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Brahmandam A, Lee M, Bellamkonda K, Provance JB, Sumpio B, Ochoa Chaar CI, Smolderen KG, Mena-Hurtado C, Guzman RJ. Variability in Antithrombotic Therapy After Infrainguinal Lower Extremity Bypass. Ann Vasc Surg 2022; 88:51-62. [DOI: 10.1016/j.avsg.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/01/2022]
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Meloni M, Izzo V, Giurato L, Da Ros V, Morosetti D, Ferrannini M, Brocco E, Gandini R, Uccioli L. Peripheral arterial disease in patients with renal-diabetic foot ulcers. J Wound Care 2021; 30:660-664. [PMID: 34382847 DOI: 10.12968/jowc.2021.30.8.660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe the angiographic characteristics of peripheral arterial disease (PAD) in persons with diabetic foot ulcers (DFUs) on dialysis treatment. METHOD The study is a retrospective analysis of patients with DFUs and PAD who had been referred to our diabetic foot clinic. All patients had been managed by a pre-set limb salvage protocol including revascularisation of the affected limb. Arterial lesions (stenosis between 50-99% and occlusions) were retrospectively evaluated through angiogram analysis. According to the presence or not of dialysis, patients were divided into two patient groups: renal-diabetic foot (RDF) and diabetic foot (DF). Distribution of PAD and immediate revascularisation outcome (technical revascularisation outcome) for RDF and DF were separately reported and compared. RESULTS The sample included 239 patients: mean age was 71.8 years; 72.4% were male; 87.4% had type 2 diabetes; mean diabetes duration was 21.4 years; and the mean HbA1c was 63±22mmol/mol. The RDF group compared with the DF group reported higher numbers of vessels affected (n=5±1.6 versus 3.9±1.5, respectively, p<0.0001), greater involvement of the superficial femoral artery (90.2% versus 75.8%, respectively, p=0.003), the tibial-peroneal trunk (53.7% versus 25.5%, respectively, p=0.01), the anterior tibial artery (93.9% versus 80.9%, respectively, p=0.03) and below-the-ankle (BTA) arteries (70.7% versus 35.7%, respectively, p=0.0001). The RDF group showed a higher rate of revascularisation failure in comparison to DF patients (43.9% versus 15.3%, respectively, p<0.0001). BTA arterial disease (odds ratio 9.5; 95% Confidence Interval: 3.5-25.4; p=0.0001) resulted as the only independent predictor of revascularisation failure. CONCLUSION In this study, RDF patients showed a widespread distribution of arterial lesions with a higher involvement of foot arteries in comparison with DF patients. BTA arterial disease was found to be an independent predictor of revascularisation failure.
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Affiliation(s)
- Marco Meloni
- Diabetic Foot Unit, Department of Systems Medicine, University of Rome 'Tor Vergata', Italy
| | - Valentina Izzo
- Diabetic Foot Unit, Department of Systems Medicine, University of Rome 'Tor Vergata', Italy
| | - Laura Giurato
- Diabetic Foot Unit, Department of Systems Medicine, University of Rome 'Tor Vergata', Italy
| | - Valerio Da Ros
- Department of Interventional Radiology, University of Rome 'Tor Vergata', Italy
| | - Daniele Morosetti
- Department of Interventional Radiology, University of Rome 'Tor Vergata', Italy
| | - Michele Ferrannini
- Division of Hypertension and Nephrology, Department of Systems Medicine, University of Rome 'Tor Vergata', Italy
| | - Enrico Brocco
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Italy
| | - Roberto Gandini
- Department of Interventional Radiology, University of Rome 'Tor Vergata', Italy
| | - Luigi Uccioli
- Diabetic Foot Unit, Department of Systems Medicine, University of Rome 'Tor Vergata', Italy
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Rathnayake A, Saboo A, Malabu UH, Falhammar H. Lower extremity amputations and long-term outcomes in diabetic foot ulcers: A systematic review. World J Diabetes 2020; 11:391-399. [PMID: 32994867 PMCID: PMC7503503 DOI: 10.4239/wjd.v11.i9.391] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/06/2020] [Accepted: 08/15/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diabetes mellitus causes a large majority of non-traumatic major and minor amputations globally. Patients with diabetes are clinically complex with a multifactorial association between diabetic foot ulcers (DFU) and subsequent lower extremity amputations (LEA). Few studies show the long-term outcomes within the cohort of DFU-associated LEA.
AIM To highlight the long-term outcomes of LEA as a result of DFU.
METHODS PubMed/MEDLINE and Google Scholar were searched for key terms, “diabetes”, “foot ulcers”, “amputations” and “outcomes”. Outcomes such as mortality, re-amputation, re-ulceration and functional impact were recorded. Peer-reviewed studies with adult patients who had DFU, subsequent amputation and follow up of at least 1 year were included. Non-English language articles or studies involving children were excluded.
RESULTS A total of 22 publications with a total of 2334 patients were selected against the inclusion criteria for review. The weighted mean of re-amputation was 20.14%, 29.63% and 45.72% at 1, 3 and 5 years respectively. The weighted mean of mortality at 1, 3 and 5 years were 13.62%, 30.25% and 50.55% respectively with significantly higher rates associated with major amputation, re-amputation and ischemic cardiomyopathy.
CONCLUSION Previous LEA, level of the LEA and patient comorbidities were significant risk factors contributing to re-ulceration, re-amputation, mortality and depreciated functional status.
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Affiliation(s)
- Ayeshmanthe Rathnayake
- Department of Medicine, Townsville University Hospital, Townsville 4814, Queensland, Australia
| | - Apoorva Saboo
- Department of Medicine, Townsville University Hospital, Townsville 4814, Queensland, Australia
| | - Usman H Malabu
- Department of Medicine, Townsville University Hospital, Townsville 4814, Queensland, Australia
- Department of Medicine, Townsville University Hospital, Townsville 4814, Queensland, Australia
- School of Medicine and Dentistry, James Cook University, Townsville 4811, Queensland, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm 17176, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm 17176, Sweden
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Chou HH, Huang HL, Hsieh CA, Jang SJ, Tzeng IS, Ko YL. Drug-Coated Balloon vs. Conventional Balloon Angioplasty in Dialysis Patients With Symptomatic Femoropopliteal Disease - A Matched Comparison. Circ J 2018; 82:1908-1916. [PMID: 29695655 DOI: 10.1253/circj.cj-18-0077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Recent randomized trials have shown the treatment benefits of use of a drug-coated balloon (DCB) over conventional percutaneous transluminal angioplasty (PTA) in patients with femoropopliteal disease. However, the effectiveness and safety of DCB for dialysis patients remain unclear.Methods and Results:Consecutive dialysis patients, who underwent PTA or DCB for femoropopliteal disease, were assessed retrospectively via 2:1 propensity score matching. Effectiveness and safety endpoints, including binary restenosis, clinically driven target lesion revascularization (CD-TLR), amputations, major adverse cardiac events (MACE), and deaths, were compared between groups. A total of 278 dialysis patients with 339 limbs were eligible for matching: 84 limbs from 77 patients treated with PTA and 46 limbs from 37 patients treated with DCB were compared after matching. Baseline patient and lesion characteristics were not different between groups. Patients treated with DCB had significantly higher rates of freedom from binary restenosis (52.4% vs. 18.6%, P<0.001) and CD-TLR (56.4% vs. 25.9%, P=0.001) at 2 years compared with patients treated with PTA. Both groups had similar outcomes for amputation, MACE, and death. Cox proportional analysis showed that treatment with DCB was independently associated with a reduction of binary restenosis (hazard ratio [HR] 0.368, P=0.001) and CD-TLR (HR 0.390, P=0.004). CONCLUSIONS This study suggested superior 2-year outcomes using DCB compared with PTA and similar safety profiles in dialysis patients with femoropopliteal disease.
