Percutaneous transluminal angioplasty for intermittent claudication: evidence on which to base the medicine

Long-term outcomes of large artery thromboangiitis obliterans and comparison with small artery thromboangiitis obliterans

ABSTRACT

Although the distribution of arterial involvement is still the subject of controversy for defining the diagnostic criteria for thromboangiitis obliterans (TAO), several reports have described TAO involving the more proximal arterial segment. This study aimed to investigate the clinical characteristics and outcomes of large artery TAO in comparison with those of small artery TAO.Between January 2007 and July 2019, 83 consecutive symptomatic patients with a diagnosis of lower extremity TAO were stratified according to the most proximal arterial involvement, with the cutoff level of the adductor canal as a reference (large artery TAO versus small artery TAO), and analyzed retrospectively. The study outcomes included any amputations and major amputations.The large artery TAO group consisted of 30 patients (36.1%), and the small artery TAO group consisted of 53 patients (63.9%). In terms of clinical symptoms and signs, the proportion of major tissue loss (Rutherford class 6) was significantly higher among patients with large artery TAO than among those with small artery TAO (13.3% versus 0%, P = .02). Any amputation rate was similar between the large and small artery TAO groups during the median follow-up period of 148 months (range, 0-376 months) (43.3% versus 28.3%, P = .16). However, the major amputation rate was significantly higher among patients with large artery TAO (13.3% versus 0%, P = .02). On Kaplan-Meier survival analysis of the cumulative event-free rates, although there was a similar 10-year amputation-free survival rate (P = .24) between the 2 groups, the large artery TAO group had a significantly lower 10-year major amputation-free survival rate (P < .01) than the small artery TAO group.Large artery TAO is a limb-threatening condition and had a worse prognosis than small artery TAO.

Impact of iliac arterial calcification on procedure success and long-term outcomes among patients undergoing endovascular intervention

OBJECTIVES

Vascular calcification is a well-known phenomenon and affects coronary and carotid arteries as well as other arterial beds. Presence of arterial calcification is associated with major adverse events in patients undergoing percutaneous coronary artery or carotid artery intervention. Even though there is a clear association between worse outcome and coronary-carotid calcification, there is no research that interrogated the relationship between iliac arterial calcification and clinical outcomes because of lack of data. Therefore, in this study, we aimed to investigate the impact of iliac arterial calcification on procedure success rates and long-term outcomes among patients undergoing endovascular intervention.

METHODS

The records of 453 consecutive patients who underwent endovascular intervention due to symptomatic peripheral artery disease were analyzed. Patients were divided into two groups based on the presence or absence of heavy calcification of iliac arteries. For each group, technical aspects of procedures and subsequent clinical outcomes were analyzed.

RESULTS

According to our study, the rate of restenosis following endovascular intervention at 6 and 12 months were similar between two groups. On the other hand, long-term restenosis was significantly higher in patients with heavy calcification of iliac arteries as compared to patients with low calcification on iliac arteries (32.2% vs. 12.8%, p < 0.05).

CONCLUSIONS

Our data showed that there was a strong association between heavy calcification of iliac arteries and long-term restenosis in patients undergoing endovascular intervention.

The association of preprocedural C-reactive protein/albumin ratio with in-stent restenosis in patients undergoing iliac artery stenting

Introduction: In-stent restenosis (ISR) still constitutes a major problem after percutaneous vascular interventions and the inflammation has a pivotal role in the pathogenesis of such event. The C-reactive protein/albumin ratio (CAR) is a newly identified inflammatory biomarker, and it may be used as an indicator to predict ISR in subjects with coronary artery stenting. In light of these data, our main objective was to investigate the relationship between the preprocedural CAR and ISR in patients undergoing successful iliac artery stent implantation.

Methods: In total, 138 consecutive patients who had successful iliac artery stent implantation in a tertiary heart center between 2015 and 2018 were enrolled in the study. The study population was categorized into two groups; patients with ISR and those without ISR during follow-up. The CAR was determined by dividing CRP by serum albumin.

Results: In the multivariable regression analysis; the CAR (HR: 2.66, 95% CI: 1.66-4.25, P < 0.01), stent length (HR: 1.01, 95% CI: 0.99-1.02, P = 0.04), and HbA1c levels (HR: 1.22, 95% CI: 0.99-1.51, P = 0.04) were independently related with ISR. A receiver operating curve analysis displayed that the CAR value of >0.29 predicted ISR with sensitivity of 97.5% and specificity of 88.8% (AUC 0.94, P < 0.01).

Conclusion: Our findings provide evidence that the CAR may be an applicable inflammatory biomarker in predicting ISR in subjects undergoing iliac artery stenting for the treatment of peripheral artery disease (PAD). Also, the stent length and poor glycemic control were found to be associated with ISR.

Durable Clinical Effectiveness With Paclitaxel-Eluting Stents in the Femoropopliteal Artery: 5-Year Results of the Zilver PTX Randomized Trial

Background—

This randomized controlled trial evaluated clinical durability of Zilver PTX, a paclitaxel-coated drug-eluting stent (DES), for femoropopliteal artery lesions. Outcomes compare primary DES versus percutaneous transluminal angioplasty (PTA), overall DES (primary and provisional) versus standard care (PTA and provisional Zilver bare metal stent [BMS]), and provisional DES versus provisional BMS.

