion: Adherence to guideline recommended medical therapy is crucial for improved outcomes in PAD management. Systematic assessment of risk-reduction interventions could help increase adherence to clinically beneficial interventions and improve the overall prognosis of patients with PAD undergoing revascularization procedures. Additionally, optimization of current follow up protocols is needed, with the optimal goal to develop standardized cost-effective algorithms regarding early detection of disease recurrence and re-intervention.

Evaluation of Clinical Outcomes After Revascularization in Patients With Chronic Limb-Threatening Ischemia: Results From a Prospective National Cohort Study (RIVALUTANDO)

We evaluated the outcomes of revascularization in patients with chronic limb-threatening ischemia (CLTI) treated in real-world settings. This is a prospective multicenter cohort study with 12-month follow-up enrolling patients (n = 287) with CLTI undergoing open, endovascular, or hybrid lower extremity revascularization. The primary end point was amputation-free survival (AFS) at 12 months. Cox proportional analysis was used to determine independent predictors of amputation and restenosis. At 30 days, major adverse cardiovascular and major adverse limb events (MALE) rates were 3.1% and 2.1%, respectively. At 1 year, the overall survival rate was 88.8%, the AFS was 86.6%, and the primary patency was 70.5%. Freedom from MALE was 62.5%. After multivariate analysis, smoking (hazard ratio [HR] = 2.2, P = 0.04), renal failure (HR = 2.3, P = 0.03), Rutherford class (≥5) (HR = 3.2, P = 0.01), and below-the-knee disease (HR = 2.0, P = 0.05) were significant predictors of amputation; iloprost infusion (>10 vials) (HR = 0.64, P = 0.05) was a significant protective factor. Cilostazol administration (HR = 0.77, P = 0.05) was a significant protective factor for restenosis. Results from this prospective multicenter registry offer a consistent overview of clinical outcomes of CLTI patients at 1 year when adequately revascularized. Medical treatment, including statins, cilostazol and iloprost, were associated with improved 1-year freedom from restenosis and amputation.

Outcome benefit of arterial duplex stent imaging after superficial femoral artery stent implantation

OBJECTIVE

In-stent stenosis is a frequent complication of superficial femoral artery (SFA) endovascular intervention and can lead to stent occlusion or symptom recurrence. Arterial duplex stent imaging (ADSI) can be used in the surveillance for recurrent stenosis; however, its uniform application is controversial. In this study, we aimed to determine, in patients undergoing SFA stent implantation, whether surveillance with ADSI yielded a better outcome than in those with only ankle-brachial index (ABI) follow-up.

METHODS

We performed a retrospective analysis of all patients undergoing SFA stent implantation for occlusive disease at a tertiary care referral center between 2009 and 2016. The patients were divided into those with ADSI and those with ABI follow-up only. Life-table analysis comparing stent patency, major adverse limb events (MALEs), limb salvage, and mortality between groups was performed.

RESULTS

There were 248 patients with SFA stent implantation included, 160 in the ADSI group and 88 in the ABI group. Groups were homogeneous in clinical indications of claudication and critical limb-threatening ischemia (for ADSI, 39% and 61%; for ABI, 38% and 62%; P = .982) and TransAtlantic Inter-Society Consensus class A, B, C, and D lesions (for ADSI, 17%, 45%, 16%, and 22%; for ABI, 21%, 43%, 16%, and 20%; P = .874). Primary patency was similar between groups at 12, 36, and 56 months (ADSI, 65%, 43%, and 32%; ABI, 69%, 34%, and 34%; P = .770), whereas ADSI patients showed an improved assisted primary patency (84%, 68%, and 54%) vs ABI patients (76%, 38%, and 38%; P = .008) and secondary patency. There was greater freedom from MALEs in the ADSI group (91%, 76%, and 64%) vs the ABI group (79%, 46%, and 46%; P < .001) at 12, 36, and 56 months of follow-up. ADSI patients were more likely to undergo an endovascular procedure as their initial post-SFA stent implantation intervention (P = .001), whereas ABI patients were more likely to undergo an amputation (P < .001).

