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Tan W, Boodagh P, Selvakumar PP, Keyser S. Strategies to counteract adverse remodeling of vascular graft: A 3D view of current graft innovations. Front Bioeng Biotechnol 2023; 10:1097334. [PMID: 36704297 PMCID: PMC9871289 DOI: 10.3389/fbioe.2022.1097334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 12/23/2022] [Indexed: 01/11/2023] Open
Abstract
Vascular grafts are widely used for vascular surgeries, to bypass a diseased artery or function as a vascular access for hemodialysis. Bioengineered or tissue-engineered vascular grafts have long been envisioned to take the place of bioinert synthetic grafts and even vein grafts under certain clinical circumstances. However, host responses to a graft device induce adverse remodeling, to varied degrees depending on the graft property and host's developmental and health conditions. This in turn leads to invention or failure. Herein, we have mapped out the relationship between the design constraints and outcomes for vascular grafts, by analyzing impairment factors involved in the adverse graft remodeling. Strategies to tackle these impairment factors and counteract adverse healing are then summarized by outlining the research landscape of graft innovations in three dimensions-cell technology, scaffold technology and graft translation. Such a comprehensive view of cell and scaffold technological innovations in the translational context may benefit the future advancements in vascular grafts. From this perspective, we conclude the review with recommendations for future design endeavors.
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Affiliation(s)
- Wei Tan
- Department of Mechanical Engineering, University of Colorado Boulder, Boulder, CO, United States,*Correspondence: Wei Tan,
| | - Parnaz Boodagh
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | | | - Sean Keyser
- Department of Mechanical Engineering, University of Colorado Boulder, Boulder, CO, United States
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2
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Weissler EH, Wang Y, Gales JM, Feldman DN, Arya S, Secemsky EA, Aronow HD, Hawkins BM, Gutierrez JA, Patel MR, Curtis JP, Jones WS, Swaminathan RV. Cardiovascular and Limb Events Following Endovascular Revascularization Among Patients ≥65 Years Old: An American College of Cardiology PVI Registry Analysis. J Am Heart Assoc 2022; 11:e024279. [PMID: 35723018 PMCID: PMC9238644 DOI: 10.1161/jaha.121.024279] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 02/21/2022] [Indexed: 11/17/2022]
Abstract
Background We aimed to characterize the occurrence of major adverse cardiovascular and limb events (MACE and MALE) among patients with peripheral artery disease (PAD) undergoing peripheral vascular intervention (PVI), as well as associated factors in patients with chronic limb threatening ischemia (CLTI). Methods and Results Patients undergoing PVI in the American College of Cardiology's (ACC) National Cardiovascular Data Registry's PVI Registry who could be linked to Centers for Medicare and Medicaid Services data were included. The primary outcomes were MACE, MALE, and readmission within 1 month and 1 year following index CLTI-PVI or non-CLTI-PVI. Cox proportional hazards regression was used to identify factors associated with the development of the primary outcomes among patients undergoing CLTI-PVI. There were 1758 (49.7%) patients undergoing CLTI-PVI and 1779 (50.3%) undergoing non-CLTI-PVI. By 1 year, MACE occurred in 29.5% of patients with CLTI (n=519), and MALE occurred in 34.0% of patients with CLTI (n=598). By 1 year, MACE occurred in 8.2% of patients with non-CLTI (n=146), and MALE occurred in 26.1% of patients with non-CLTI (n=465). Predictors of MACE at 1 year in CLTI-PVI included end-stage renal disease on hemodialysis, congestive heart failure, prior CABG, and severe lung disease. Predictors of MALE at 1 year in CLTI-PVI included treatment of a prior bypass graft, profunda femoral artery treatment, end-stage renal disease on hemodialysis, and treatment of a previously treated lesion. Conclusions Patients ≥65 years old undergoing PVI experience high rates of MACE and MALE. A range of modifiable and non-modifiable patient factors, procedural characteristics, and medications are associated with the occurrence of MACE and MALE following CLTI-PVI.