Methods and Results—

Patients with symptomatic femoropopliteal artery disease were randomly assigned to DES (n=236) or PTA (n=238). Approximately 91% had claudication; 9% had critical limb ischemia. Patients experiencing acute PTA failure underwent secondary randomization to provisional BMS (n=59) or DES (n=61). The 1-year primary end points of event-free survival and patency showed superiority of primary DES in comparison with PTA; these results were sustained through 5 years. Clinical benefit (freedom from persistent or worsening symptoms of ischemia; 79.8% versus 59.3%, P<0.01), patency (66.4% versus 43.4%, P<0.01), and freedom from reintervention (target lesion revascularization, 83.1% versus 67.6%, P<0.01) for the overall DES group were superior to standard care in nonrandomized comparisons. Similarly, clinical benefit (81.8% versus 63.8%, P=0.02), patency (72.4% versus 53.0%, P=0.03), and freedom from target lesion revascularization (84.9% versus 71.6%, P=0.06) with provisional DES were improved over provisional BMS. These results represent >40% relative risk reduction for restenosis and target lesion revascularization through 5 years for the overall DES in comparison with standard care and for provisional DES in comparison with provisional BMS.

Conclusions—

The 5-year results from this large study provide long-term information previously unavailable regarding endovascular treatment of femoropopliteal artery disease. The Zilver PTX DES provided sustained safety and clinical durability in comparison with standard endovascular treatments.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00120406.

Management of Atherosclerotic Aortoiliac Occlusive Disease

Development of aortoiliac occlusive disease (AIOD) is associated with classic risk factors for atherosclerotic disease such as hyperlipidemia, hypertension, diabetes, or smoking. Risk factor modification, smoking cessation, and prevention of cardiovascular events remain the cornerstones of AIOD management. Symptom improvement and limb loss prevention are considered secondary goals of therapy. Continuous technological advances, new devices, as well as new revascularization techniques are constantly changing the landscape of AIOD management. Surgical interventions, which were considered a gold standard therapy for nearly 50 years, currently give way to newer and less invasive endovascular techniques.

Role of the latest endovascular technology in the treatment of intermittent claudication

Intermittent claudication is a serious symptom in patients with peripheral arterial disease, and severely limits activities of daily living. Conservative treatment (optimal medical therapy and exercise rehabilitation programs) and revascularization procedures (endovascular treatment [EVT] or open bypass surgery) can relieve intermittent claudication. Among these treatment options, EVT has developed dramatically during the past decade, and has enabled physicians to offer less invasive treatment options with increasing durability. EVT for aortoiliac lesions has matured, and its long-term patency now approaches that of open bypass surgery. The latest EVT technologies include drug-eluting stents, stent grafts, drug-coated balloons, and bioresorbable stents. The recently reported patency of stent grafts in the femoropopliteal lesions was comparable with that of the prosthetic bypass graft. In the course of the paradigm shift from bypass surgery to EVT, evidence of any long-term benefit of EVT compared with supervised exercise is still inconclusive. EVT could improve walking performance in the short-term, while supervised exercise could improve walking performance more efficiently in the long-term. Combined treatment with EVT and exercise may offer the most sustainable and effective symptom relief. This paper reviews the relevant literature on the treatment of intermittent claudication, focusing on the latest EVT technologies, and outlines a strategy for achieving long-term benefits.

Comparison of quality of life in patients with peripheral arterial disease caused by atherosclerosis obliterans or Buerger's disease

OBJECTIVE

Buerger's disease and atherosclerosis obliterans (ASO) are two peripheral arterial diseases (PAD) that are frequently encountered. The aim of this study was to compare quality of life (QOL) in patients with Buerger's disease and ASO.

METHODS

We prospectively followed 86 patients who were admitted to our hospital due to ASO or Buerger's disease. Their ischaemia was evaluated according to the clinical category chronic limb ischaemia at the time of hospital admission and at six and 12 months. The QOL was measured at the time of hospital admission and at six and 12 months with the Short Form Health Status Survey (SF-36) and Vascular Quality of Life Questionnaire (VASCUQOL).

RESULTS

A total of 86 patients with ASO or Buerger's disease (47 and 39, respectively) were included in the study. Pain parameters from both SF-36 and VASCUQOL scores were lower in patients with Buerger's disease at the time of hospital admission and at six months. The impairment in QOL was found to be proportional to the extent of chronic limb ischaemia. Conversely, when patients with critical limb ischaemia were evaluated, no difference was observed between those with ASO or Buerger's disease in terms of QOL. Amputations were found to have a negative effect on quality of life.

CONCLUSION

Buerger's disease had a more pronounced negative effect on QOL than ASO, particularly in terms of pain score. When critical limb ischaemia was considered, ASO and Buerger's disease impaired quality of life at the same rate.

Randomized clinical trial of percutaneous transluminal angioplasty, supervised exercise and combined treatment for intermittent claudication due to femoropopliteal arterial disease

Background

The aim was to compare percutaneous transluminal angioplasty (PTA), a supervised exercise programme (SEP) and combined treatment (PTA plus SEP) for intermittent claudication due to femoropopliteal arterial disease.

Methods

Consenting patients with femoropopliteal arterial lesions were randomized to one of three treatment arms: PTA, SEP, or PTA plus SEP. All patients received optimal medical treatment. Patients were assessed at baseline and 1, 3, 6 and 12 months after intervention. Clinical (ankle pressures, walking distances, symptoms) and quality-of-life (QoL) outcomes (Short Form 36, VascuQol) were analysed.

Results

A total of 178 patients (108 men, median age 70 years) were included. All three treatment groups demonstrated significant clinical and QoL improvements. One year after PTA (60 patients, 8 withdrew), 37 patients (71 per cent) had improved (16 mild, 16 moderate, 5 marked), nine (17 per cent) showed no improvement and six (12 per cent) had deteriorated. After SEP (60 patients, 14 withdrew), 32 patients (70 per cent) had improved (19 mild, 10 moderate, 3 marked), six (13 per cent) showed no improvement and eight (17 per cent) had deteriorated. After PTA plus SEP (58 patients, 11 withdrew), 40 patients (85 per cent) had improved (18 mild, 20 moderate, 2 marked), seven (15 per cent) showed no improvement and none had deteriorated. On intergroup analysis, PTA and SEP alone were equally effective in improving clinical outcomes, although the effect was short-lived. PTA plus SEP produced a more sustained clinical improvement, but there was no significant QoL advantage.