CONCLUSIONS

In SFA stent implantation, patients with ADSI follow-up demonstrate an advantage in assisted primary patency and secondary patency and are more likely to undergo an endovascular reintervention. These factors are likely to have effected a decrease in MALEs, indicating the benefit of a more universal adoption of post-SFA stent implantation follow-up ADSI.

A Review of Antithrombotic Treatment in Critical Limb Ischemia After Endovascular Intervention

Endovascular intervention is often used to treat critical limb ischemia (CLI). Post-intervention treatment with antiplatelet and/or anticoagulant therapy has reduced morbidity and mortality due to cardiovascular complications. The purpose of this review is to shed light on the various pharmacologic treatment protocols for treating CLI following endovascular procedures. We reviewed the literature comparing outcomes after antithrombotic treatment for patients with CLI. We characterized antithrombotic therapies into three categories: (1) mono-antiplatelet therapy (MAPT) vs. dual antiplatelet therapy (DAPT), (2) MAPT vs. antiplatelet (AP) + anticoagulant (AC) therapy, and (3) AC vs. AP + AC therapy. Relevant results and statistics were extracted to determine differences in the rates of the following outcomes: (1) re-stenosis, (2) occlusion, (3) target limb revascularization (TLR), (4) major amputation, (5) major adverse cardiac events, (6) all-cause death, and (7) bleeding. Studies suggest that DAPT reduces post-surgical restenosis, TLR, and amputation for diabetic patients, without increasing major bleeding incidences, compared to MAPT. Also, AP + AC therapy provides overall superior efficacy, with no difference in bleeding incidences, compared to antiplatelet alone. Additionally, the effects were significant for restenosis, limb salvage, survival rates, and cumulative rate of above ankle amputation or death. These results suggest that treatment with DAPT and AP + AC might provide better outcomes than MAPT following the endovascular intervention for CLI, and that the ideal treatment may be related to the condition of the individual patient. However, the studies were few and heterogenous with small patient populations. Therefore, further large controlled studies are warranted to confirm these outcomes.

Contemporary follow-up imaging after endovascular repair of lower extremity atherosclerotic lesions

Atherosclerotic disease is currently one of the most important problems of modern medicine because it is a leading cause of increased morbidity, morbidity and mortality, and disability in the Western World. Atherosclerosis of the lower limbs (peripheral arterial disease - PAD) significantly affects the quality of life and in a considerable proportion of patients is a cause of disability. Radical treatment of PAD, both surgical and endovascular, aims at revascularisation of ischaemic tissues distal to obstructed arteries. Surveillance imaging is an important part of patient management after endovascular repair of PAD. Apart from availability and contraindications, challenges of imaging include calcifications, flow dynamics, and stent-related artefacts. The aim of this paper was to review the current literature on imaging methods for follow-up after endovascular repair of atherosclerotic lesions, with special attention paid to novel techniques. As a non-invasive modality, ultrasound is still the first-line examination, but computed tomography angiography remains a current state-of-the art technique for follow-up. However, since current imaging recommendations seem not to adhere to contemporary imaging possibilities, more attention should be paid to recent improvements in magnetic resonance angiography technology.

Ultrasound Surveillance in Endovascular Revascularization of Lower Limbs

BACKGROUND

Endovascular surgery has become the initial treatment for most patients with chronic ischemia of the lower limbs. Few studies support ultrasound surveillance (US) of this kind of procedures. The purpose of this study was to evaluate the initial efficacy of duplex ultrasound as a surveillance method in endovascular treatment in symptomatic peripheral arterial disease patients in our center.

MATERIAL AND METHODS

A total of 113 endovascular procedures performed in 106 patients between February 2013 and June 2015 were included. Follow-up included clinical assessment, physical examination, ankle-brachial index (ABI), plethysmography, and ultrasound at 1, 3, 6, 12, 18, and 24 months after surgery. Patients without a minimum follow-up of two controls were excluded. Worsening was defined as follows: (1) in ultrasound, a restenosis >70%; (2) from ABI, a decrease >0.15; (3) clinically, a decrease in claudication distance, reappearance rest pain, or worsening injuries; (4) in plethysmography, flattening in the curve.