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Affiliation(s)
- Hsin-Hua Chou
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation.,School of Medicine, Tzu Chi University
| | - Hsuan-Li Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation.,School of Medicine, Tzu Chi University
| | - Chien-An Hsieh
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Shih-Jung Jang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - I-Shiang Tzeng
- Department of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Yu-Lin Ko
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation.,School of Medicine, Tzu Chi University
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Meloni M, Izzo V, Giurato L, Cervelli V, Gandini R, Uccioli L. Impact of heart failure and dialysis in the prognosis of diabetic patients with ischemic foot ulcers. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2018; 11:31-35. [PMID: 29686969 PMCID: PMC5910511 DOI: 10.1016/j.jcte.2018.01.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/20/2018] [Accepted: 01/21/2018] [Indexed: 11/25/2022]
Abstract
Aim To establish the role of heart failure (HF) and dialysis (D) in the prognosis of diabetic patients with critical limb ischemia and foot ulcers (FUs). Methods Consecutive diabetic patients with ischemic FUs who referred to our Diabetic Foot Centre were prospectively included. All patients underwent a preset limb salvage protocol including peripheral revascularization. According to the presence of HF and D, they were divided in four groups: group 1 without HF and without D defined as ischemic foot (IF); group 2 with HF and without D defined as heart ischemic foot (H-IF); group 3 without HF and with D defined as renal ischemic foot (R-IF); group 4 with HF and with dialysis defined as heart-renal foot (HR-IF). Survival with limb salvage, survival with major amputation and death were reported after 1 year of follow-up. Results 136 patient have been included: 66 with IF, 26 with H-IF, 24 with R-IF and 20 with HR-IF. The mean age was 68,9 ± 9,7 years, the diabetes duration 20,7 ± 11,6 years, the mean HbA1c 62,7 ± 22,3 mmol/mol. 103/136 (75,7%) survived with limb salvage, 10/136 (7,4%) survived with major amputation, 23/136 (16,9%) died. The outcomes for group IF patients, H-IF, R-IF and HR-IF were respectively: survival with limb salvage (92,4%, 61,5%, 79,2% and 35%), survival with major amputation (6,1%, 7,7%, 8,3% and 10%), death (1,5%, 30,8%, 12,5% and 55%) χ = 0.0001. Heart failure was an independent predictor of death. Discussion The presence of heart failure and dialysis in diabetic patients with ischemic foot ulcers was associated to high risk of amputation and mortality.
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Affiliation(s)
- Marco Meloni
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Valentina Izzo
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Laura Giurato
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Valerio Cervelli
- Plastic Surgery, Department of Plastic and Reconstructive Surgery, University of Tor Vergata, Rome, Italy
| | - Roberto Gandini
- Department of Interventional Radiology and Neuroradiology, University of Tor Vergata, Rome, Italy
| | - Luigi Uccioli
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
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Shiraki T, Iida O, Takahara M, Soga Y, Mii S, Okazaki J, Kuma S, Yamaoka T, Kamoi D, Shintani Y, Ishikawa T, Kitano I, Uematsu M. Comparison of Clinical Outcomes after Surgical and Endovascular Revascularization in Hemodialysis Patients with Critical Limb Ischemia. J Atheroscler Thromb 2017; 24:621-629. [PMID: 27733731 PMCID: PMC5453687 DOI: 10.5551/jat.35915] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 09/14/2016] [Indexed: 11/11/2022] Open
Abstract
AIM The treatment strategy for hemodialysis (HD) patients with critical limb ischemia (CLI) has been clinically debatable. Here we compared clinical outcomes after bypass surgery (BSX) and after endovascular therapy (EVT) using propensity score matching. METHODS A retrospective multicenter database of 246 (68 BSX and 178 EVT) consecutive HD patients with CLI (79% with tissue loss) who underwent infrainguinal revascularization from 2007 to 2009 was used to compare clinical outcomes, including overall survival (OS), major amputation (MA), major adverse limb event (MALE: repeat EVT, surgical reconstruction, or MA), and MALE-free survival after BSX vs. EVT using propensity score matching. RESULTS The median (interquartile range) follow-up duration after revascularization was 21 (8-33) months. The analysis of the 63 propensity score-matched pairs revealed no significant difference in OS (53% vs. 52%, P=0.96), MA (25% vs. 14%, P=0.71), MALE (42% vs. 58%, P=0.63), and MALE-free survival (33% vs. 11%, P=0.37) at 3 year after BSX vs. EVT. CONCLUSIONS In HD patients with CLI who underwent infrainguinal revascularization, OS, MA, MALE, and MALE-free survival rates were not significantly different after EVT vs. BSX. The less invasive EVT should be considered as the first-choice therapeutic strategy for HD patients with CLI.