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Affiliation(s)
- E. Hope Weissler
- Division of Vascular and Endovascular SurgeryDepartment of SurgeryDuke University School of MedicineDurhamNC
| | - Yongfei Wang
- Section of Cardiovascular MedicineDepartment of Internal MedicineYale School of MedicineNew HavenCT
- Center of Outcome Research and EvaluationYale‐New Haven Health ServicesNew HavenCT
| | | | | | - Shipra Arya
- Division of Vascular and Endovascular SurgeryStanford University School of MedicinePalo AltoCA
| | - Eric A. Secemsky
- Division of CardiologyBeth Israel Deaconess Medical CenterBostonMA
- Smith Center for Outcomes Research in CardiologyBostonMA
| | - Herbert D. Aronow
- Lifespan Cardiovascular Institute/Alpert Medical School at Brown UniversityProvidenceRI
| | - Beau M. Hawkins
- Cardiovascular SectionUniversity of Oklahoma Health Sciences CenterOklahomaOK
| | - J. Antonio Gutierrez
- Division of CardiologyDuke University Health SystemDurhamNC
- Cardiology Section, Durham VA Medical CenterDurhamNC
| | | | - Jeptha P. Curtis
- Section of Cardiovascular MedicineDepartment of Internal MedicineYale School of MedicineNew HavenCT
- Center of Outcome Research and EvaluationYale‐New Haven Health ServicesNew HavenCT
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Kim Y, Decarlo CS, Thangappan K, Zacharias N, Mohapatra A, Dua A. Distal Bypass Versus Infrageniculate Endovascular Intervention for Chronic Limb-Threatening Ischemia. Vasc Endovascular Surg 2022; 56:539-544. [PMID: 35356834 DOI: 10.1177/15385744221086347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) carries a high risk of amputation and warrants urgent intervention. CLTI involving the infrageniculate vessels, in particular, carries a considerably higher risk of major limb amputation. Open surgical bypass is the historical gold standard for the treatment of tibial arterial disease; however, endovascular therapy provides an attractive alternative in this high-risk patient population. In this article, we review the existing literature regarding distal bypass and infrageniculate endovascular intervention in patients with CLTI.
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Affiliation(s)
- Young Kim
- Division of Vascular and Endovascular Surgery, Harvard Medical School, 2348Massachusetts General Hospital, Boston, MA. USA
| | - Charles S Decarlo
- Division of Vascular and Endovascular Surgery, Harvard Medical School, 2348Massachusetts General Hospital, Boston, MA. USA
| | - Karthik Thangappan
- Division of Vascular and Endovascular Surgery, Harvard Medical School, 2348Massachusetts General Hospital, Boston, MA. USA
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Harvard Medical School, 2348Massachusetts General Hospital, Boston, MA. USA
| | - Abhisekh Mohapatra
- Division of Vascular and Endovascular Surgery, Harvard Medical School, 2348Massachusetts General Hospital, Boston, MA. USA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Harvard Medical School, 2348Massachusetts General Hospital, Boston, MA. USA
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Biscetti F, Cecchini AL, Rando MM, Nardella E, Gasbarrini A, Massetti M, Flex A. Principal predictors of major adverse limb events in diabetic peripheral artery disease: A narrative review. ATHEROSCLEROSIS PLUS 2021; 46:1-14. [PMID: 36643723 PMCID: PMC9833249 DOI: 10.1016/j.athplu.2021.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/10/2021] [Accepted: 10/28/2021] [Indexed: 01/18/2023]
Abstract
Background and aims The increasing prevalence of diabetes mellitus is causing a massive growth of peripheral artery disease incidences, a disabling complication of diabetic atherosclerosis, which leads often to the amputation of the affected limb. Critical limb ischemia is the terminal disease stage, which requires a prompt intervention to relieve pain and save limbs. However, patients undergoing revascularization often suffer from cardiovascular, cerebrovascular and major adverse limb events with poor outcomes. Furthermore, the same procedure performed in apparently similar patients has various outcomes and lack of an outcome predictive support causes a high lower limb arterial revascularization rate with disastrous effects for patients. We collected the main risk factors of major adverse limb events in a more readable and immediate format of the topic, to propose an overview of parameters to manage effectively peripheral artery disease patients and to propose basics of a new predictive tool to prevent from disabling vascular complications of the disease. Methods Most recent and updated literature about the prevalence of major adverse limb events in peripheral artery disease was reviewed to identify possible main predictors. Results In this article, we summarized major risk factors of limb revascularization failure and disabling vascular complications collecting those parameters principally responsible for major adverse limb events, which provides physio-pathological explanation of their role in peripheral artery disease. Conclusion We evaluated and listed a panel of possible predictors of MALE (Major Adverse Limb Event) in order to contribute to the development of a predictive score, based on a summary of the main risk factors reported in scientific articles, which could improve the management of peripheral artery disease by preventing vascular accidents.