RESULTS

The average age was 68.3 years, with 72% being men. Twenty-two percent of treated lesions were iliac, 57% were femoropopliteal, and 21% were distal. There were 329 visits, with a mean follow-up of 13.5 months (3-31). The US detected permeability or moderate stenosis in 66 patients (58.4%) and restenosis or occlusion in 47 (41.6%). When compared with clinical status, there was a noncorrelation in 23% and a discrepancy with respect to the ABI of 27% and of 39% with plethysmography. All these differences were statistically significant (P < 0.001). Twenty-one reinterventions were performed (18.6%), six patients died (5.3%), and 11 required major amputation (9.7%).

CONCLUSIONS

Clinical status and hemodynamics can detect restenosis or occlusion of the procedure in a large part of the cases, but it can omit more than 20% of these that were only detected by US. The ultrasound follow-up is of great help to increase the reliability of the control in patients with endovascular revascularization of lower limbs.

Additional functional outcomes after endovascular treatment for intermittent claudication

Background Endovascular treatment (EVT) for intermittent claudication (IC) is performed in selected patients where conservative treatment and training fail. Treatment outcomes reported in vascular registries (survival, limb-survival, and re-intervention rate) are inadequate for low-risk patients with IC. Additional measurements of blood flow reduction and functional impairment clarify the indication for treatment and facilitate outcome evaluation. Purpose To analyze the additional outcome information on peripheral arterial pressures and walking capacity obtained from a local registry of EVT. Material and Methods Patients with IC treated with endovascular technique (angioplasty or stent) were prospectively entered into a local registry in addition to the national registry (NORKAR), with information on arterial pressures (ankle brachial index [ABI]) and treadmill performance (maximum walking distance [MWD]). Results A total of 242 consecutive patients (41% women; median age, 70 years) receiving the first treatment between July 2010 and December 2012 were included, 61% with aorto-iliac lesions. After 3 months, mean ABI increased from 0.62 (0.59-0.64) to 0.85 (0.83-0.87). The median MWD increased from 160 m to 410 m. Sixty-two percent reached the test maximum of 10 min. The improvement in ABI and MWD persisted after 1 year. When preoperative ABI was moderately reduced (0.5-0.9), ABI was normal in 61% after 3 months and in 55% after 1 year. When preoperative ABI was low (<0.5), ABI was normal in 43% both after 3 months and 1 year. Conclusion ABI and walking capacity were important outcome variables and improved after EVT. ABI improvement was better for patients with moderately reduced preoperative ABI than with low ABI.

Lack of Evidence for Dual Antiplatelet Therapy after Endovascular Arterial Procedures: A Meta-analysis

INTRODUCTION

Dual antiplatelet therapy (DAPT) has mainly replaced mono antiplatelet therapy (MAPT) and is recommended after arterial endovascular revascularization. The aim of this meta-analysis was to summarize the available evidence for DAPT after endovascular revascularization throughout the arterial system.

METHODS

A systematic search was performed in Medline, Embase, and the Cochrane Register. Two reviewers independently performed data extraction and quality assessment using the Cochrane Collaboration risk of bias assessment tool. Included in the search were randomized controlled trials (RCTs) comparing DAPT with MAPT after endovascular procedures for the treatment of coronary, carotid, or peripheral artery disease, reporting at least one clinical outcome. Articles were excluded if patients received anticoagulation in addition to antiplatelet therapy in the post-procedural phase. The primary outcome was restenosis or stent thrombosis, and secondary outcomes were major adverse cardiac events (MACE), target lesion revascularization, cerebrovascular accident or transient ischemic attack, bleeding, and death. Meta-analyses of binary outcomes were performed using the random effects model and described as risk ratios (RRs) and 95% confidence intervals (95% CIs). Chi-square tests were used to test for heterogeneity.