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Affiliation(s)
- Tatsuya Shiraki
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Osamu Iida
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Shinsuke Mii
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan
| | - Jin Okazaki
- Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Sosei Kuma
- Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Daisuke Kamoi
- Department of Cardiology, Nagoya Kyoritsu Hospital, Nagoya, Japan
| | | | | | - Ikuro Kitano
- Department of Surgery, Shinsuma General Hospital, Kobe, Japan
| | - Masaaki Uematsu
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
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Moon HG, Cho SC, Jeong SW, Lee GI, Jo YE, Youn B, Kang WY, Hwang SH, Kim W, Kim W. Early versus late thrombolysis in acute arterial occlusion of lower extremity. Int J Cardiol 2016; 228:86-89. [PMID: 27863366 DOI: 10.1016/j.ijcard.2016.10.112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/30/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute arterial occlusion in lower extremity is an urgent condition which occurs when there is an abrupt interruption of blood flow into an extremity. Reperfusion through early intervention can increase limb salvage and decrease mortality. There was no common agreement when is the best to start thrombolysis in treating acute arterial occlusion. This study was designed to study the efficacy of an early thrombolysis compared with a late thrombolysis. METHOD We identified all patients discharged from the Gwangju Veterans hospital with a diagnosis of acute arterial occlusion between 2006 and 2014. 72 patients were eligible, and every patient had treated with catheter-directed thrombolysis on the day or 1day after admission. Among them, 42 patients had undergone an early thrombolysis (less than 7days after the onset of symptoms) and the other 30 patients had undergone a late thrombolysis (more than 7days after the onset of symptoms). The primary outcome was amputation rate at 6months. The secondary outcomes were all cause mortality at 6months and increase of ankle brachial index (ABI). RESULTS Amputation rate at 180days in the early thrombolysis group was 7.1% as compared with 30% in the late thrombolysis group. All cause mortality at 6months and increase of ABI were not different between two groups. In multivariable Cox-regression analysis, late thrombolysis was independent predictor of amputation at 6months. CONCLUSION Early thrombolysis was superior in preventing amputation than late thrombolysis.
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Affiliation(s)
- Hyun Gee Moon
- Department of Cardiology, Gwangju Veterans Hospital, Gwangju, Korea
| | - Sang Cheol Cho
- Department of Cardiology, Gwangju Veterans Hospital, Gwangju, Korea.
| | - Sang Woo Jeong
- Department of Cardiology, Gwangju Veterans Hospital, Gwangju, Korea
| | - Gyu Ik Lee
- Department of Cardiology, Gwangju Veterans Hospital, Gwangju, Korea
| | - Young Eun Jo
- Department of Cardiology, Gwangju Veterans Hospital, Gwangju, Korea
| | - Boram Youn
- Department of Cardiology, Gwangju Veterans Hospital, Gwangju, Korea
| | - Won Yu Kang
- Department of Cardiology, Gwangju Veterans Hospital, Gwangju, Korea
| | - Sun Ho Hwang
- Department of Cardiology, Gwangju Veterans Hospital, Gwangju, Korea
| | - Wan Kim
- Department of Cardiology, Gwangju Veterans Hospital, Gwangju, Korea
| | - Weon Kim
- Department of Cardiology, Kyung Hee University Hospital, Seoul, Korea
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Townley WA, Carrell TWG, Jenkins MP, Wolfe JHN, Cheshire NJW. Critical Limb Ischemia in the Dialysis-Dependent Patient: Infrainguinal Vein Bypass Is Justified. Vasc Endovascular Surg 2016; 40:362-6. [PMID: 17038569 DOI: 10.1177/1538574406293739] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The combination of critical limb ischemia and end-stage renal failure (ESRF, ie, dialysis- dependent) represents severe systemic atherosclerosis and is associated with a very poor medium-term survival. Many nephrologists and surgeons advocate primary amputation. We examined the recent experience in this unit to determine whether infrainguinal bypass in these patients can be justified. Retrospective study of all patients with critical limb ischemia and ESRF undergoing surgery in a regional vascular and renal unit between January 1996 and May 2003. Forty-two patients with ESRF (median age 65 years) were referred with critical limb ischemia. Seventeen patients underwent 24 (7 bilateral) infrainguinal bypasses (17 autologous vein, 7 polytetrafluoroethylene [PTFE] conduit; tissue loss in 21/24, 88%), and 25 patients had primary major amputations of 32 limbs. Early occlusion occurred in 5 grafts (21%, all 5/5 PTFE). In-hospital mortality was 13% in the bypass group, 24% in the amputation group. Median in-hospital stay was 59 days in the bypass group, 46 days in the amputation group. Thirty-day, 1- and 2-year survival was 88%, 50%, and 33% in the bypass group; 83%, 39%, and 35% in the amputation group. The limb salvage rate was 66% at 1 year. Seventy-five percent (18/24) of operated on limbs (15/17 of vein grafts) avoided major amputation at follow-up (median 18 months) or death. The combination of critical limb ischemia and end- stage renal failure carries a poor medium-term survival independent of primary amputation or surgical revascularization. Infrainguinal bypass in selected cases with vein conduit can, however, allow the majority of these patients to avoid major limb amputation.
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Meloni M, Giurato L, Izzo V, Stefanini M, Pampana E, Gandini R, Uccioli L. Long term outcomes of diabetic haemodialysis patients with critical limb ischemia and foot ulcer. Diabetes Res Clin Pract 2016; 116:117-22. [PMID: 27321326 DOI: 10.1016/j.diabres.2016.04.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 03/23/2016] [Accepted: 04/18/2016] [Indexed: 01/28/2023]
Abstract
AIM To evaluate the outcomes of diabetic dialysis patients with critical limb ischemia and foot ulcer. METHODS The study group included 599 diabetic, 99 dialyzed (Ds) (16.5%) and 500 not dialyzed (NDs) (83%) patients with critical limb ischemia and foot ulcers identified as stage C (ischemia) or D (ischemia plus infection) of Texas Wound Classification. All patients were treated by endovascular revascularization. Outcomes were expressed as healing, major amputation, death and non healing after 12months. The mean follow-up was 15±13months. RESULTS The outcomes of the whole population were: 48.9% healing, 11.3% major amputation, 12.7% death, 27.1 non healing. At the multivariate analysis dialysis was a negative predictor of healing and a positive predictor of major amputation. Outcomes for Ds and NDs were respectively: healing (30.3 vs 52.6%), major amputation (14.4 vs 10.8%), death (21.1 vs 11%) and non-healing (34.2 vs 25.6%) (X=0.0004). Amputation occurred earlier in Ds than in NDs. According to the multivariate analysis in Ds ischemic heart disease and lower ΔTcPO2 were negative predictors for healing. Successful revascularization was a negative predictor for major amputation. HDL and carotid artery disease were predictive factors of death among NDs. Among Ds high blood pressure values were the only predictor of amputation while no variable resulted predictive of healing or death. CONCLUSIONS Our study shows that our limb salvage protocol ensures a good rate of limb salvage in Ds even if they have a higher risk of amputation and death compared to NDs.