Conclusion

For patients with intermittent claudication due to femoropopliteal disease, PTA, SEP, and PTA plus SEP were all equally effective in improving walking distance and QoL after 12 months. Registration number: NCT00798850 (http://www.clinicaltrials.gov). Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

The 1-Year Clinical Impact of Rotational Aspiration Atherectomy of Infrainguinal Lesions

The present study was carried out to provide information about outcome of the Jetstream atherectomy device for treatment of infrainguinal arteries. From February 2006 to February 2007, 172 patients with Rutherford class 1 to 5 lower limb ischemia were enrolled at 9 study sites. The endpoints were evaluation of quality of life according to the walking impairment questionnaire (WIQ) besides technical parameters. In the total study cohort, the WIQ scale maintained improved up to 12-month follow-up. Furthermore, target lesion revascularization rate was 26% (42/162), ankle-brachial index (ABI) increased from 0.59 ± 0.21 at baseline to 0.82 ± 0.27 ( P < 0.05), and mean Rutherford class dropped from 3.0 ± 0.9 at baseline to 1.5 ± 1.3 at 1 year ( P < .05). The results of this prospective, multicenter, clinical study demonstrate that the Jetstream atherectomy device is a potential treatment alternative for the endovascular management to improve clinical outcome in patients with peripheral arterial occlusive disease.

Assessment of functional status and quality of life in claudication

BACKGROUND

Treadmill walking is commonly used to evaluate walking impairment and efficacy of treatment for intermittent claudication (IC) in clinical and research settings. Although this is an important measure, it does not provide information about how patients perceive the effects of their treatments on more global measures of health-related quality of life (HRQOL).

METHODS

PubMed/Medline was searched to find publications about the most commonly used questionnaires to assess functional status and/or general and disease-specific HRQOL in patients with peripheral artery disease (PAD) who experience IC. Inclusion criteria for questionnaires were based on existence of a body of literature in symptomatic PAD.

RESULTS

Six general questionnaires and seven disease-specific questionnaires are included, with details about the number of domains covered and how each tool is scored. The Medical Outcomes Study Short Form 36-item questionnaire and Walking Impairment Questionnaire are currently the most used general and disease-specific questionnaires at baseline and after treatment for IC, respectively.

CONCLUSIONS

The use of tools that assess functional status and HRQOL has importance in both the clinical and research areas to assess treatment efficacy from the patient's perspective. Therefore, assessing HRQOL in addition to treadmill-measured walking ability provides insight as to the effects of treatments on patient outcomes and may help guide therapy.

Does percutaneous transluminal angioplasty improve quality of life?

PURPOSE

To prospectively assess the impact of peripheral percutaneous transluminal angioplasty (PTA) on quality of life (QOL) in patients with intermittent claudication or critical limb ischemia (CLI). The secondary purpose was to determine if periprocedural medication altered patient QOL.

MATERIALS AND METHODS

A total of 72 patients underwent lower-limb PTA (86 lesions) over a period of 12 months. QOL data were obtained before PTA and at 1 and 6 months after PTA with use of the Short Form-36 (SF-36) questionnaire.

RESULTS

The SF-36 questionnaire was completed in 100% of cases before PTA, in 89% at 1 month after PTA, and in 78% at 6 months after PTA. Baseline QOL was worse than the QOL quoted for the normal population. Overall, there was an improvement in QOL in seven of the nine health domains at 1 month after PTA, and the improvements were significant (P < .01) in five. Improvement was demonstrated at 6 months in all nine QOL domains measured, which was significant (P < .01) in five. Patients with intermittent claudication (n = 40) exhibited an improvement in all nine health domains at 6 months, which was significant (P < .05) in seven. The CLI group (n = 32) showed an improvement in five domains at 6 months, which was significant (P < .05) in two. Subjects with intermittent claudication experienced a more significant improvement than those with CLI. SF-36 pain scores at 1 month after PTA were significantly better in patients taking aspirin than in those who were not (P < .001).

CONCLUSIONS

PTA results in improved QOL in patients with intermittent claudication and CLI as early as 1 month, which was shown to be maintained at 6 months in our small series. Aspirin significantly improves pain after PTA. QOL assessment is useful after peripheral angioplasty.

Impact of Endovascular Treatment on Clinical Status and Health-Related Quality of Life

Background and Aims:

Investigating the impact of percutaneous transluminal angioplasty (PTA) on clinical status and health related quality of life in patients with claudication and critical limb ischaemia (CLI).

Material and Methods:

61 patients and 64 limbs underwent a primary PTA (30 claudication and 34 CLI cases). Clinical status was graded according to Ahn and Rutherford and ankle/brachial index (ABI). Quality of life was assessed using the Nottingham Health Profile (NHP) preoperatively, one month and one year after the procedure. Triplex scan evaluation of the treated arterial segment was carried out postoperatively and one year after the procedure.

Results:

Claudication: 24/27 patients underwent one-year follow up, after which 20/24 had no claudication. In triplex evaluation 17 (63.0%) treated segments were open with 0–50% restenosis, 9 (33.3%) with 51–99% restenosis and one (3.7%) was occluded. CLI: 13/34 (38.2%) patients underwent one-year follow-up after which eight patients (61.5%) were asymptomatic and five (38.1%) had claudication. In triplex evaluation there was 0–50% restenosis in 6 (46.2%) segments treated with PTA and 51–99% restenosis in 7 (53.8%) segments. 21 (61.8%) patients did not conclude the one year follow up: 7 had died, 5 had undergone bypass surgery and 6 an amputation and 3 did not attend the follow-up up for unknown reasons. Quality of life: For CLI patients, improvement was observed in the domain of pain, which continued throughout the follow-up period. Among the claudicants, the domain of physical mobility was improved at one month's follow-up, but this effect disappeared during the following year and could not be seen at one the one- year follow-up.