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Affiliation(s)
- Federico Biscetti
- Internal and Cardiovascular Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy,Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy,Corresponding author. Internal and Cardiovascular Medicine Unit. Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, Rome, 00168, Italy.
| | | | - Maria Margherita Rando
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Elisabetta Nardella
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, Universitá Cattolica del Sacro Cuore, Roma, Italy
| | - Massimo Massetti
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Andrea Flex
- Internal and Cardiovascular Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy,Department of Medical and Surgical Sciences, Universitá Cattolica del Sacro Cuore, Roma, Italy
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Chang H, Rockman CB, Jacobowitz GR, Cayne NS, Veith FJ, Han DK, Patel VI, Kumpfbeck A, Garg K. Interplay of Diabetes Mellitus and End-Stage Renal Disease in Open Revascularization for Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2020; 72:552-562. [PMID: 33227468 DOI: 10.1016/j.avsg.2020.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/15/2020] [Accepted: 10/02/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic limb-threatening ischemia (CLTI) in patients with end-stage renal disease (ESRD) confers a significant survival disadvantage and is associated with a high major amputation rate. Moreover, diabetes mellitus (DM) is an independent risk factor for developing CLTI. However, the interplay between end-stage renal disease (ESRD) and DM on outcomes after peripheral revascularization for CLTI is not well established. Our goal was to assess the effect of DM on outcomes after an infrainguinal bypass for CLTI in patients with ESRD. METHODS Using the Vascular Quality Initiative dataset from January 2003 to March 2020, records for all primary infrainguinal bypasses for CLTI in patients with ESRD were included for analysis. One-year and perioperative outcomes of all-cause mortality, reintervention, amputation-free survival (AFS), and major adverse limb event (MALE) were compared for patients with DM versus those without DM. RESULTS Of a total of 1,058 patients (66% male) with ESRD, 726 (69%) patients had DM, and 332 patients did not have DM. The DM group was younger (median age, 65 years vs. 68 years; P = 0.002), with higher proportions of obesity (body-mass index>30 kg/m2; 34% vs. 19%; P < 0.001) and current smokers (26% vs. 19%; P = 0.013). The DM group presented more frequently with tissue loss (76% vs. 66%; P < 0.001). A distal bypass anastomosis to tibial vessels was more frequently performed in the DM group compared to the non-DM group (57% vs. 45%; P < 0.001). DM was independently associated with higher perioperative MALE (OR 1.34; 95% CI, 1.06-1.68; P = 0.013), without increased risks of loss of primary patency and composite outcomes of amputation or death. On the mean follow-up of 11.4 ± 5.5 months, DM patients had a significantly higher rate of one-year MALEs (43% vs. 32%; P = 0.001). However, the one-year primary patency and AFS did not differ significantly. After adjusting for confounders, the risk-adjusted hazards for MALE (HR 1.34; 95% CI, 1.06-1.68; P = 0.013) were significantly increased in patients with DM. However, DM was not associated with increased risk of AFS (HR 1.16; 95% CI, 0.91-1.47; P = 0.238), or loss of primary patency (HR 1.04; 95% CI, 0.79-1.37; P = 0.767). CONCLUSIONS DM and ESRD each independently predict early and late major adverse limb events after an infrainguinal bypass in patients presenting with CLTI. However, in the presence of ESRD, DM may increase perioperative adverse events but does not influence primary patency and AFS at one year. The risk profile associated with ESRD appears to supersede that of DM, with no additive effect.
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Affiliation(s)
- Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Neal S Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Frank J Veith
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Daniel K Han
- Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, New York, NY
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New-York Presbyterian / Columbia University Medical Center / Columbia University College of Physicians and Surgeons, New York, NY
| | | | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY; New York University Grossman School of Medicine, New York, NY.