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Affiliation(s)
- Marco Meloni
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy.
| | - Laura Giurato
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Valentina Izzo
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | | | - Enrico Pampana
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Roberto Gandini
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy
| | - Luigi Uccioli
- University of Tor Vergata, Viale Oxford 81, Rome 00133, Italy
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Shiraki T, Iida O, Takahara M, Soga Y, Mii S, Okazaki J, Kuma S, Yamaoka T, Kamoi D, Shintani Y, Ishikawa T, Kitano I, Uematsu M. Predictors of 2-Year Mortality and Risk Stratification After Surgical or Endovascular Revascularization of Infrainguinal Artery Disease in Hemodialysis Patients With Critical Limb Ischemia. J Endovasc Ther 2015; 22:719-24. [PMID: 26276552 DOI: 10.1177/1526602815599413] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To examine the 2-year mortality in hemodialysis (HD) patients with critical limb ischemia (CLI) and determine predictors that may aid in the selection of a revascularization strategy [bypass surgery or endovascular therapy (EVT)] according to current guidelines. METHODS From 2007 to 2009, 246 consecutive CLI patients (mean age 69±10 years; 170 men) on HD underwent revascularization for de novo infrainguinal lesions (178 EVT and 68 bypass grafting). The majority of the patients had diabetes (170, 69%) and tissue loss (194, 79%); nearly half (111, 45%) were nonambulatory. Overall survival after revascularization was estimated by Kaplan-Meier analysis. Predictors for 2-year mortality after revascularization were determined using a Cox proportional hazards model; results are given as the hazard ratio (HR) and 95% confidence interval (CI). RESULTS Overall survival rate was 77% at 1 year and 66% at 2 years. Predictors of 2-year mortality after revascularization were age >75 years (HR 1.82, 95% CI 1.14 to 2.91, p=0.012), albumin <3 g/dL (HR 2.31, 95% CI 1.39 to 3.84, p=0.001), and ejection fraction <50% (HR 1.73, 95% CI 1.06 to 2.83, p=0.027). Patients with more predictors had a higher incidence of death within 2 years after revascularization. CONCLUSION Advanced age, low albumin level, and low ejection fraction were independently associated with 2-year mortality after revascularization in HD patients with CLI. Risk stratification by these factors would be useful for deciding on a revascularization strategy.
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Affiliation(s)
- Tatsuya Shiraki
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Osamu Iida
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Mitsuyoshi Takahara
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Shinsuke Mii
- Department of Vascular Surgery, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Jin Okazaki
- Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Sosei Kuma
- Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Daisuke Kamoi
- Department of Cardiology, Nagoya Kyoritsu Hospital, Nagoya, Japan
| | | | | | - Ikuro Kitano
- Department of Surgery, Shinsuma General Hospital, Kobe, Japan
| | - Masaaki Uematsu
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
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Huang TY, Huang TS, Wang YC, Huang PF, Yu HC, Yeh CH. Direct Revascularization With the Angiosome Concept for Lower Limb Ischemia: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2015; 94:e1427. [PMID: 26313796 PMCID: PMC4602934 DOI: 10.1097/md.0000000000001427] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The angiosome concept provides practical information regarding the vascular anatomy of reconstructive and vascular surgery for the treatment of peripheral arterial occlusive disease and, particularly, critical lower limb ischemia.The aim of the study was to confirm the efficacy of direct revascularization with the angiosome concept (DR) for lower limb ischemia.Complementary manual searches were performed through the Pubmed, Cochrane Library, and EMBASE databases.We searched all randomized and nonrandomized studies (NRSs) comparing DR with indirect revascularization (IR) (without the angiosome concept) for lower limb ischemia. Only 9 nonrandomized controlled retrospective cohort studies were found and included. Trials published in any language were included.Primary endpoints were time to limb amputation and time to wound healing. Data extraction and trial quality assessment were performed by two authors independently. A third author was consulted for disagreements settlement and quality assurance.Five NRSs involving 779 lower limbs revealed that DR significantly improved the overall survival of limbs (hazard ratio [HR] 0.61; 95% confidence interval [CI] = 0.46-0.80; P < 0.001; I = 0%). In addition, DR significantly improved time to wound healing (HR 1.38; 95% CI = 1.13-1.69; P = 0.002; I = 0%, in 5 studies including 605 limbs).All included studies were retrospective comparative studies, and no consensus was obtained in describing wound conditions in the included studies.Our results suggested that treatment of lower limb ischemia using DR is more effective in salvaging limbs and healing wounds than IR is. Additional randomized controlled studies are necessary to confirm these results.
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Affiliation(s)
- Tzu-Yen Huang
- From the Department of Thoracic and Cardiovascular Surgery (T-YH, Y-CW, P-FH, C-HY), Chang Gung Memorial, Hospital, Keelung; College of Medicine (T-YH, T-SH, C-HY), Chang Gung University, Tao-Yuan; Department of General Surgery (T-SH), Chang Gung Memorial Hospital, Keelung; and Department of Nursing (H-CY), Chang Gung Memorial Hospital, Keelung, Taiwan, ROC
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Kodama A, Sugimoto M, Kuma S, Okazaki J, Mii S, Komori K. Clinical Outcomes After Infrainguinal Bypass Grafting for Critical Limb Ischaemia in Patients with Dialysis-dependent End-stage Renal Failure. Eur J Vasc Endovasc Surg 2014; 48:695-702. [DOI: 10.1016/j.ejvs.2014.08.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 08/20/2014] [Indexed: 11/26/2022]
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13
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The Risk of Major Elective Vascular Surgical Procedures in Patients With End-Stage Renal Disease. Ann Surg 2013; 257:766-73. [DOI: 10.1097/sla.0b013e3182686b87] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Giurato L, Gandini R, Meloni M, Pampana E, Ruotolo V, Izzo V, Fabiano S, Giudice CD, Uccioli L. Percutaneous Angioplasty in Diabetic Patients with Critical Limb Ischemia and Chronic Kidney Disease. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/ojemd.2013.33028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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15
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Peña-Cortés R, Sanz-Pastor N, Fernández-Samos R, Alonso-Argüeso G, Ortega-Martín J, Vaquero-Morillo F. Tratamiento de la isquemia crítica de las extremidades inferiores. Cirugía distal y endovascular. ANGIOLOGIA 2012. [DOI: 10.1016/j.angio.2012.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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16