Conclusions:

Technical success and one-year results in claudication are good, and the rate of complications is low. However, although PTA resulted in an immediate improvement in the quality of life, this effect was not seen in the long term. In critical limb ischemia there was a group of patients in whom PTA led to a significant benefit in terms of limb salvage and quality of life.

Quality of life after balloon angioplasty versus stent implantation in the superficial femoral artery: findings from a randomized controlled trial

PURPOSE

To investigate whether primary nitinol stenting in the superficial femoral artery (SFA) is beneficial to patients' quality of life (QoL).

METHODS

One hundred four patients (55 men; mean age 66+/-19 years) with chronic limb ischemia and SFA disease were randomly assigned to primary stent implantation (n=51) or balloon angioplasty (n=53) with optional stenting for a suboptimal angioplasty result (17 of 53). QoL was measured by the SF-36 questionnaire at baseline and at 3, 6, and 12 months post intervention.

RESULTS

QoL was significantly improved post intervention and up to 12 months in both treatment groups. Significant inverse associations were observed between QoL parameters and restenosis. Comparing primary stenting (n=51) versus balloon angioplasty with optional stenting (n=53) by the intention to treat, no significant differences in QoL were observed. Analyses of stented patients (n=68) versus balloon angioplasty (n=36) patients, however, demonstrated significantly improved measures of QoL after stenting.

CONCLUSION

Endovascular revascularization of SFA disease improves QoL, and restenosis negatively affects QoL outcomes. After stent implantation, whether primary or secondary, QoL was significantly ameliorated compared to balloon angioplasty alone. However, it remains to be proven in larger cohorts whether primary stenting yields a QoL benefit compared to balloon angioplasty with optional secondary stenting.

Poor health-related quality of life in patients with peripheral arterial disease: Type D personality and severity of peripheral arterial disease as independent predictors

BACKGROUND

Peripheral arterial disease (PAD) is associated with poor health-related quality of life (HRQOL), but individual differences in this patient-based outcome are not fully understood. We examined the impact of PAD severity, invasive treatment, and type D personality, defined as tendencies to experience negative emotions and be socially inhibited, on HRQOL in a 1-year follow-up study.

METHOD

At their first visit to the department of surgery at the St. Elisabeth Hospital in Tilburg, The Netherlands, 203 consecutive PAD patients completed the DS14 type D personality and RAND-36 questionnaires (all self-report). Clinical data were derived from patients' medical files and included ankle-brachial index (ABI), initial and absolute claudication distance (ICD, ACD), and invasive treatment. The main outcome was HRQOL at 1-year follow-up.

RESULTS

HRQOL improved between baseline and follow-up, and invasive treatment led to significant improvements in the subscales Physical Functioning (P = .005) and Pain (P = .003). Type D patients were severely impaired in their HRQOL compared with other patients at baseline (P < .01) and at follow-up (P < .05). ABI and ACD also predicted HRQOL at follow-up. After adjusting for ABI and ACD, invasive treatment and type D personality independently predicted all HRQOL domains, except for Physical Functioning. Overall, type D personality predicted increased risk for both poor General Health (odds ratio [OR], 3.70; 95% confidence interval [CI], 1.69 to 8.08; P = .001) and poor Mental Health (OR, 6.01; 95% CI, 2.44 to 14.79, P < .0001) at 1 year after the PAD diagnosis.

CONCLUSION

Despite an overall improvement, type D patients remained more impaired in 1-year HRQOL than other patients, adjusting for ABI and ACD. Type D personality is a psychologic risk factor that predicts poor patient-based outcomes in PAD and should be taken into account when HRQOL in PAD is evaluated.

Endoluminal therapy in patients with peripheral arterial disease: prospective assessment of quality of life in 190 patients

OBJECTIVE

The objective of our study was to assess the impact of endoluminal treatment on health-related quality of life in patients with peripheral arterial disease.

SUBJECTS AND METHODS

Changes in quality of life were prospectively evaluated in 190 patients before and 1, 3, 6, and 12 months after treatment. Physical, emotional, and general health components were determined using the short-form (36 items) health survey (SF-36). Claudicant patients were compared with patients who had critical limb ischemia. The influence of the lesion location (iliac, femoropopliteal, or crural) restenosis, and additional interventions on quality of life were evaluated.

RESULTS

Six- and 12-month follow-up data were available for 136 and 103 patients, respectively. Significant improvements in quality of life were observed in most of the patients after the intervention. Many of the SF-36 scores decreased from the 6- to the 12-month follow-up but remained significantly higher than the score before the intervention. Reduction of bodily pain was the most evident effect of treatment. Claudicant patients seemed to benefit more from treatment than patients with critical limb ischemia. In terms of SF-36 scores, percutaneous transluminal angioplasty of the crural arteries was equally as effective as endoluminal revascularization of the iliac and femoropopliteal arteries and multilevel interventions were as effective as single-level interventions. The occurrence of a restenosis was significantly related to lower SF-36 scores, and restenosis not followed by a second intervention was associated with lower SF-36 scores.

CONCLUSION

Although there were several differences between the groups, significant improvements in quality of life up to 12 months after endoluminal therapy were observed in most patients.

The PADHOC Device is a Better Guide to the Actual Incapacity Suffered by Claudicants than the Gold Standard Constant Load Treadmill Test

BACKGROUND

The Constant Load Treadmill Test (CLTT) is currently the primary method used to measure walking impairment in patients with peripheral vascular disease. The aim of this study was to compare the CLTT and PADHOC device as assessments of walking impairment.