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6
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Lee KB, Macsata RA, Lala S, Sparks AD, Amdur RL, Ricotta JJ, Sidawy AN, Nguyen BN. Outcomes of open and endovascular interventions in patients with chronic limb threatening ischemia. Vascular 2020; 29:693-703. [PMID: 33190618 DOI: 10.1177/1708538120971972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Widespread adoption of endovascular therapy for the treatment of chronic limb-threatening ischemia has transformed the field of vascular surgery. In this modern era, we aimed to define where open surgical interventions are of greatest benefit for limb salvage. METHODS Patients who underwent interventions for chronic limb-threatening ischemia were identified in the vascular-targeted lower extremity National Surgical Quality Improvement Program database for open surgical interventions (OPEN) and endovascular surgical interventions (ENDO) from 2011 to 2017. Patients were further stratified based on the criteria of chronic limb-threatening ischemia (rest pain or tissue loss), and the location of the diseased arteries (femoropopliteal or tibioperoneal). The main outcomes measured included 30-day mortality, amputation, and major adverse cardiovascular events. RESULTS A total of 17,193 patients were revascularized for chronic limb-threatening ischemia: 10,532 were OPEN and 6661 were ENDO. OPEN had higher 30-day mortality, major adverse cardiovascular events, pulmonary, renal dysfunction, and wound complications. However, OPEN resulted in significantly lower 30-day major amputation (3.8% vs. 5.0%, odds ratio (OR): 0.83 [0.72-0.97], P = .018). Subgroup analysis revealed a higher mortality rate in OPEN was observed only in tibioperoneal intervention for tissue loss. Major adverse cardiovascular event was higher in OPEN for most subgroups. OPEN for patients with tissue loss had significantly lower amputation rate than ENDO in both femoropopliteal and tibioperoneal subgroups (3.7% vs. 5.1%, OR: 0.76 [0.59-0.98], P = .036, and 4.7% vs. 6.6%, OR: 0.74 [0.57-0.96], P = .024, respectively). The benefit of open surgery in reducing the amputation rate was not seen in patients with rest pain. CONCLUSIONS Open surgical intervention is associated with significantly better limb salvage than endovascular intervention in patients with tissue loss. Surgical options should be given more emphasis as the first-line option in this cohort of patients unless the cardiopulmonary risk is prohibitive.
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Affiliation(s)
- K Benjamin Lee
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Robyn A Macsata
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Salim Lala
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Andrew D Sparks
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Richard L Amdur
- Department of Surgery, George Washington University, Washington, DC, USA
| | - John J Ricotta
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Anton N Sidawy
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Bao-Ngoc Nguyen
- Department of Surgery, George Washington University, Washington, DC, USA
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7
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Martini R. Current opinion on the role of the foot perfusion in limb amputation risk assessment. Clin Hemorheol Microcirc 2020; 76:405-412. [PMID: 32675403 DOI: 10.3233/ch-200901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The most important and consulted guidelines dealing with not healing foot ulcers suggest the measurement of the foot perfusion (FP) to exclude the critical limb ischemia (CLI), because of the high risk of limb amputation. But the recommended cut-off values of FP fail to include all the heterogeneity of patients of the real-life with a not healing ulcer. Often these patients are diabetics with a moderate PAD but with a high level of infection. To meet this goal, in 2014, the Society for Vascular Surgery has published the "Lower Extremity Threatened Limb Classification System: Risk stratification based on Wound, Infection, and foot Ischemia (WIfI)." This new classification system has changed the criteria of assessment of limb amputation risk, replacing the single cut-off value role with a combination of a spectrum of perfusion values along with graded infection and dimension levels of skin ulcers. The impact of this new classification system was remarkable so to propose the substitution of the CLI definition, with the new Critical limb-threatening ischemia (CLTI), that seems to define the limb amputation risk more realistically.
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Affiliation(s)
- Romeo Martini
- Unità Operativa di Angiologia, Azienda Ospedaliera Universitaria di Padova, Padova, Italy
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8
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Yanagisawa W, Gomes ML, Menting TP, De Loose KR, Varcoe RL. The current state of surgical bypass versus drug eluting stents for long femoropopliteal occlusive lesions. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:450-455. [PMID: 31062570 DOI: 10.23736/s0021-9509.19.10984-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Considerable advances have been made over the last decade in the management of patients with peripheral artery disease. Historically, endovascular treatment has been the accepted approach for short lesions and surgical bypass for long, complex femoropopliteal lesions. However, bypass surgery holds significant risk of mortality and morbidity for the patient. That toll includes prolonged hospitalization, as well as the potential for wound healing and systemic complications, all of which are intensified by the ageing population. Advances in endovascular devices, such as drug eluting stents present an alternative, minimally invasive treatment option which may more suitable for complex lesions in a high-risk population. The aim of this review is to discuss the current literature which addresses surgical bypass and drug eluting stents, particularly for the treatment of long, complex femoropopliteal disease.