RESULTS

Nine articles were included in this study, involving lower limb peripheral arteries (1), carotid arteries (2), and coronary arteries (6). The pooled results of coronary trials showed a RR for restenosis with DAPT of 0.60 (95% CI 0.28-1.31) and for myocardial infarction 0.49 (95% CI 0.12-2.03). In the carotid artery trials the RR for restenosis was 0.22 (95% CI 0.04-1.20) and for peripheral arteries 1.02 (95% CI 0.56-1.82). A meta-analysis of bleeding risk of all the included trials showed a RR of 1.06 (95% CI 0.32-3.52) with DAPT.

CONCLUSION

The available evidence comparing DAPT with MAPT after endovascular arterial revascularization is limited and the majority of trials were conducted in the cardiology field. No significant evidence for superiority of DAPT compared with MAPT was found, but there was also no evidence of an increased bleeding risk with DAPT over MAPT.

High On-Treatment Platelet Reactivity in Peripheral Arterial Disease: A Pilot Study to Find the Optimal Test and Cut Off Values

OBJECTIVE

Restenosis and stent thrombosis after endovascular intervention in patients with peripheral arterial disease (PAD) can potentially be tackled by more intensive antiplatelet therapy, such as dual antiplatelet therapy (DAPT) consisting of aspirin and P2Y12 inhibitor. Despite clopidogrel treatment, some patients still display high platelet reactivity (HCPR). Tailored antiplatelet therapy, based on platelet reactivity testing, might overcome HCPR. However, more data are warranted regarding the proportion of patients with HCPR in the PAD population, different platelet reactivity tests, their correlation, and the optimal timing for these tests as a stepping stone for a future trial investigating the potential benefit of tailored antiplatelet therapy in PAD patients.

METHODS

Thirty patients on DAPT after percutaneous transluminal angioplasty underwent platelet reactivity testing by VerifyNow, vasodilator-stimulated phosphoprotein (VASP) and platelet activation assay, and CYP2C19-polymorphism testing.

RESULTS

The proportion of patients with HCPR measured by VerifyNow varied between 43.3% and 83.3%, depending on the cut off values used. Testing within 24 hours of initiation of DAPT gave a higher proportion of HCPR than testing after more than 24 hours. According to DNA testing, 14.8% were CYP2C19*2 homozygote, 22.2% heterozygote, and 63% CYP2C19*2 negative. VASP assay revealed 24% HCPR. The highest HCPR rate was found with a VerifyNow cut off of less than 40% inhibition, whereas the lowest HCPR rate was found with the VASP assay. There was a low correlation between the tests.

CONCLUSION

HCPR is present in PAD patients and research on HCPR is needed in this population; timing of tests is relevant and standardisation of tests is needed. The optimal conditions for platelet function testing should be determined.

Role of Vitamin K Antagonists in the Prevention of Thrombotic Bypass Occlusion After Infrainguinal Venous Bypass

CLINICAL VIGNETTE

Despite being the most common antithrombotic strategy in trials comparing venous with prosthetic grafts, the use of vitamin K antagonists (VKAs) to improve the outcome of venous bypass remains the subject of debate. In this systematic review, evidence supporting the use of VKAs for improving venous patency following infrainguinal venous bypass is provided.

CLINICAL QUESTION

A 67 year old man with lifestyle limiting claudication underwent a successful infrainguinal venous bypass. Can VKAs help preserve patency after venous bypass surgery?

METHODS

A systematic review of electronic databases, including MEDLINE and Embase, was conducted. Only randomized controlled studies comparing VKAs with aspirin (ASA) were included. The main outcome was bypass patency.

RESULTS

Four studies using different intensities of anticoagulation ± ASA were identified. All but one showed a benefit of VKAs over ASA with respect to primary patency. However, this benefit was also accompanied by an increased risk of bleeding. The Dutch Bypass Oral Anticoagulants, or ASA, study was the largest included and showed that VKAs (without concomitant ASA) were superior to ASA alone for the prevention of graft occlusion (hazard ratio 0.69, 95% confidence interval 0.54-0.88).