METHODS

55 patients with intermittent claudication underwent a CLTT and a Double Physiological Walking Test (DPWT) using the PADHOC device. Health-related quality of life was measured using the Short Form 36 and the Claudication Scale.

RESULTS

The initial claudication and maximum walking distance from the first part of the DPWT showed the best correlation with domains of pain and physical function.

CONCLUSIONS

The DPWT is more representative of the functional incapacity experienced by patients with intermittent claudication. We believe that the PADHOC is a suitable alternative to the CLTT in the assessment of this patient group.

Dutch Iliac Stent Trial: Long-term Results in Patients Randomized for Primary or Selective Stent Placement

PURPOSE

To determine long-term results of the prospective Dutch Iliac Stent Trial.

MATERIALS AND METHODS

The study protocol was approved by local institutional review boards. All patients gave written informed consent. Two hundred seventy-nine patients (201 men, 78 women; mean age, 58 years) with iliac artery disease were randomly assigned to undergo primary stent placement (143 patients) or percutaneous transluminal angioplasty (PTA) with selective stent placement in cases in which the residual mean pressure gradient was greater than 10 mm Hg across the treated site (136 patients). Before and at 3, 12, and 24 months and 5-8 years after treatment, all patients underwent assessment, which included duplex ultrasonography (US), ankle-brachial index (ABI) measurement, Fontaine classification of symptoms, and completion of the Rand 36-Item Health survey for quality-of-life assessment. Treatment was considered successful for symptoms if symptoms increased at least one Fontaine grade, for ABI if ABI increased more than 0.10, for patency if peak systolic velocity ratio at duplex US was less than 2.5, and for quality of life if the RAND 36-Item Health Survey score increased more than 15 points. Effects of both treatments on symptoms, quality of life, patency, and ABI were compared by using survival analyses.

RESULTS

Patients who underwent PTA and selective stent placement had better improvement of symptoms (hazard ratio [HR], 0.8; 95% confidence limits [CLs]: 0.6, 1.0) than did patients treated with primary stent placement, whereas ABI (HR, 0.9; 95% CLs: 0.7, 1.3), iliac patency (HR, 1.3; 95% CLs: 0.8, 2.1), and score for quality of life for nine survey dimensions did not support a difference between treatment groups.

CONCLUSION

Patients treated with PTA and selective stent placement in the iliac artery had a better outcome for symptomatic success compared with patients treated with primary stent placement, whereas data about iliac patency, ABI, and quality of life did not support a difference between groups.

Wound infection after infrainguinal bypass operations: multivariate analysis of putative risk factors

Reported wound infection rates for infrainguinal bypass operations range from 17% to 44%, but there is limited appreciation of which characteristics of patients or operations are reliable markers of increased wound infection risk. The purpose of the present study was to analyze all wound infections observed after infrainguinal bypass operations during 20 years of practice in a large teaching institution. Independent risk factors for wound infection development were identified. During the 20-year period ending 31 December, 1997, 978 male patients underwent infrainguinal bypass operations at the Minneapolis Department of Veterans Affairs Medical Center. Wound infections complicated the recovery of 129 of these patients during a 30-day postoperative surveillance interval. Multivariate logistic regression analysis was used to test the association between wound infection occurrence and putative risk factors that were either features of patients or characteristics of the operations. The following variables were examined: obesity, prosthetic graft placement, diabetes mellitus, steroid use, anticoagulation use, length of preoperative hospital stay, development of incisional hematoma, duration of operation, and the preoperative presence of a non-healing wound in the extremity being revascularized. The overall wound infection rate was 13.2% (129/978). In a final logistic regression model, obesity was a significant and independent predictor of wound infection (Relative Risk 2.6, 95% confidence interval, 1.35-4.90), as was development of a post-operative incisional hematoma (Relative Risk 6.44, 95% confidence interval, 2.95-14.08). No other explanatory variable was significantly associated with wound infection development.

Intermittent Claudication: Functional Capacity and Quality of Life after Exercise Training or Percutaneous Transluminal Angioplasty—Systematic Review

PURPOSE

To systematically review published data about the short- and long-term effects of exercise training and angioplasty on functional capacity and quality of life of patients with intermittent claudication.

MATERIALS AND METHODS

Articles published between January 1980 and February 2003 were included if patients had intermittent claudication treated with exercise training or angioplasty and if both functional capacity and quality-of-life scores from Medical Outcomes Study 36-Item Short Form health survey were reported for at least 3 months of follow-up. Data were pooled by using a random effects model and weighted means. Pooled results were compared between the treatment groups by using the chi2 test and the Student t test (alpha = .05, two sided).

RESULTS

In the analyses, five studies (202 patients) were included in the exercise group, and three studies (470 patients), in the angioplasty group. At 3 months of follow-up, the ankle-brachial index was significantly improved in the angioplasty group (mean change, 0.18; P < .01) but not in the exercise group (mean change, 0.01; P = .29). At 3 months, quality of life was significantly improved with regard to ratings of physical functioning and bodily pain in the exercise group (mean change, 18 and 10, respectively; P < .01) and physical role functioning in the angioplasty group (mean change, 30; P = .03). Mean change in ankle-brachial index significantly differed between the two treatment groups at 3 and 6 months (P < .01); mean change in quality-of-life scores did not.

CONCLUSION

Improvement in quality of life was demonstrated after both exercise training and angioplasty, whereas functional capacity showed significant improvement after angioplasty. The ankle-brachial index significantly differed between the two treatment groups at 3 and 6 months, whereas the quality-of-life scores did not.