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Affiliation(s)
- Waka Yanagisawa
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia
| | - Miguel L Gomes
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia
| | - Theo P Menting
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia
| | - Koen R De Loose
- Department of Vascular Surgery, AZ Sint Blasius Hospital, Dendermonde, Belgium
| | - Ramon L Varcoe
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia - .,Department of Vascular Surgery, AZ Sint Blasius Hospital, Dendermonde, Belgium.,Faculty of Medicine, University of New South Wales, Sydney, Australia
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Abualhin M, Sonetto A, Faggioli G, Mirelli M, Freyrie A, Gallitto E, Spath P, Stella A, Gargiulo M. Outcomes of Duplex-Guided Paramalleolar and Inframalleolar Bypass in Patients with Critical Limb Ischemia. Ann Vasc Surg 2018; 53:154-164. [DOI: 10.1016/j.avsg.2018.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 04/10/2018] [Accepted: 04/10/2018] [Indexed: 10/14/2022]
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10
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Cheban AV, Karpenko AA, Popova IV, Saaya SB, Gostev AA, Rabtsun АA, Novikova ОA, Laktionov PP. Modern endovascular methods in treatment of patients with the tibial arteries lesion: determinants and perspectives. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2018. [DOI: 10.15829/1728-8800-2018-4-74-80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Endovascular interventions have proved efficacy in the treatment of the shin arteries lesion management. Lots of published works witness on the significance and future perspective of the field. The article is focused on the analysis of studies for previous 5 years, on various treatment approaches, balloons and cytostatics coated stents usage. The ways for interventions relsults improvement are sketched on tibial arteries with drug eluting stents.
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Affiliation(s)
| | | | | | | | | | | | | | - P. P. Laktionov
- Meshalkin National Medical Research Centre; Institute of Biological Chemistry and Fundamental Medicine of the SD RAS
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11
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Miyake K, Kikuchi S, Okuda H, Koya A, Abe S, Sawa Y, Ota T, Azuma N. Successful limb salvage through staged bypass combined with free gracilis muscle transfer for critical limb ischemia with osteomyelitis after failed endovascular therapy. Surg Case Rep 2018; 4:40. [PMID: 29717398 PMCID: PMC5930295 DOI: 10.1186/s40792-018-0449-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/19/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Critical limb ischemia with osteomyelitis is so difficult to treat that even appropriate revascularization and wound therapy cannot achieve limb salvage because of uncontrollable infection. It is still difficult to judge the possibility of limb salvage before revascularization. CASE PRESENTATION A 73-year-old male complained of a small ulcer on his left toe, which was treated with multiple endovascular therapy. After failed endovascular therapy, he suffered extensive tissue loss with tibial osteomyelitis. We carried out staged surgery that was composed of dual bypass to the sural artery and posterior tibial artery. After intensive debridement and wound care, insertion of a subsequent free gracilis muscle flap to cover the exposed tibial bone was performed, achieving functional limb salvage. CONCLUSION Even in the threatened limb with extensive tissue loss and osteomyelitis, intensive and multidisciplinary treatment with staged revascularization, muscle transfer, and appropriate wound care achieved functional limb salvage.
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Affiliation(s)
- Keisuke Miyake
- Department of Vascular Surgery, Asahikawa Medical University, 1-1-1, Midorigaoka-higashi-2jyo, Asahikawa, 078-8510, Japan.,Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shinsuke Kikuchi
- Department of Vascular Surgery, Asahikawa Medical University, 1-1-1, Midorigaoka-higashi-2jyo, Asahikawa, 078-8510, Japan
| | - Hiroko Okuda
- Department of Vascular Surgery, Asahikawa Medical University, 1-1-1, Midorigaoka-higashi-2jyo, Asahikawa, 078-8510, Japan
| | - Atsuhiro Koya
- Department of Vascular Surgery, Asahikawa Medical University, 1-1-1, Midorigaoka-higashi-2jyo, Asahikawa, 078-8510, Japan
| | - Satomi Abe
- Department of Orthopedic Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Tetsuo Ota
- Department of Physical Medicine and Rehabilitation, Asahikawa Medical University Hospital, Asahikawa, Japan
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University, 1-1-1, Midorigaoka-higashi-2jyo, Asahikawa, 078-8510, Japan.