CONCLUSION

Current evidence suggests that VKAs are superior to ASA for the prevention of infrainguinal autologous venous graft thrombosis.

Endovascular intervention for peripheral artery disease

Advances in endovascular therapies during the past decade have broadened the options for treating peripheral vascular disease percutaneously. Endovascular treatment offers a lower risk alternative to open surgery in many patients with multiple comorbidities. Noninvasive physiological tests and arterial imaging precede an endovascular intervention and help localize the disease and plan the procedure. The timing and need for revascularization are broadly related to the 3 main clinical presentations of claudication, critical limb ischemia, and acute limb ischemia. Many patients with claudication can be treated by exercise and medical therapy. Endovascular procedures are considered when these fail to improve quality of life and function. In contrast, critical limb ischemia and acute limb ischemia threaten the limb and require more urgent revascularization. In general, endovascular treatments have greater long-term durability for aortoiliac disease than femoral popliteal disease. Infrapopliteal revascularization is generally reserved for critical and acute limb ischemia. Balloon angioplasty and stenting are the mainstays of endovascular therapy. New well-tested innovations include drug-eluting stents and drug-coated balloons. Adjunctive devices for crossing chronic total occlusions or debulking plaque with atherectomy are less rigorously studied and have niche roles. Patients receiving endovascular procedures need a structured surveillance plan for follow-up care. This includes intensive treatment of cardiovascular risk factors to prevent myocardial infarction and stroke, which are the main causes of death. Limb surveillance aims to identify restenosis and new disease beyond the intervened segments, both of which may jeopardize patency and lead to recurrent symptoms, functional impairment, or a threatened limb.

Adaptation of trustworthy guidelines developed using the GRADE methodology: a novel five-step process

BACKGROUND

Adaptation of guidelines for use at the national or local level can facilitate their implementation. We developed and evaluated an adaptation process in adherence with standards for trustworthy guidelines and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, aiming for efficiency and transparency. This article is the first in a series describing our adaptation of Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines for a Norwegian setting.

METHODS

Informed by the ADAPTE framework, we developed a five-step adaptation process customized to guidelines developed using GRADE: (1) planning, (2) initial assessment of the recommendations, (3) modification, (4) publication, and (5) evaluation. We developed a taxonomy for describing how and why recommendations from the parent guideline were modified and applied a mixed-methods case study design for evaluation of the process.

RESULTS

We published the adapted guideline in November 2013 in a novel multilayered format. The taxonomy for adaptation facilitated transparency of the modification process for both the guideline developers and the end users. We excluded 30 and modified 131 of the 333 original recommendations according to the taxonomy and developed eight new recommendations. Unforeseen obstacles related to acquiring a licensing agreement and procuring a publisher resulted in a 9-month delay. We propose modifications of the adaptation process to overcome these obstacles in the future.

CONCLUSIONS

This case study demonstrates the feasibility of a novel guideline adaptation process. Replication is needed to further validate the usefulness of the process in increasing the organizational and methodologic efficiency of guideline adaptation.

Efficacy of clopidogrel treatment and platelet responsiveness in peripheral arterial procedures

INTRODUCTION

Long-term antiplatelet therapy with clopidogrel has been recommended in patients undergoing peripheral arterial procedures. Poor antiplatelet effect of clopidogrel or high on-clopidogrel platelet reactivity (HCPR) has been recently identified in patients with peripheral arterial disease (PAD).

AREAS COVERED

This review focuses on the use of clopidogrel and the phenomenon of HCPR in PAD patients treated for intermittent claudication or critical limb ischaemia (CLI). The authors summarize current guidelines and recommendations for use of clopidogrel following peripheral arterial procedures and explore the prevalence and clinical impact of HCPR in the PAD population. Underlying mechanisms of HCPR and relevant clinical and genetic factors are analyzed with particular attention to the potential utility of point-of-care platelet function testing (PFT).