Impaired health status and invasive treatment in peripheral arterial disease: a prospective 1-year follow-up study

OBJECTIVE

It has been argued that health status and quality of life (QOL) should be taken into account in the treatment policy of patients with peripheral arterial disease (PAD). In cardiac patients, it has been shown that poor perceived health status is an independent predictor of mortality and hospitalization. We therefore examined (1) the role of health status, QOL, and clinical indices of disease severity as determinants of invasive treatment in patients with PAD and (2) the effect of invasive treatment on health status and QOL.

METHODS

At their first visit, patients completed the RAND 36-item Health Survey and World Health Organization Quality of Life assessment instrument questionnaires to assess health status and QOL, respectively. During the 1-year follow-up period, data concerning hospitalization were derived from the patients' medical files. Furthermore, patients completed the RAND 36 and the World Health Organization Quality of Life assessment instrument again at 1-year follow-up. The setting was a vascular outpatient clinic of a teaching hospital in Tilburg, The Netherlands; participants were 200 consecutive patients newly diagnosed with intermittent claudication, a common expression of PAD. Diagnosis was based on history, physical examination, treadmill walking distance, and ankle-brachial pressure indices. Main outcome measures were (1) invasive treatment of PAD that took place during the 1-year follow-up, derived from the patients' medical files, and (2) health status and QOL after 1 year of follow-up.

RESULTS

After 1 year of follow-up, 107 patients (53.5%) were event free, whereas 77 patients (38.5%) had been hospitalized for invasive treatment of PAD. Sixteen patients (8%) were hospitalized for other cardiovascular reasons. In a multivariate logistic regression model, age (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.91-0.99; P = .024), pain-free walking distance (OR, 2.74; 95% CI, 1.05-7.17; P = .04), and physical functioning (OR, 4.46; 95% CI, 1.79-11.12; P = .001) were independent predictors of invasive treatment of intermittent claudication. After 1 year of follow-up, patients who were treated invasively experienced a significant improvement in their physical functioning ( P = .004), role limitations due to emotional problems ( P = .018), and bodily pain ( P = .026).

CONCLUSIONS

Patients with poor self-reported physical functioning, limited walking distance, and a younger age were likely to be treated invasively. The physician's clinical judgment about when to intervene adequately reflects the patient's own opinion about his or her health status. Invasive treatment led to a significant improvement in patients' health status. These findings indicate the effectiveness of the strategy to include patients' perceived physical functioning into the process of clinical decision-making.

Comparison of generic and disease-specific questionnaires for the assessment of quality of life in patients with peripheral arterial disease

OBJECTIVE

This study compared the ability of generic and disease-specific questionnaires to assess quality of life (QOL) at baseline and to detect change in QOL after treatment in patients with peripheral arterial disease (PAD).

METHODS

This prospective multicenter trial recruited 514 patients with PAD who needed an imaging workup and had an ankle brachial pressure index of less than 0.90. Patients with severe comorbidity were excluded, leaving a study population of 450 patients. Patients completed two generic questionnaires, the Short Form 36 (SF-36) and the European Quality of Life 5D (EuroQol-5D), and one disease-specific questionnaire, the Vascular Quality of Life (VascuQol) at baseline and after 6 months of follow-up. Rutherford classification and treadmill walking distance were determined at baseline and after 6 months of follow-up and were considered indicators of disease severity. Receiver operating characteristic (ROC) curves and areas under the curves (AUCs) were used to evaluate each of the three questionnaires for its ability to discriminate between severe and mild disease at baseline and to discriminate between a large and small change in disease severity after follow-up. The underlying assumption was that disease severity is a major determinant of QOL. This implies that the validity of a QOL questionnaire is reflected by its ability to discriminate between mildly and severely diseased patients.

RESULTS

At baseline, 443 patients and after follow-up, 386 patients completed questionnaires. At baseline, no significant ( P >.05) differences were observed among AUCs for the total scores of the three questionnaires, indicating that all three questionnaires assessed the disease severity equally well. After follow-up, the AUCs for the VascuQol were significantly higher than the AUCs for the SF-36 and EuroQol-5D with respect to detection of improvement in Rutherford classification ( P < .05), indicating that change in disease severity after follow-up was best detected by the VascuQol.

CONCLUSION

The VascuQol is the preferred questionnaire as outcome measure for QOL in future trials and clinical follow-up of patients with PAD.

The effect of peripheral percutaneous transluminal angioplasty on quality of life in patients with intermittent claudication

BACKGROUND AND OBJECTIVE

intermittent claudication is associated with a significant reduction in quality of life. Treatment of claudicants aims to reduce mortality from cardio- and cerebro-vascular events and to improve quality of life. Quality of life assessment should be used to guide and evaluate treatment in this group of patients. Peripheral percutaneous transluminal angioplasty (PTA) is now widely used in the treatment of intermittent claudication. The aim of this review is to examine the effect of PTA on quality of life (QOL) in patients with intermittent claudication.

METHODS

a review was conducted of prospective clinical trials assessing the effect of peripheral PTA on QOL. Publications were retrieved by searching Medline and PreMedline, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of systematic reviews, AMED and CINAHL. The reference lists of the relevant publications were also searched.

RESULTS

seven prospective studies (10 publications) on the effect of PTA on QOL in claudicants were identified. Several different questionnaires were used to measure quality of life (Nottingham Health Profiile, SF-36, EuroQol) none of which were disease specific. All the studies showed some improvement in QOL after PTA at follow-up periods of between 6 weeks and 24 months, except for one which showed some improvement at 6 months but not at 24 months.

CONCLUSIONS

despite the fact that studies on the effect of PTA on QOL in claudicants have used generic QOL questionnaires which are relatively insensitive, the findings suggest that PTA may result in some improvement in QOL in these patients, although level I evidence to support this is lacking. The availability of disease-specific questionnaires should enable a more accurate assessment of PTA on QOL in these patients.