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12
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Hicks CW, Canner JK, Kirkland K, Malas MB, Black JH, Abularrage CJ. Hemodialysis patients have worse outcomes after infrageniculate revascularization procedures. J Surg Res 2018; 226:72-81. [PMID: 29661291 DOI: 10.1016/j.jss.2018.01.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 12/14/2017] [Accepted: 01/12/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hemodialysis (HD) has been shown to be an independent predictor of poor outcomes after femoropopliteal revascularization procedures in patients with chronic limb-threatening ischemia. However, HD patients tend to have isolated infrageniculate disease, an anatomic risk factor for inferior patency. We aimed to compare outcomes for HD versus non-HD patients after infrageniculate open lower extremity bypass (LEB) and endovascular peripheral vascular interventions (PVIs). METHODS Data from the Society for Vascular Surgery Vascular Quality Initiative database (2008-2014) were analyzed. All patients undergoing infrageniculate LEB or PVI for rest pain or tissue loss were included. One-year primary patency (PP), secondary patency (SP), and major amputation outcomes were analyzed for HD versus non-HD patients stratified by treatment approach using both univariable and multivariable analyses. RESULTS A total of 1688 patients were included, including 348 patients undergoing LEB (HD = 44 versus non-HD = 304) and 1340 patients undergoing PVI (HD = 223 versus non-HD = 1117). Patients on HD more frequently underwent revascularization for tissue loss (89% versus 77%, P < 0.001) and had ≥2 comorbidities (91% versus 76%, P < 0.001). Among patients undergoing LEB, 1-y PP (66% versus 69%) and SP (71% versus 78%) were similar for HD versus non-HD (P ≥ 0.25) groups, but major amputations occurred more frequently in the HD group (27% versus 14%; P = 0.03). Among patients undergoing PVI, 1-y PP (70% versus 78%) and SP (82% versus 90%) were lower and the frequency of major amputations was higher (27% versus 10%) for HD patients (all, P ≤ 0.02). After correcting for baseline differences between the groups, outcomes were similar for HD versus non-HD patients undergoing LEB (P ≥ 0.21) but persistently worse for HD patients undergoing PVI (all, P ≤ 0.006). CONCLUSIONS HD is an independent predictor of poor patency and higher risk of major amputation after infrageniculate endovascular revascularization procedures for the treatment of chronic limb-threatening ischemia. The use of endovascular interventions in these higher risk patients is not associated with improved limb salvage outcomes and may be an inappropriate use of healthcare resources.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph K Canner
- Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Kevin Kirkland
- Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Mahmoud B Malas
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland; Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland.
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Sultan S, Kavanagh EP, Hynes N. Minimising failure in critical lower limb ischaemia intervention: Adjuvant capillary bed recruitment is the missed opportunity. Vascular 2018; 26:449-454. [PMID: 29419359 DOI: 10.1177/1708538117753213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Critical limb ischaemia is the end stage of peripheral arterial disease before limb loss. Contemporary interventions to restore blood flow have high morbidity and mortality and fail to provide sustained restoration of peripheral circulation. Cell-based therapies designed to promote neovascularisation or angiogenesis have been shown in trials to be safe but clinically ineffective. Notwithstanding endless research in the area, no headway has been made in identifying a successful therapy designed specifically to target muscle disease in critical lower limb ischaemia. Thus, the quest to find an effective, lasting solution for critical lower limb ischaemia continues and requires more innovative therapeutic tactics. Our aim is to highlight the crucially interlinked role of the capillary bed, skeletal muscle mass and mitochondria in critical lower limb ischaemia patients and to identify novel therapeutic mechanisms that the vascular interventionalist can add to their armamentarium.
