Outcome of symptomatic leg ischaemia: four year morbidity and mortality in Vadstena, Sweden

Analysis of the relationship between sex and prescriptions for guideline-recommended therapy in peripheral arterial disease, in relation to 1-year all-cause mortality: a primary care cohort study

OBJECTIVES

To explore population patterns of sex-based incidence and prevalence of peripheral arterial disease (PAD), guideline-directed best medical therapy prescriptions and its relationship with all-cause mortality at 1 year.

DESIGN

A retrospective cohort study.

SETTING

Anonymised electronic primary care from 787 practices in the UK, or approximately 6.2% of the UK population.

PARTICIPANTS

All registered patients over 40 with a documented diagnosis of peripheral arterial disease.

OUTCOME MEASURE

Population incidence and prevalence of PAD by sex. Patterns of guideline-directed therapy, and correlation with all-cause mortality at 1 year (defined as death due to any outcome) in patients with and without an existing diagnosis of cardiovascular disease. Covariates included Charlson comorbidity, sex, age, body mass index, Townsend score of deprivation, smoking status, diabetes, hypertension, statin and antiplatelet prescription.

RESULTS

Sequential cross-sectional studies from 2010 to 2017 found annual PAD prevalence (12.7-14.3 vs 25.6 per 1000 in men) and incidence were lower in women (11.6-12.4 vs 22.7-26.8 per 10 000 person years in men). Cox proportional hazards models created for PAD patients with and without cardiovascular disease over one full year analysed 25 121 men and 13 480 women, finding that following adjustment for age, women were still less likely to be on a statin (OR 0.69; 95% CI 0.66 to 0.72; p<0.001) or antiplatelet (OR: 0.87; 95% CI 0.83 to 0.90; p<0.001). Once fully adjusted for guideline recommended medical therapy, all-cause mortality was similar between women and men (adjusted HR (aHR) 0.95, 95% CI 0.87 to 1.03, p=0.198 for all patients, aHR 1.01, 95% CI 0.88 to 1.16, p=0.860 for those with cardiovascular disease).

CONCLUSIONS

Women with a new diagnosis of PAD were not prescribed guideline-directed therapy at the same rate as men. However once adjusted for factors including age, all-cause mortality in men and women was similar.

The distaflo graft: a valid alternative to interposition vein?

INTRODUCTION

the rationale behind the Distaflo graft is inhibition of myointimal hyperplasia through optimisation of haemodynamic forces at the distal anastomosis. This prospective study reports our early clinical results.

METHOD

patients with critical limb ischaemia, but no autologous vein, underwent infrainguinal bypass using Distaflo. Clinical and Duplex assessment provided prospective data from which one year cumulative patency, limb salvage and survival rates were calculated using Kaplan-Meier analysis. Log rank test enabled comparison with an historical control group of Miller cuff grafts.

RESULTS

fifty Distaflo were inserted over 29 months into 46 patients, median age 68.5 years, 27 male (59%), of which 27 (54%) were re-do procedures. Proximal anastomoses were to common femoral arteries in 40 cases (80%); distal anastomoses were to popliteal vessels in 20 (40%), and tibial vessels in 30 (60%). The Distaflo graft had patency, limb salvage and survival rates of 39, 50 and 82% respectively compared to 49, 56 and 85% respectively in the control group, with no statistical difference (p = 0.39; 0.65; 0.67 respectively; log rank).

CONCLUSION

in this non-randomised study, the Distaflo has similar one year patency, limb salvage and survival rates to the Miller cuff, potentially justifying its use an alternative in distal prosthetic arterial reconstruction for critical limb ischaemia.

Epidemiology and pathophysiology of peripheral arterial disease

Evidence that both asymptomatic and symptomatic peripheral arterial disease (PAD) represent an independent risk for cardiovascular morbidity and mortality has triggered a resurgence in epidemiologic and clinical interest in PAD. Between 8 and 12 million people in the United States are presumed to have PAD, and as the US population ages the incidence of PAD is expected to increase. Epidemiologic studies have shown that the prevalence of PAD among men and women is similar, and autopsy studies of young adults have shown a high frequency of advanced atherosclerotic lesions in distal abdominal aorta by the second decade of life. The pathophysiology of PAD is complex and has not been studied thoroughly. Additional research to understand the pathophysiologic mechanisms in disease-specific circulatory beds is crucial for the advancement of medical therapy for PAD.

Ankle-brachial index and mortality in a cohort of questionnaire recorded leg pain on walking

OBJECTIVE

To study the association between the ankle-brachial pressure index (ABPI), premature death and the need for surgical treatment for lower limb ischaemia.

DESIGN

Population based cohort study.

SUBJECTS

Three hundred and fifty-three men and women, 50-89 years old, underwent a leg pain questionnaire and measurement of ABPI and was then followed for 10 years.

OUTCOME MEASURES

All cause mortality, vascular procedures and major amputations.

RESULTS

A low ABPI was independently associated with premature all cause mortality in the multiple regression analysis, carrying a relative risk of 3.4 (95% confidence interval 2.0-5.9) and 2.1 (1.3-3.3) for ABPIs <or=0.50 and 0.51-0.80, respectively, compared to those with ABPI >or=1.0. Individuals with an ABPI in the interval 0.81-0.99 suffered only a slight, not statistically significant risk increase compared to normals. A low ABPI at baseline implied a continuous constant increased risk of death throughout the study period. The same risk was observed among elderly (70-89, median 77 years), and in the middle aged (50-69, median 63 years) individuals. The vast majority of those subjected to vascular intervention or major amputation during follow-up had an ABPI<or=0.8 at baseline (83 and 89%, respectively). However, within that group, the individual ABPI was not predictive for surgical intervention.