EXPERT OPINION

Clopidogrel is a safe, effective and well-tolerated antiplatelet agent in PAD patients following peripheral arterial revascularization. Dual-antiplatelet therapy could also be considered after complex endovascular procedures. HCPR has been identified in more than 50% of PAD patients on clopidogrel and has been related with significantly increased re-intervention rates. Incidence of HCPR is significantly higher in patients with CLI, diabetes mellitus and chronic renal disease. Personalized antiplatelet therapy on the basis of PFT is an elegant emerging concept for optimization of platelet inhibition and potential identification of patients at increased risk of bleeding and warrants investigation in future large-scale trials.

Distal bypasses in patients with diabetes and infrapopliteal disease: technical considerations to achieve success

The combination of diabetes and peripheral arterial disease (PAD) is challenging in many ways. The characteristic and complex distal distribution of PAD often encountered in patients with diabetes means that bypass surgery in this context is technically challenging. In addition, many of these patients have a burden of serious comorbidities that must be optimized and managed concurrently. While the authors acknowledge that "achieving success" in distal bypass relies on much more than technical expertise, there are some technical aspects that should be considered when planning surgery on these patients. This article outlines some important issues in the treatment pathway of a patient with diabetes and PAD requiring distal bypass surgery--from selection and optimization of the patient (in the context of a multidisciplinary team) and preoperative workup, to the operative strategy planning, technical tips, and nonoperative adjuncts. These considerations, as well as sound knowledge of the underlying disease process, confounding medical factors and awareness of the difficulty in predicting treatment outcomes, should help maximize the chances of success.

Treatment of peripheral arterial disease in diabetes: a consensus of the Italian Societies of Diabetes (SID, AMD), Radiology (SIRM) and Vascular Endovascular Surgery (SICVE)

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.

Duplex surveillance after endovascular revascularisation for critical limb ischaemia

OBJECTIVE

Despite the popularity of endovascular therapy (EVT) for critical limb ischaemia (CLI), there are few studies investigating the efficacy of duplex ultrasound (DUS) surveillance after endovascular interventions. The aim of this study was to evaluate DUS surveillance after EVT for CLI.

METHODS

146 endovascular procedures in 134 consecutive patients with CLI between 2011 and 2012 were included. Follow-up visits with ankle-brachial index (ABI), toe pressure, and target vessel DUS were performed at 1, 3, and 6 months after revascularisation.

RESULTS

The median age of the study population was 79 years, 58% were males, and 55% had diabetes. The target artery was at the iliac, femoro-popliteal, and infrapopliteal level in 2%, 54%, and 44% of cases, respectively. There were 282 follow-up visits. In 15 (5.3%) DUS examinations, the target vessel was not seen properly. In the remaining 267 DUS, the majority of the target arteries were patent with no or mild restenosis (n = 169, 63.3%), but in 98 (36.7%) examinations, the target artery was stenosed or occluded. When DUS was compared with the clinical presentation, there was no correlation in 30% and when DUS and toe pressure were compared, discrepancy was seen in 29%. A re-angiogram was performed for 29 patients, and the DUS finding was verified in each case. During the mean follow-up of 11 months, a new endovascular intervention was performed on 37 (25.3%) limbs, and 4 (2.7%) underwent surgical bypass. Four (3.0%) patients died and 6 (4.5%) underwent major amputation.

CONCLUSION

Clinical status or toe pressure alone were adequate markers of endovascular revascularisation failure in the majority of the patients, but would have missed up to one-third of the clinically significant re-stenoses or occlusions. DUS is therefore a valuable aid in surveillance after EVT for CLI, especially for patients with an ischaemic tissue lesion.

Effectiveness of combined therapy with angiotensin-converting enzyme inhibitors and statins in reducing mortality in diabetic patients with critical limb ischemia: an observational study

AIMS

To investigate the effect of combined treatment with angiotensin-converting enzyme inhibitors (ACE) and statins on mortality in diabetic patients with critical limb ischemia (CLI).