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Affiliation(s)
- Sherif Sultan
- 1 Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland Galway, Galway, Ireland.,2 Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Doughiska, Galway, Ireland.,3 Royal College of Surgeons in Ireland Affiliated Hospitals, National University of Ireland Galway Affiliated Hospitals, Galway, Ireland
| | - Edel Patricia Kavanagh
- 1 Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland Galway, Galway, Ireland.,2 Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Doughiska, Galway, Ireland.,3 Royal College of Surgeons in Ireland Affiliated Hospitals, National University of Ireland Galway Affiliated Hospitals, Galway, Ireland
| | - Niamh Hynes
- 1 Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland Galway, Galway, Ireland.,2 Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Doughiska, Galway, Ireland.,3 Royal College of Surgeons in Ireland Affiliated Hospitals, National University of Ireland Galway Affiliated Hospitals, Galway, Ireland
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14
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Mohapatra A, Henry JC, Avgerinos ED, Boitet A, Chaer RA, Makaroun MS, Leers SA, Hager ES. Bypass versus endovascular intervention for healing ischemic foot wounds secondary to tibial arterial disease. J Vasc Surg 2018; 68:168-175. [PMID: 29336904 DOI: 10.1016/j.jvs.2017.10.076] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/16/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Pedal (inframalleolar) bypass is a long-standing therapy for tibial arterial disease in patients with ischemic tissue loss. Endovascular tibial intervention is an appealing alternative with lower risks of perioperative mortality or complications. Our objective was to compare the effectiveness of these two treatment modalities with respect to patency and limb-related clinical outcomes. METHODS We performed a retrospective chart review of patients presenting between 2006 and 2013 with ischemic foot wounds and infrapopliteal arterial disease who underwent a revascularization procedure (either open surgical bypass to an inframalleolar target or endovascular tibial intervention). Data were collected on baseline demographics and comorbidities, procedural details, and postprocedure outcomes. The primary outcome was successful healing of the index wound, with mortality, major amputation, and patency assessed as secondary outcomes. RESULTS We identified 417 patients who met our eligibility criteria; 105 underwent surgical bypass and 312 underwent endovascular intervention, with mean follow-up of 25.0 and 20.2 months, respectively (P = .08). The endovascular patients were older at baseline (P = .009), with higher rates of hyperlipidemia (P = .02), prior cerebrovascular accidents (P = .04), and smoking history (P = .04). Within 30 days postoperatively, there was no difference in mortality (P = .31), but bypass patients had longer hospital length of stay (P < .0001), higher rate of discharge to nursing facility (P < .001), and higher rates of myocardial infarctions (P = .03) and wound complications (P < .001). At 6 months, the rate of wound healing was 22.4% in the bypass group compared with 29.0% in the endovascular group (P = .02). At 1 year, survival was higher after bypass (86.2% vs 70.4%; P < .0001), but freedom from major amputation was similar (84.9% vs 82.8%; P = .42). Primary patency (53.1% vs 38.2%; P = .002) and primary assisted patency (76.6% vs 51.7%; P < .0001) were higher in the bypass group, but there was no difference in secondary patency (77.3% vs 73.8%; P = .13). CONCLUSIONS Endovascular tibial intervention is associated with poorer primary patency but similar secondary patency and wound healing rates compared with the "gold standard" of surgical bypass to a pedal target. In patients with tibial arterial disease, endovascular intervention should be considered a lower risk alternative to pedal bypass that provides similar clinical outcomes.
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Affiliation(s)
- Abhisekh Mohapatra
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - Jon C Henry
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Efthimios D Avgerinos
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Aureline Boitet
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Rabih A Chaer
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michel S Makaroun
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Steven A Leers
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Eric S Hager
- Division of Vascular Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
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AbuRahma AF. When Are Endovascular and Open Bypass Treatments Preferred for Femoropopliteal Occlusive Disease? Ann Vasc Dis 2018; 11:25-40. [PMID: 29682105 PMCID: PMC5882358 DOI: 10.3400/avd.ra.18-00001] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Several meta-analyses and multicenter trials have shown that chronic limb ischemia did not occur for up to 5 years in 50%–70% of patients who underwent saphenous vein grafts, with limb salvage and perioperative mortality rates of >80% and 3%, respectively. However, open surgical bypass can have limitations, including postoperative morbidity/wound complications of 10%–20% and prolonged length of hospital stay and outpatient care. Several studies have analyzed clinical outcomes for patients with critical limb ischemia treated with endovascular therapies, but they have been mainly retrospective with significant heterogeneity or were single center. Only few randomized trials have compared surgical vs. endovascular therapy. These included the Bypass vs. Angioplasty in Severe Ischemia of the Leg (BASIL) trial, with no differences found in amputation-free or overall survival rates at 1 year; however, late outcomes favored the surgical group. The Bypass or Angioplasty in Severe Intermittent Claudication (BASIC) trial concluded that the 1-year patency rates were 82% and 43% for bypass and angioplasty, respectively. The BEST Endovascular vs. Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trial is currently enrolling patients. This review analyzed studies comparing open vs. endovascular therapy in patients with femoropopliteal disease. (This is a review article based on the invited lecture of the 45th Annual Meeting of Japanese Society for Vascular Surgery.)