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Hirakata H, Nitta K, Inaba M, Shoji T, Fujii H, Kobayashi S, Tabei K, Joki N, Hase H, Nishimura M, Ozaki S, Ikari Y, Kumada Y, Tsuruya K, Fujimoto S, Inoue T, Yokoi H, Hirata S, Shimamoto K, Kugiyama K, Akiba T, Iseki K, Tsubakihara Y, Tomo T, Akizawa T. Japanese Society for Dialysis Therapy Guidelines for Management of Cardiovascular Diseases in Patients on Chronic Hemodialysis. Ther Apher Dial 2012; 16:387-435. [DOI: 10.1111/j.1744-9987.2012.01088.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Azuma N, Uchida H, Kokubo T, Koya A, Akasaka N, Sasajima T. Factors Influencing Wound Healing of Critical Ischaemic Foot after Bypass Surgery: Is the Angiosome Important in Selecting Bypass Target Artery? Eur J Vasc Endovasc Surg 2012; 43:322-8. [DOI: 10.1016/j.ejvs.2011.12.001] [Citation(s) in RCA: 157] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 12/05/2011] [Indexed: 11/15/2022]
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Lepäntalo M, Fiengo L, Biancari F. Peripheral arterial disease in diabetic patients with renal insufficiency: a review. Diabetes Metab Res Rev 2012; 28 Suppl 1:40-5. [PMID: 22271722 DOI: 10.1002/dmrr.2233] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Peripheral arterial disease is common among diabetic patients with renal insufficiency, and most of the diabetic patients with end-stage renal disease (ESRD) have peripheral arterial disease. Ischaemia is probably overrepresented as an etiological factor for a diabetic foot ulcer in this group of patients compared with other diabetic patients. ESRD is a strong risk factor for both ulceration and amputation in diabetic patients. It increases the risk of nonhealing of ulcers and major amputation with an OR of 2.5-3. Renal disease is a more important predictor of poor outcome after revascularizations than commonly expected. Preoperative vascular imaging is also affected by a number of limitations, mostly related to side effects of contrast agents poorly eliminated because of kidney dysfunction. Patients with renal failure have high perioperative morbidity and mortality. Persistent ischaemia, extensive infection, forefoot and heel gangrene, poor run-off, poor cardiac function, and the length of dialysis-dependent renal failure all affect the outcome adversely. Despite dismal overall outcome, recent data indicate that by proper selection, favourable results can be obtained even in ESRD patients, with the majority of studies reporting 1-year limb salvage rates of 65-75% after revascularization among survivors. High 1-year mortality of 38% reported in a recent review has to be taken into consideration, though. The preferential use of endovascular-first approach is attractive in this vulnerable multimorbid group of patients, but the evidence for endovascular treatment is very scarce. The need for complete revascularization of the foot may be even more important than in other patients with ischaemic ulcerated diabetic foot because there are a number of factors counteracting healing in these patients. Typically, half of the patients are reported to lose their legs despite open bypass. To control tissue damage and improve chances of ulcer healing, one should understand that early referral to vascular consultation is necessary.
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Affiliation(s)
- Mauri Lepäntalo
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland.
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Engelhardt M, Boos J, Bruijnen H, Wohlgemuth W, Willy C, Tannheimer M, Wölfle K. Critical Limb Ischaemia: Initial Treatment and Predictors of Amputation-free Survival. Eur J Vasc Endovasc Surg 2012; 43:55-61. [DOI: 10.1016/j.ejvs.2011.09.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 09/09/2011] [Indexed: 10/16/2022]
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Simons JP, Goodney PP, Nolan BW, Cronenwett JL, Messina LM, Schanzer A. Failure to achieve clinical improvement despite graft patency in patients undergoing infrainguinal lower extremity bypass for critical limb ischemia. J Vasc Surg 2010; 51:1419-24. [PMID: 20456908 DOI: 10.1016/j.jvs.2010.01.083] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2009] [Revised: 01/26/2010] [Accepted: 01/26/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Studies of infrainguinal lower extremity bypass for critical limb ischemia (CLI) have traditionally emphasized outcomes of patency, limb salvage, and death. Because functional outcomes are equally important, our objectives were to describe the proportion of CLI patients who did not achieve symptomatic improvement 1 year after bypass, despite having patent grafts, and identify preoperative factors associated with this outcome. METHODS The prospectively collected Vascular Study Group of Northern New England database was used to identify all patients with elective infrainguinal lower extremity bypass for CLI (2003 to 2007) for whom long-term follow-up data were available. The primary composite study end point was clinical failure at 1 year after bypass, defined as amputation or persistent or worsened ischemic symptoms (rest pain or tissue loss), despite a patent graft. Variables identified on univariate screening (inclusion threshold, P < .20) were included in a multivariable logistic regression model to identify independent predictors. RESULTS Long-term follow-up data were available for 1012 patients who underwent infrainguinal bypasses for CLI, of which 788 (78%) remained patent at 1 year. Of these, 79 (10%) met criteria for the composite end point of clinical failure: 21 (2.7%) for major amputations and 58 (7.4%) for persistent rest pain or tissue loss. In multivariable analysis, significant predictors of clinical failure included dialysis dependence (odds ratio [OR], 3.74; 95% confidence interval [CI], 1.84-7.62; P < .001) and preoperative inability to ambulate independently (OR, 2.17; 95% CI, 1.26-3.73; P = .005). A history of coronary artery bypass graft or percutaneous coronary intervention was protective (OR, 0.52; 95% CI, 0.29-0.93; P = .03). CONCLUSIONS After infrainguinal lower extremity bypass for CLI, 10% of patients with a patent graft did not achieve clinical improvement at 1 year. Preoperative identification of this specific patient subgroup remains challenging. To improve surgical decision making and the overall care of CLI patients, further emphasis needs to be placed on functional outcomes in addition to traditional surgical end points.
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Affiliation(s)
- Jessica P Simons
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass 01655, USA
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21
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Loor G, Skelly CL, Wahlgren CM, Bassiouny HS, Piano G, Shaalan W, Desai TR. Is atherectomy the best first-line therapy for limb salvage in patients with critical limb ischemia? Vasc Endovascular Surg 2009; 43:542-50. [PMID: 19640919 DOI: 10.1177/1538574409334825] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the efficacy of atherectomy for limb salvage compared with open bypass in patients with critical limb ischemia. METHODS Ninety-nine consecutive bypass and atherectomy procedures performed for critical limb ischemia between January 2003 and October 2006 were reviewed. RESULTS A total of 99 cases involving TASC C (n = 43, 44%) and D (n = 56, 56%) lesions were treated with surgical bypass in 59 patients and atherectomy in 33 patients. Bypass and atherectomy achieved similar 1-year primary patency (64% vs 63%; P = .2). However, the 1-year limb salvage rate was greater in the bypass group (87% vs 69%; P = .004). In the tissue loss subgroup, there was a greater limb salvage rate for bypass patients versus atherectomy (79% vs 60%; P = .04). CONCLUSIONS Patients with critical limb ischemia may do better with open bypass compared with atherectomy as first-line therapy for limb salvage.
