Lower limb occlusive arterial disease in the North of England: workload and development of management guidelines. The Northern Regional Vascular Surgeons

Therapeutic approach to CLI with tissue loss--a comparative prospective cohort study in Finland and Japan

BACKGROUND

To compare the demographics, chosen treatment options, and 1-year outcome of patients with severe critical limb ischemia (Fontaine IV) in 2 different patient cohorts.

METHODS

A total of 118 consecutive patients with an ischemic tissue lesion in a lower extremity referred for the first time to the vascular surgery outpatient clinic of Helsinki University Hospital and 96 patients referred to the Division of Vascular Surgery of the Tokyo Medical and Dental University Hospital were included in this comparative analysis. Kaplan-Meier estimates were used to assess survival, leg salvage, and amputation-free survival (AFS). Propensity score analysis was used to adjust for differences between the study groups.

RESULTS

The median age of the study cohorts was greater in Finland than in Japan (80 vs. 69 years, P < 0.001). The prevalence of coronary artery disease and hypertension were greater in the Finnish cohort (72% vs. 41%, P < 0.001 and 86% vs. 51%, P < 0.001, respectively). The prevalence of male gender (77% vs. 42%, P < 0.001), cerebrovascular disease (35% vs. 20%, P = 0.015), end-stage renal disease (35% vs. 5%, P < 0.001), and current smoking (64% vs. 21%, P < 0.001) was greater in the Japanese cohort. The prevalence of diabetes did not differ between the cohorts (52% vs. 47%, P = 0.286). The proportion of independently ambulant patients at referral was greater in Finland (80% vs. 54%, P < 0.001). In Helsinki and Tokyo, the initial treatment was bypass, an endovascular procedure, conservative treatment, and amputation in 42% vs. 41%, 24% vs. 14%, 24% vs. 41%, and 10% vs. 5% of the cases, respectively. One-year survival, leg salvage, and AFS were 65% vs. 71% (P = 0.326), 82% vs. 74% (P = 0.216), and 59% vs. 55% (P = 0.573) in the Finnish and Japanese cohorts, respectively. AFS was significantly better in ambulant than in nonambulant patients in the combined data (68% vs. 36%, P < 0.001). Adjusted propensity score analysis showed no statistical difference in survival between the study cohorts.

CONCLUSIONS

The pattern of comorbid conditions in these 2 patient cohorts is significantly different, but the outcome did not differ significantly between cohorts.

The impact of diabetes on current revascularisation practice and clinical outcome in patients with critical lower limb ischaemia

OBJECTIVE

To compare current revascularisation practice and outcome in diabetic and non-diabetic patients presenting with critical limb ischaemia (CLI) to a single vascular surgeon.

METHODS

Data for 113 patients presenting with CLI were collected prospectively over a 3-year period. Forty-four (39%) were diabetic. Treatment was classified as percutaneous angioplasty, arterial reconstruction, primary major amputation, and conservative therapy. Main outcome measures were 30-day mortality, major amputation, survival, and amputation-free survival.

RESULTS

Diabetic patients were more likely to present with gangrene, give a history of angina, be treated with nitrates and statins, and have lower cholesterol levels. No significant differences were found in the initial treatment options between diabetics and non-diabetics: angioplasty 39 vs 26%, surgical revascularisation 34 vs 33%, primary major amputation 9% vs 17%, and conservative treatment 11 vs 19% (p = ns in all). There were eight deaths (7%) within 30-days. At follow-up (1-44 months, median 14 months), rates of major amputation and death for the entire population were 23 and 8%, respectively. The 12-month cumulative survival and amputation-free survival rates were 90 and 72%, respectively. When comparing diabetic to non-diabetic patients, there were no significant differences in the 30-day mortality (6.8 vs 7.2%, p = 0.4), cumulative survival (93 vs 89% at 12 months, log-rank test: 0.00, p = 0.9), amputation-free survival (71 vs 73% at 12 months, log-rank test: 0.00, p = 0.99), and major amputation rates (22.7 vs 23.1% at 12 months, p = 0.96). Similarly, there were no differences in limb salvage rates between diabetic and non-diabetic patients undergoing revascularisation procedures (78 vs 90% at 12 months, log-rank test: 2.04, p = 0.15).

CONCLUSIONS

In current practice, an aggressive multidisciplinary approach in diabetic patients presenting with CLI leads to similar limb salvage, amputation-free survival, mortality, and major amputation rates to those seen in non-diabetic patients. The presence of diabetes should not deter clinicians from attempting revascularisation by means of angioplasty or surgical reconstruction.

Bypass versus angioplasty to treat severe limb ischemia: factors that affect treatment preferences of UK surgeons and interventional radiologists

OBJECTIVE

There is continuing controversy as to whether surgical bypass or angioplasty should be first-line treatment of severe limb ischemia. We undertook this study to examine angiographic and clinical factors that influence the treatment of severe limb ischemia by vascular surgeons and interventional radiologists.

METHODS

Twenty consultant vascular surgeons and 17 consultant vascular interventional radiologists evaluated 596 hypothetical clinical or angiographic scenarios, and recorded whether, in their opinion, the most appropriate first-line treatment was surgical bypass, angioplasty, or primary amputation. Stepwise multiple linear regression was used to identify the factors that significantly affected responses from the entire group and from surgeons and radiologists separately.

RESULTS

There were significant differences between surgeons and radiologists with regard to how clinical and angiographic variables determined treatment preferences. Increasing disease severity, absence of runoff into the foot, presence of a suitable vein, and tissue loss as opposed to rest pain only (the latter only significant to surgeons) all increased the response score toward surgery. However, surgeons and radiologists weighted each of these factors quite differently. Even in the most complex statistical model, 19% of surgical and 13% of radiologic response variations remained unexplained.

CONCLUSIONS

Individual surgeons and radiologists vary considerably in their views of the relative merits of surgery and angioplasty in patients with severe limb ischemia. This broad gray area mandates the need for randomized controlled trial data to inform joint decision-making and to optimize patient outcome.