CONCLUSION

The association found between an ABPI <or=0.8 and premature mortality in this cohort of symptomatic subjects implies that the ABPI is a powerful, independent predictor for premature death. The prognostic information carried by an ABPI in the interval 0.81-0.99 remains uncertain. Septuagenarians and octogenarians carry the same risk increase associated with a low ABPI as those in the middle ages.

Efficacy of oral anticoagulants compared with aspirin after infrainguinal bypass surgery (The Dutch Bypass Oral Anticoagulants or Aspirin Study): a randomised trial

BACKGROUND

Oral anticoagulants and aspirin are antithrombotic drugs that are commonly used in patients with vascular disease. We investigated whether either of these treatments prevented more effectively than the other bypass complications after infrainguinal bypass surgery.

METHODS

We did a multicentre, randomised, open trial. 2690 patients who had undergone infrainguinal grafting were randomly assigned oral anticoagulants (target international normalised ratio 3.0-4.5, n=1339) or aspirin (80 mg daily, n=1351). We followed up patients for a mean of 21 months. The primary outcome was graft occlusion.

FINDINGS

308 graft occlusions occurred in the oral-anticoagulants group compared with 322 in the aspirin group (hazard ratio 0.95 [95% CI 0.82-1.11]), which suggested no overall advantage for either treatment. Oral anticoagulants were beneficial in patients with vein grafts (0.69 [0.54-0.88]), whereas aspirin had better results for nonvenous grafts (1.26 [1.03-1.55]). The composite outcome of vascular death, myocardial infarction, stroke, or amputation occurred 248 times in the oral-anticoagulants group and 275 times in the aspirin group (0.89 [0.75-1.06]). Patients treated with oral anticoagulants had more major bleeding episodes than those treated with aspirin (108 vs 56; 1.96 [1.42-2.71]).

INTERPRETATION

Oral anticoagulation was better for the prevention of infrainguinal-vein-graft occlusion and for lowering the rate of ischaemic events. Aspirin was better for the prevention of non-venous graft occlusion, and was associated with fewer bleeding episodes.

Systematic review of randomized controlled trials of aspirin and oral anticoagulants in the prevention of graft occlusion and ischemic events after infrainguinal bypass surgery

PURPOSE

We sought to determine the efficacy of antiplatelet therapy and oral anticoagulants in maintaining graft patency and preventing ischemic complications in patients after infrainguinal bypass surgery.

METHODS

We performed a meta-analysis of randomized controlled trials of aspirin with or without other antiplatelet therapy and oral anticoagulants after infrainguinal bypass surgery. Outcome measures studied were graft occlusion, stroke, myocardial infarction, vascular and total mortality, and the composite outcome of stroke, myocardial infarction, and vascular mortality.

RESULTS

Five trials of antiplatelet therapy versus placebo were included. The relative risk (RR) for occlusion was 0.78 (95% CI, 0.64-0.95). For prevention of stroke, myocardial infarction, and death, and for the composite outcome, no significant effect was measured. Only one trial of oral anticoagulants versus control treatment was included. The RR for occlusion was 0.55 (95% CI, 0.30-0.99), and that for amputation was 0.30 (95% CI, 0.10-0.87). The mortality rate did not differ significantly between the groups. One trial of oral anticoagulant therapy plus aspirin versus aspirin alone in high-risk patients was included. The RR for occlusion was 0.38 (95% CI, 0.15-0. 95). There were no significant differences for prevention of amputation, myocardial infarction, and death between the groups.

CONCLUSION

Antiplatelet therapy and oral anticoagulants reduce the risk of graft occlusion. Oral anticoagulant therapy appears to be the more effective treatment in high-risk patients. Data on the reduction of the risk of stroke, myocardial infarction, and death are inconclusive. Evidence for the beneficial effects of antiplatelet and oral anticoagulant therapy after infrainguinal bypass surgery is based on a small number of trials only. There is no proof as to which modality is the most effective in the prevention of graft occlusion and ischemic events in patients after infrainguinal bypass surgery, which is reason for a randomized comparison of aspirin with oral anticoagulants.

Long-term prognosis for patients with chronic leg ulcers: a prospective cohort study

OBJECTIVES

To assess the long-term prognosis of leg ulcers.

DESIGN

A 5 year prospective cohort study.

MATERIALS

A random sample of 382 patients with open leg ulcers (foot ulcers included) treated in the community.

METHODS

Interim analyses were made at 15 months (arterial ulcers) and at 20 months (varicose ulcers). Long-term healing was assessed at 54 months by a postal questionnaire. Five year survival was assessed by official population registries.

RESULTS

At 54 months 212 patients (55%) were still alive, of whom 124 (58%) had healed their ulcers, 80 (38%) had open ulcers and eight (4%) were amputated. The healing was worst for patients with venous ulcers, only 44% had healed their original ulcers without recurrence. The 5 year survival was 52%, significantly lower than for age- and sex-matched controls (68%) (p = 0.0002). Patients with venous ulcers had a survival not significantly different from controls and patients with arterial or other aetiologies had a doubled risk of death. Diabetic patients had a lower survival than non-diabetics (p < 0.05) and controls (p < 0.0001), but the healing prognosis was not significantly different.

CONCLUSION

Only patients with non-venous ulcers have a higher mortality than expected. The long-term healing prognosis for leg ulcer patients is poor and worst for patients with venous ulcers.