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Affiliation(s)
- Gabriel Loor
- Department of Vascular Surgery, University of Chicago, Chicago, Illinois, USA
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22
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Komai H, Shibata R, Juri M, Matsushita K, Ouchi N, Murohara T. Plasma adiponectin as a predictive factor of survival after a bypass operation for peripheral arterial disease. J Vasc Surg 2009; 50:95-9. [PMID: 19563957 DOI: 10.1016/j.jvs.2008.12.044] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Revised: 11/28/2008] [Accepted: 12/19/2008] [Indexed: 12/01/2022]
Abstract
OBJECTIVE We investigated an association between adiponectin and long-term survival in patients requiring an arterial bypass operation for peripheral arterial disease. METHODS An enzyme-linked immunosorbent assay kit was used to measure plasma adiponectin levels in 49 patients (38 men, 11 women) before they underwent an arterial bypass operation. Median patient age was 70 years (range, 49-90 years). The study excluded patients with hemodialysis requirement, heart failure, malignant neoplasm, or collagen disease. The symptoms at the first visit were severe intermittent claudication in 27 patients (55%) and critical limb ischemia with rest pain or ulcer, or both, in 22 (45%). RESULTS Plasma adiponectin levels were a mean 7.8 +/- 5.3 microg/mL (range, 1.0-25.2 microg/mL). Multiple regression analyses revealed that plasma adiponectin was positively correlated with age (r = 0.49, P = .0003) and negatively correlated with body mass index (r = -0.51, P = .0002) and systolic blood pressure (r = -0.41, P = .0059). The Cox proportional hazards model revealed that plasma adiponectin (hazard ratio, 1.30; P = .03) and critical limb ischemia (hazard ratio, 16.67; P = .047) were significant independent predictors of patient survival after a bypass operation. CONCLUSION Plasma adiponectin could be indicative of mortality after a bypass operation for patients with advanced peripheral arterial disease.
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Affiliation(s)
- Hiroyoshi Komai
- Department of Cardiovascular Surgery, Saiseikai Wakayama Hospital, Wakayama, Japan.
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23
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Owens CD, Ho KJ, Kim S, Schanzer A, Lin J, Matros E, Belkin M, Conte MS. Refinement of survival prediction in patients undergoing lower extremity bypass surgery: stratification by chronic kidney disease classification. J Vasc Surg 2007; 45:944-52. [PMID: 17391900 DOI: 10.1016/j.jvs.2007.01.025] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Accepted: 01/05/2007] [Indexed: 01/28/2023]
Abstract
OBJECTIVE End-stage renal disease (ESRD) imparts a significant survival disadvantage to individuals undergoing lower extremity revascularization; however, the influence of lesser degrees of renal impairment remains unclear. This study examined the prognostic significance of the chronic kidney disease (CKD) classification on survival, limb salvage, and graft patency in patients undergoing lower extremity arterial reconstruction. METHODS A prospective registry was evaluated for consecutive patients between January 31, 1995, and December 21, 2004, undergoing first-time, lower extremity vein bypass surgery. Glomerular filtration rate (GFR) was estimated with the Modification of Diet in Renal Disease equation using each patient's preoperative creatinine concentration. CKD categories were taken from current National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria. RESULTS The cohort included 456 subjects, with a mean (+/- SD) age of 68.1 +/- 10.8 years. There were 274 men (60%) and 378 Caucasians (82.5%). Comorbidities included diabetes mellitus in 270 (59.0%), hypertension in 333 (72.7%), coronary artery disease in 242 (52.8%), and dyslipidemia in 203 (44.5%). The surgical indication was critical limb ischemia in 384 (83.8%). Among the variables examined, diabetes and critical ischemia as the indication for bypass were significantly skewed toward higher CKD classifications (P < .001). The 5-year survival rates by CKD class were, CKD 1 and 2, 57%; CKD 3, 46%; CKD 4, 23%; and CKD 5, 9.5%. On univariate analysis, age, coronary artery disease, diabetes mellitus, hypertension, critical ischemia, and CKD were significant predictors of mortality. After adjustment, however, only age (hazard ratio [HR], 1.05, 95% confidence interval [CI], 1.03 to 1.06) and CKD stages 4 (HR, 4.23; 95% CI, 2.04 to 8.75) and 5 (HR, 3.27; 95% CI, 1.96 to 5.45) retained significance. Subjects within the CKD 5 classification were more likely to have a major amputation (P = .018) compared with all other CKD classes. Notably, no relationship was detected between CKD category and graft patency. CONCLUSION CKD staging adequately differentiates survival curves and risk for major amputation among patients with renal impairment who are undergoing lower extremity bypass surgery. This may help in clinical decision analysis as well as in the refinement of stratification in future clinical trial design where survival is an end point.
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Affiliation(s)
- Christopher D Owens
- Division of Vascular Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
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Albers M, Romiti M, De Luccia N, Brochado-Neto FC, Nishimoto I, Pereira CAB. An updated meta-analysis of infrainguinal arterial reconstruction in patients with end-stage renal disease. J Vasc Surg 2007; 45:536-42. [PMID: 17257801 DOI: 10.1016/j.jvs.2006.11.036] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2006] [Accepted: 11/13/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND A previous meta-analysis reported on the mid-term outcomes of infrainguinal bypass grafts in patients with critical limb ischemia and end-stage renal disease. Given the competing interest in endovascular procedures, the results of bypass surgery must be assessed as precisely as possible for future comparison. In this study, the original meta-analysis was refined and updated by increasing the number of studies reviewed, estimating primary graft patency, extending follow-up time, and investigating the problem of early amputation despite a patent graft. METHODS Studies published from 1987 through 2005 were identified from two electronic databases. Two investigators independently extracted the survival data from life tables, survival curves, and texts. Pooled survival curves were then constructed for graft patency, limb salvage, and patient survival according to a random-effects protocol for meta-analysis. RESULTS Of 28 articles included, 18 reported amputation despite a patent graft in 84 (10%) out of 844 limbs, and 25 described a perioperative mortality of 88 (8.8%) out of 996 patients. The 5-year pooled estimate (SE) was 50.4% (15.4%) for primary patency, 50.8% (19.0%) for secondary patency, 66.6% (11.2%) for limb salvage, and 23.0% (11.7%) for patient survival. No publication bias was detected. CONCLUSIONS Limb salvage can be achieved in most end-stage renal disease patients who undergo bypass surgery for critical ischemia, but survival is poor. To avoid early amputation despite a patent graft, bypass grafting should not be offered to patients with a great amount of tissue loss or extensive infection.
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Affiliation(s)
- Maximiano Albers
- Vascular Surgery Section, Department of Surgery, Health and Medical Sciences Sector, Lusiada Foundation (UNILUS), Santos, SP, Brazil.