METHODS

Prospective observational study of 553 consecutive diabetic patients admitted because of CLI followed for a mean of 2.2 years. All patients underwent peripheral revascularization and antithrombotic therapy was prescribed or continued and therapy with statin and ACE was recorded. Mortality from any cause was assessed and Kaplan-Meier analyses were performed to compare the relationship between survival and recorded variables.

RESULTS

One hundred thirty-nine patients did not have therapy with statin or an ACE, 78 had therapy with statin without ACE, 164 had therapy with ACE without statin and 172 patients had therapy with both statin and ACE. One hundred thirty-six patients died, 45/139 with neither statin nor ACE, 40/164 with ACE only, 26/78 with statin only, and 25/172 with both statin and ACE. Multivariate analysis confirmed the independent role of age, history of stroke, renal insufficiency and dialysis. Combined treatment with ACE and statin appeared to have a protective role.

CONCLUSIONS

In patients with diabetes and CLI mortality after two years is high. Life expectancy was better in patients receiving combined therapy with ACE and statin but not with therapy with only a statin or an ACE.

Clinical efficacy of successful angioplasty in critical ischemia--a cohort study

BACKGROUND

To evaluate the impact of percutaneous angioplasty (PA), objectively assessed with duplex-ultrasound, on 3-year clinical outcome.

METHODS

Thirty-nine patients with atherosclerotic disease successfully treated by PA were included (40 limbs). All patients had critical ischemia with rest pain and ischemic ulcers due to infrainguinal obstructions alone. The patients were submitted to duplex ultrasound examination on the day before and on the first or second day after the procedure. Peak systolic velocities (PSV) were recorded in the anterior tibial, posterior tibial, and fibular arteries at the level of distal third of the leg. All patients were followed for 3 years. Comparison between groups with good and bad results were based on perioperative VPS gradient (GPSV) of the mean of the VPS in the 3 arteries. After 3 years, a good result was defined as a patient having no pain and complete healing of a previous ulcer or minor amputations.

RESULTS

Mean age was 68.5±8.1 years with no difference in demographic characteristics (P>0.05). In 26 cases, the long-term result was good. Healing time ranged from 4 to 130 weeks (median 26.5). Bad long-term results were observed in 12 cases. Two lesions remained unhealed despite patent angioplasty. In 10 cases, a second procedure was carried out (repeat angioplasty in 6 and bypass in 4). TransAtlantic Inter-Society Consensus (TASC) II category A/B registered better clinical success then TASC II category C/D (P<0.05) at 1-year follow-up but not at 3 years (P=0.36). Two-year limb salvage was 92.5%±4.2%. Primary patency was 52.5%±9.5% at 3 years. GVPS was 21.9 cm/sec in the good results group and 24.7 cm/sec in the bad results group (P>0.05). The quality of the initial result, as measured by GPSV, was not associated with long-term success (P>0.05).

CONCLUSIONS

An initially successful procedure indicated by the degree of increased flow is not related to long-term durability and ulcer healing.

Surveillance after distal revascularization for critical limb ischaemia

Patients with critical limb ischaemia (CLI) are usually elderly and suffer from several co-morbidities. The goal of surveillance after both endovascular and surgical revascularization for CLI is not only the protection of re-established distal perfusion and sustained ambulation but also the reduction of systemic atherothrombotic risk and mortality by ensuring continued best medical care. However, preferred format and rhythm of structured follow-up programs have remained controversial, mainly because of lack of compelling evidence. This review aims to summarize and to appraise available information critically. Thereby, it underlines the importance of systematic surveillance after both surgical and endovascular revascularization for CLI. Recent European guidelines are considered and areas of uncertainty are highlighted and discussed. According to currently available literature and recent guidelines, the early duplex scan is justified in all patients undergoing endovascular or surgical distal revascularization for CLI. There is no best level evidence supporting continued long term duplex surveillance of revascularizations with normal findings at early duplex scan, whereas those patients with abnormal early duplex scan or high risk revacularization are likely to benefit from continued duplex surveillance. Regular clinical follow-up is suggested and clinical deterioration should trigger duplex scanning to ensure revascularization patency.