A new device for the measurement of disease severity in patients with intermittent claudication

OBJECTIVES

To assess a new method of determining functional impairment in patients with intermittent claudication, the Double Physiological Walking Test (DPWT) using the PADHOC (Peripheral Arterial Disease Holter Control) device, against a standard treadmill test.

DESIGN

Patients with intermittent claudication presenting to the department were considered for both the DPWT and a standard treadmill test.

METHODS

initial claudicating distance, maximal walking distance and speed of walking were determined for both parts of the DPWT. Initial claudicating distance and maximal walking distance were determined from the treadmill test. Comparisons were made between the treadmill test and the DPWT.

RESULTS

The treadmill test was unable to be performed in 22% of patients due to defined contraindications. There were strong correlations in both walking distances and disease severity when comparing the DPWT and the treadmill test. Patients in whom the treadmill test was contraindicated had significantly shorter walking distances on the DPWT than those who were able to complete a treadmill walking test.

CONCLUSIONS

The DPWT correlates strongly with walking distances obtained from a standard treadmill test. However, the PADHOC can be used in a number of differing locations and settings as well as in patients in whom a treadmill test is contraindicated. It therefore has a role to play in the initial assessment of patients presenting with intermittent claudication.

Quality of life in patients with intermittent claudication using the World Health Organisation (WHO) questionnaire

OBJECTIVE

to assess quality of life (QOL) in patients with intermittent claudication.

DESIGN

a prospective, open study.

MATERIAL AND METHOD

one hundred and fifty-one consecutive claudicants (100 men, 51 women), and 161 healthy controls (70 men and 91 women) completed an adapted version of the World Health Organisation Quality of Life Assessment Instrument-100.

RESULTS

patients scored significantly worse on the domains Physical health and Level of independence, as well as on the facets Pain and discomfort, Energy and fatigue, Mobility, Activities of daily living, Dependence on medication and treatments, Working capacity, Negative feelings, Recreation and leisure and Overall QOL and general health. Increasing disease to incapacitating claudication affected only the facet Mobility and the domain Level of independence.

CONCLUSION

QOL in patients with intermittent claudication is reduced in many aspects. Where co-morbidity seems to affect QOL strongly, the effect of walking distance on QOL might be small. These findings may justify a reserved attitude towards invasive, even minimally invasive treatment of these patients.

A 1-year follow-up quality of life study after hemodynamically successful or unsuccessful surgical revascularization of lower limb ischemia

PURPOSE

The impact of hemodynamically successful or unsuccessful bypass grafting or angioplasty on patients' quality of life was assessed throughout the first year postsurgery.

METHODS

A total of 146 patients, 97 patients who underwent successful revascularization and 49 patients who underwent unsuccessful revascularization, were assessed for quality of life with the Nottingham Health Profile.

RESULTS

Hemodynamically successful revascularization resulted in an immediate and lasting impact on the patients' quality of life. Despite hemodynamic failure, patients had improvements in pain, emotional reactions, sleep, and family relationships at the 1-year follow-up assessment. A successful revascularization in patients with claudication demonstrated the most marked quality of life benefits, including all health dimensions that were not normal at baseline. Patients with critical ischemia had improved quality of life for pain, sleep, and physical mobility. High ankle pressure, in the claudicant group, and a high sense of coherence were significantly associated with high quality of life.

CONCLUSION

The treatment of lower limb ischemia resulted in an immediate and relatively lasting improvement in patients' quality of life. Patients who underwent hemodynamically successful bypass grafting procedures or angioplasty demonstrated higher quality of life benefits than patients who underwent a failed bypass grafting procedure. Quality of life was further determined by means of the patients' sense of coherence.

Extensible expanded polytetrafluoroethylene vascular grafts for aortoiliac and aortofemoral reconstruction

The operative experience and medium-term outcome achieved with longitudinally extensible ('stretch') expanded polytetrafluoroethylene (ePTFE) bifurcated grafts in patients undergoing aortoiliac or aortofemoral reconstruction for occlusive disease at our institution was reviewed. Between 1991 and 1998, 242 patients received a bifurcated stretch graft. Forty-one patients (17%) required an aortic endarterectomy, and 63 (26%) underwent femoral artery endarterectomy. 228 patients were followed for a mean of 32 months. One patient (0.4%) died perioperatively. The perioperative morbidity included cardiac (3.7%), respiratory (2.5%), and renal (3.3%) complications. Three patients required early reoperation for bleeding. Four (1.7%) grafts thrombosed within 24h of surgery; eight additional grafts (3.3%) thrombosed 5-8 months later. There were three postoperative aortic graft infections, one inguinal infection, three inguinal pseudoaneurysms, and one aortic pseudoaneurysm. Ultrasonography during follow-up showed no periprosthetic fluid collections or graft dilatations. The bifurcated ePTFE stretch graft is suitable for aortoiliac and aortofemoral reconstruction, and its physical characteristics may help to reduce graft-related complications.

Assessment of generic health-related quality of life in patients with intermittent claudication

OBJECTIVES

to measure quality of life in patients with intermittent claudication and evaluate the ability of patients and vascular surgeons to make a similar assessment.

DESIGN, MATERIALS AND METHODS

in this prospective study patients with intermittent claudication attending two vascular clinics were asked to complete a generic health-related quality of life instrument (MOS SF-36). Patient quality of life and vascular surgeons' assessment of patient quality of life were further evaluated using a single question/adjectival scale response combination.

RESULTS

patients' self-assessment of their quality of life correlated better with the SF-36 score than did the surgeons' assessment. There was little correlation between the surgeons' and patients' own assessment of quality of life. The surgeons differed significantly from each other in their assessments. Claudicants had lower SF-36 scores than population norms in pain and physical aspects of quality of life.