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Garg AX, Iansavichus AV, Kastner M, Walters LA, Wilczynski N, McKibbon KA, Yang RC, Rehman F, Haynes RB. Lost in publication: Half of all renal practice evidence is published in non-renal journals. Kidney Int 2006; 70:1995-2005. [PMID: 17035946 DOI: 10.1038/sj.ki.5001896] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Physicians often scan a select number of journals to keep up to date with practice evidence for patients with kidney conditions. This raises the question of where relevant studies are published. We performed a bibliometric analysis using 195 renal systematic reviews. Each review used a comprehensive method to identify all primary studies for a focused clinical question relevant to patient care. We compiled all the primary studies included in these reviews, and considered where each study was published. Of the 2779 studies, 1351 (49%) were published in the top 20 journals. Predictably, this list included Transplantation Proceedings (5.9% of studies), Kidney International (5.3%), American Journal of Kidney Diseases (4.7%), Nephrology Dialysis Transplantation (4.3%), Transplantation (4.2%), and Journal of the American Society of Nephrology (2.4%). Ten non-renal journals were also on this list, including New England Journal of Medicine (2.4%), Lancet (2.3%), and Diabetes Care (2.2%). The remaining 1428 (51%) studies were published across other 446 journals. When the disciplines of all journals were considered, 59 were classified as renal or transplant journals (42% of articles). Other specialties included general and internal medicine (16%), endocrinology (diabetes) and metabolism (6.5%), surgery (6.2%), cardiovascular diseases (6.1%), pediatrics (4.3%), and radiology (3.3%). About half of all renal practice evidence is published in non-renal journals. Browsing the top journals is important. However, relevant studies are also scattered across a large range of journals that may not be routinely scanned by busy physicians, and keeping up with this literature requires other continuing education strategies.
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Affiliation(s)
- A X Garg
- Division of Nephrology, University of Western Ontario, London, Ontario, Canada.
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Engelhardt M, Bruijnen H, Scharmer C, Jezdinsky N, Wölfle K. Improvement of Quality of Life Six Months After Infrageniculate Bypass Surgery: Diabetic Patients Benefit Less than Non-Diabetic Patients. Eur J Vasc Endovasc Surg 2006; 32:182-7. [PMID: 16567116 DOI: 10.1016/j.ejvs.2006.02.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2005] [Accepted: 02/01/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The aim of the study was to assess the change in health related quality of life (HRQoL) after infrageniculate bypass grafting in patients with critical limb ischaemia (CLI). DESIGN Observational, prospective clinical study. MATERIALS AND METHODS In total, 86 patients (72% male; age 71 (IQR, 64-78) years) undergoing infrageniculate bypass grafting for limb salvage were assessed by the short form (SF)-36 questionnaire before and 6 months after surgery. In subgroup analysis, the influence of diabetes mellitus, age, gender, and stage of peripheral arterial occlusive disease on HRQoL-outcome were assessed. RESULTS Following revascularization HRQoL significantly improved in all eight dimensions of the SF-36. While baseline HRQoL-values of diabetic and non-diabetic patients did not differ significantly, postoperative improvement was significantly less in the diabetes group. CONCLUSIONS An aggressive approach towards infrageniculate bypass surgery for limb salvage is justified by quality of life improvement. However, this improvement tends to be less in patients with diabetes mellitus.
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Affiliation(s)
- M Engelhardt
- Division of Vascular Surgery, Department of Surgery, Military Hospital Ulm, Ulm/Donau, Germany.
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Goulet S, Trepman E, Mmath MC, Koulack J, Fong H, Duerksen F, Martin B, Simonsen JN, Nicolle L, Embil J. Revascularization for peripheral vascular disease in Aboriginal and non-Aboriginal patients. J Vasc Surg 2006; 43:735-41. [PMID: 16616229 DOI: 10.1016/j.jvs.2005.11.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2005] [Accepted: 11/29/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND Canadian Aboriginal subjects have a higher prevalence of diabetes, renal disease, and lower extremity amputation than non-Aboriginal subjects. However, limited information is available about patient outcomes for arterial bypass surgery in Canadian Aboriginal compared with non-Aboriginal subjects. METHODS A retrospective study of all patients undergoing revascularization for peripheral vascular disease at a tertiary care referral center was performed. RESULTS A total of 828 procedures were performed on 678 patients between 1995 and 2002: 108 (13%) procedures on 84 (12%) Aboriginal patients and 720 (87%) procedures on 594 (88%) non-Aboriginal patients. Aboriginal patients had a higher prevalence of diabetes, chronic renal failure, and end-stage renal disease than non-Aboriginal patients. Aboriginal patients presented with more serious complications (gangrene [Aboriginal, 63 [58%] of 108 patients; non-Aboriginal, 112 [16%] of 720 patients; P < .0001] and nonhealing ulcer [Aboriginal, 29 [27%] of 108 patients; non-Aboriginal, 131 [18%] of 720 patients; P < .05]) and required urgent or emergency revascularization (Aboriginal, 47 [49%] of 95 patients; non-Aboriginal, 228 [36%] of 634 patients; P < .02) more frequently than non-Aboriginal patients. The 60-month patient mortality was similar for both groups (Aboriginal, 20 [24%] of 84 patients; non-Aboriginal, 160 [27%] of 594 patients; not significant), but Aboriginal patients had loss of limb more frequently (Aboriginal, 19 [18%] of 108 patients; non-Aboriginal, 62 [9%] of 720 patients; P < .0001) and had loss of primary graft patency more frequently (Aboriginal, 39 [36%] of 108 patients; non-Aboriginal, 155 [22%] of 720 patients; P < .0001) than non-Aboriginal patients. CONCLUSIONS Canadian Aboriginal subjects had worse outcomes with revascularization than non-Aboriginal subjects, but ethnicity and diabetes were not independent risk factors for poor outcome. Multivariate analysis showed that the poor outcomes in mortality, limb salvage, and primary graft patency among Aboriginal patients undergoing revascularization may be attributed to renal disease and a more advanced mode of presentation of peripheral vascular disease complications at the time of intervention.