CONCLUSIONS

claudicants have worse quality of life than the general population, with pain and physical limitations being the most important domains. Surgeons predict the quality of life of claudicating patients less accurately than patients do themselves, and may differ from their colleagues in such assessments. Objective quality of life assessment in claudicants should be undertaken before treatment is decided.

Exercise therapy or angioplasty? A summation analysis

OBJECTIVES

To compare the outcome of exercise therapy or angioplasty for the treatment of patients with intermittent claudication.

DESIGN

A summation analysis.

METHODS

A search using MEDLINE and PUBMED between 1966 and April 1999 followed by a review of the manuscripts yielded 54 studies involving angioplasty and 27 studies involving exercise therapy for intermittent claudication. Studies were only included (12 angioplasty and nine exercise series) when results were available for patients with intermittent claudication alone, and when outcome was assessed in terms of symptoms at a minimum of 6 months.

RESULTS

The total number of claudicants undergoing exercise therapy was 294 patients, with a mean symptomatic success rate of 38. 4% and a mean improvement in maximum walking distance of 189.7% at 6 months. The total number of claudicants undergoing angioplasty was 2071, with a mean overall symptomatic success rate of 76.6%. The mean overall complication rate was 9% and mean major complication rate was 2.7% for the angioplasty studies.

CONCLUSION

Although the result demonstrates an advantage of angioplasty over exercise therapy at 6 months, there is a small risk of major complications. However, comparison of studies was impaired due to disparity in patient numbers, limited follow-up time and lack of uniformity in outcome assessment. In order to achieve a valid comparison of these therapies in a future randomised study, a validated disease-specific instrument for the assessment of symptomatic outcome for claudicants is required.

Impact of a 4-week treatment with prostaglandin E1 on health-related quality of life of patients with intermittent claudication

Intermittent claudication impairs functional status and quality of life in many patients by limiting walking capacity. The aim of this study was to evaluate the effects of a 4-week treatment with prostaglandin E1 (PGE1), a drug inducing vasodilation and inhibiting platelet aggregation, on improving functional status and health-related quality of life in patients with disabling intermittent claudication. Forty-two untrained outpatients (37 men and five women, mean age 64 +/- 8 years) with intermittent claudication,and maximum walking distance (MWD) of at least 50 and no more than 200 m on treadmill test (5% slope, 3 km/hr) were randomized to 4 weeks of double-blind treatment either with 60 mcg PGE1 daily given IV in 250 mL saline over a period of 2 hours (21 patients) or placebo (250 mL saline, 21 patients). Treatment-free follow-up was completed 8 weeks after the final infusion. Pain free walking distance (PFWD), MWD, and questionnaire evaluation were determined at baseline, after the 4-week treatment period, and at the end of the 8 weeks of the treatment-free follow-up period. After 4 weeks of treatment with PGE1 PFWD and MWD increased from 72 +/- 16 m to 135 +/- 33 m (+87%, p<0.001)and from 140 +/- 30 m to 266 +/- 62 m (+90%, p<0.001), respectively. Analysis of the Walking Impairment Questionnaire responses in the PGE1 group at 4 weeks demonstrated significant improvements in the walking impairment score (+19 percentage points, p<0.001), in the distance score (+25 percentage points, p<0.001), in the speed score (+24 percentage points, p<0.001), in the stair climbing score (+20 percentage points, p<0.001). The RAND survey responses showed improvements in physical function and bodily pain scores (+14 percentage points, p<0.001, and +15 percentage points, p<0.01, respectively). After the treatment-free follow-up period of 8 weeks, increases in PFWD and MWD were maintained (113 +/- 26 m, +57%, p<0.001, and 229 +/- 55 m, +63%, p<0.001, respectively). Similarly, at the end of the treatment-free follow-up, the walking impairment score (+16 percentage points, p<0.001), the distance score (+23 percentage points, p<0.001), the speed score (+22 percentage points, p<0.001), the stair climbing score (+18 percentage points, p<0.001) as well as the RAND physical function and bodily pain scores (+10 percentage points, p<0.001, and +13 percentage points, p<0.01, respectively) were still increased compared with baseline. No change from baseline was found in all the target parameters in the placebo group after 4 weeks of treatment and at the end of the treatment-free follow-up period. These data show that a 4-week treatment with PGE1 improves functional status and quality of life as well as treadmill performance in patients with disabling intermittent claudication as compared with placebo-treated patients. The improvements are also maintained for a period of 8 weeks beyond the end of the treatment. Additional studies are needed to determine the duration of functional benefits after the end of treatment.

The effects of successful intervention on quality of life in patients with varying degrees of lower-limb ischaemia

OBJECTIVES

to assess the quality of life after successful intervention among patients with varying degrees of lower-limb ischaemia in comparison with healthy controls and the respondents>> degree of sense of coherence.

MATERIALS AND METHODS

one hundred and twelve patients and 102 healthy controls were assessed for quality of life (Nottingham Health Profile) and sense of coherence.

MAIN RESULTS

successful angioplasty or surgical intervention led to an improved quality of life at 6 months, in particular with regard to pain, sleep, physical mobility, hobbies and holiday and to a level similar to healthy controls in sleep, social isolation, paid employment and family relationships. It remained at a significantly lower level than that of healthy controls with regard to pain, emotional reactions, physical mobility, energy, housework, hobbies, holidays, sex and social life. Critical ischaemia patients did not reach the same level of quality of life as the claudicants or the healthy controls.

CONCLUSION

successful treatment for chronic limb ischaemia improved the quality of life significantly, more so in claudicants than in patients with critical ischaemia. The degree to which the quality of life improved was associated with the patients>> sense of coherence and their ankle pressure.