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Affiliation(s)
- Stephen Goulet
- Department of Medicine, University of Manitoba, Winnipeg, Canada
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Killewich LA. Improving Functional Status and Quality of Life in Elderly Patients with Peripheral Arterial Disease. J Am Coll Surg 2006; 202:345-55. [PMID: 16427563 DOI: 10.1016/j.jamcollsurg.2005.09.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2005] [Revised: 09/26/2005] [Accepted: 09/28/2005] [Indexed: 10/25/2022]
Affiliation(s)
- Lois A Killewich
- Section of Vascular Surgery, Department of Surgery, The University of Texas Medical Branch, Galveston, TX 77555, USA
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Koch M, Trapp R, Kulas W, Grabensee B. Critical limb ischaemia as a main cause of death in patients with end-stage renal disease: a single-centre study. Nephrol Dial Transplant 2004; 19:2547-52. [PMID: 15266035 DOI: 10.1093/ndt/gfh404] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Patients with end-stage renal disease (ESRD) have a high overall mortality rate, particularly due to cardiovascular morbidity. In an era of decline in cardiovascular diseases and early cardiovascular intervention, non-cardiac diseases seem to have a larger impact on overall mortality. METHODS From 1997 to 2003, all incident haemodialysis patients in a single centre were enrolled in this prospective study. Those with clinical signs of vascular disease were examined by coronary or peripheral angiographies. Physicians took the patients' medical histories, examined them and followed them up until the end of the study or death. Causes of death were defined by the physicians. RESULTS In all, 322 patients were enrolled in the study, 38% of whom were diabetic. At the start of dialysis treatment, 38% had coronary artery disease (CAD), defined as >50% stenosis of at least one coronary artery or as definite myocardial infarction, and 14% had critical ischaemia of at least one limb (CLI). In all patients with foot lesions, CLI was defined angiographically, as evidenced by stenosis or rarefication of distal vessels in the legs. Patients who died (n = 121) [due to cardiac causes (n = 25), complications of CLI (n = 22), stroke (n = 10), cachexia following a long-standing, non-malignant disease (n = 6), malignancy (n = 24), infection not related to CLI (n = 18) and other causes (n = 16)] were older (71+/-10 vs 65+/-13 years), more often male [74/121 (61%)] and often diabetic [56/121 (46%)]. CAD was documented in 82/121 (68%). Five-year survivals in patients with no risk and diabetes without CAD or CLI, CAD and CLI were 74%, 73%, 50% and 10%, respectively. Age, CLI and smoking habits independently increased the risk of death (hazard ratios: 1.052, 4.921 and 2.292, respectively). CONCLUSIONS These results indicate that CLI with associated complications is not only an indicator of high mortality in patients with ESRD, but is also one of the main causes of death.
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Albers M, Battistella VM, Romiti M, Rodrigues AAE, Pereira CAB. Meta-analysis of polytetrafluoroethylene bypass grafts to infrapopliteal arteries. J Vasc Surg 2003; 37:1263-9. [PMID: 12764274 DOI: 10.1016/s0741-5214(02)75332-9] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
CONTEXT Reports of polytetrafluoroethylene (PTFE) bypass grafting to the infrapopliteal arteries have often used survival analysis of acceptable quality to describe a wide range of long-term results. In theory, these results may be combined if variability between series and time intervals is considered. OBJECTIVE Meta-analysis was performed to gain insight into long-term graft patency and foot preservation after PTFE bypass grafting to infrapopliteal arteries. DATA SOURCE Studies published from 1982 through 2001 were identified from the PubMed database and pertinent original articles. STUDY SELECTION Three investigators selected 43 studies that used survival analysis, reported 2-year patency rates, and included at least 15 bypass procedures. Data extraction and transformation: Based on standard life-tables or survivor curves, an interval success rate was calculated for each month in each series. The monthly success rates were combined across series, enabling construction of pooled survivor curves. DATA SYNTHESIS Random-effects meta-analysis yielded 5-year pooled estimates (SE) of 30.5% (7.6%) for primary graft patency, 39.7% (5.5%) for secondary graft patency, and 55.7% (5.0%) for foot preservation. During the entire follow-up, pooled estimates were slightly higher for series of PTFE grafts with adjunctive procedures compared with series of PTFE grafts only. Sensitivity analysis: A simulation using only unfavorable assumptions showed a decrease of less than 5% at 5 years for all outcomes, and smaller differences at subgroup meta-analysis. Funnel plots suggested that publication bias was unlikely. CONCLUSION This meta-analysis indicated moderate success for PTFE bypass grafts to infrapopliteal arteries, but the role of adjunctive procedures at the distal anastomosis remains uncertain.
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Affiliation(s)
- Maximiano Albers
- Vascular Surgery Section, Department of Surgery, Health and Medical Sciences Sector, Lusiada University Center UNILUS, Lusiada Foundation, Santos and São Paulo, Brazil.
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O'Hare AM, Feinglass J, Sidawy AN, Bacchetti P, Rodriguez RA, Daley J, Khuri S, Henderson WG, Johansen KL. Impact of renal insufficiency on short-term morbidity and mortality after lower extremity revascularization: data from the Department of Veterans Affairs' National Surgical Quality Improvement Program. J Am Soc Nephrol 2003; 14:1287-95. [PMID: 12707397 DOI: 10.1097/01.asn.0000061776.60146.02] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Few data are available on the impact of renal insufficiency on short-term operative outcomes after lower extremity surgical revascularization. We used prospectively collected data from the Department of Veterans Affairs' National Surgical Quality Improvement Program (NSQIP) to explore the association with renal dysfunction of adverse outcomes occurring within 30 d of lower extremity surgical revascularization in a cohort of all patients undergoing at least one lower extremity surgical revascularization from 1/1/94 to 9/30/01 (n = 18,217). Even moderate renal insufficiency (estimated GFR 30-59cc/min/1.73m(2)) was associated with an increased incidence of postoperative death (adjusted odds ratio (OR) 1.44, 95% confidence interval (CI), 1.17 to 1.77, P = 0.001), cardiac arrest (OR 1.43, CI 1.09 to 1.88, P = 0.011), myocardial infarction (OR 1.68, 1.39 to 2.16, P < 0.001), unplanned intubation (OR 1.69, CI 1.39 to 2.07, P < 0.001) and prolonged intubation (OR 1.57, CI 1.28 to 1.94, P < 0.001) within 30 d of lower extremity revascularization. However, the incidence of wound infection and graft failure requiring return to the operating room did not appear to be substantially higher in this group. Our data also show that patients with renal insufficiency undergoing revascularization were more likely to require distal procedures and to present with limb-threatening infection compared to those with normal renal function. Efforts to improve pre-and post-operative care in patients with renal insufficiency undergoing lower extremity revascularization should take into account the increased incidence of postoperative death and cardiopulmonary complications in this group in addition to more traditional concerns about operative site complications. Further studies are needed to explore reasons for the higher rate of limb-threatening infection in patients with renal insufficiency undergoing revascularization.
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Affiliation(s)
- Ann M O'Hare
- Department of Medicine, San Francisco VA Medical Center, 4150 Clement Street, San Francisco, CA 94121, USA.
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Nehler MR, Hiatt WR, Taylor LM. Is revascularization and limb salvage always the best treatment for critical limb ischemia? J Vasc Surg 2003; 37:704-8. [PMID: 12618724 DOI: 10.1067/mva.2003.142] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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O'Hare AM, Johansen KL. Peripheral vascular disease in end-stage renal disease patients. Int J Artif Organs 2002; 25:1123-7. [PMID: 12518956 DOI: 10.1177/039139880202501202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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