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Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University, Charleston, West Virginia, USA
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16
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Salinas HM, Khan SI, McCormack MC, Fernandes JR, Gfrerer L, Watkins MT, Redmond RW, Austen WG. Prevention of vein graft intimal hyperplasia with photochemical tissue passivation. J Vasc Surg 2017; 65:190-196. [DOI: 10.1016/j.jvs.2015.11.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 11/15/2015] [Indexed: 10/22/2022]
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17
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Tratamiento y gestión del pie diabético. ANGIOLOGIA 2017. [DOI: 10.1016/j.angio.2016.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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18
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Hicks CW, Najafian A, Farber A, Menard MT, Malas MB, Black JH, Abularrage CJ. Below-knee endovascular interventions have better outcomes compared to open bypass for patients with critical limb ischemia. Vasc Med 2016; 22:28-34. [PMID: 27928034 DOI: 10.1177/1358863x16676901] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Both open surgery and endovascular peripheral interventions have been shown to effectively improve outcomes in patients with peripheral artery disease, but minimal data exist comparing outcomes performed at and below the knee. The purpose of this study was to compare outcomes following infrageniculate lower extremity open bypass (LEB) versus peripheral vascular intervention (PVI) in patients with critical limb ischemia. Using data from the 2008-2014 Vascular Quality Initiative, 1-year primary patency, major amputation, and mortality were compared among all patients undergoing LEB versus PVI at or below the knee for rest pain or tissue loss. Overall, 2566 patients were included (LEB=500, PVI=2066). One-year primary patency was significantly worse following LEB (73% vs 81%; p<0.001). One-year major amputation (14% vs 12%; p=0.18) and mortality (4% vs 6%; p=0.15) were similar regardless of revascularization approach. Multivariable analysis adjusting for baseline differences between groups confirmed inferior primary patency following LEB versus PVI (HR 0.74; 95% CI, 0.60-0.90; p=0.004), but no significant differences in 1-year major amputation (HR 1.06; 95% CI, 0.80-1.40; p=0.67) or mortality (HR 0.71; 95% CI, 0.44-1.14; p=0.16). Based on these data, we conclude that endovascular revascularization is a viable treatment approach for critical limb ischemia resulting from infrageniculate arterial occlusive disease.
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Affiliation(s)
- Caitlin W Hicks
- 1 Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alireza Najafian
- 2 Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alik Farber
- 3 Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA, USA
| | - Matthew T Menard
- 4 Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mahmoud B Malas
- 1 Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - James H Black
- 1 Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Christopher J Abularrage
- 1 Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
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19
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Hicks CW, Najafian A, Farber A, Menard MT, Malas MB, Black JH, Abularrage CJ. Diabetes does not worsen outcomes following infrageniculate bypass or endovascular intervention for patients with critical limb ischemia. J Vasc Surg 2016; 64:1667-1674.e1. [DOI: 10.1016/j.jvs.2016.07.107] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 07/06/2016] [Indexed: 11/28/2022]
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20
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Katsanos K, Kitrou P, Spiliopoulos S, Diamantopoulos A, Karnabatidis D. Comparative Effectiveness of Plain Balloon Angioplasty, Bare Metal Stents, Drug-Coated Balloons, and Drug-Eluting Stents for the Treatment of Infrapopliteal Artery Disease: Systematic Review and Bayesian Network Meta-analysis of Randomized Controlled Trials. J Endovasc Ther 2016; 23:851-863. [PMID: 27708143 DOI: 10.1177/1526602816671740] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To report a Bayesian network meta-analysis of randomized controlled trials (RCTs) comparing bare metal stents (BMS), paclitaxel-coated balloons (PCBs), and drug-eluting stents (DES) with balloon angioplasty (BA) or with each other in the infrapopliteal arteries. METHODS Sixteen RCTs comprising 1805 patients with 1-year median follow-up were analyzed. Bayesian random effects binomial models were employed (WinBUGS). Relative treatment effects were expressed as odds ratios (ORs) with 95% credible intervals (CrI), and the cumulative rank probabilities were calculated to provide hierarchies of competing treatments. Quality of evidence (QoE) was assessed with the GRADE (grading of recommendations assessment, development, and evaluation) system. Sensitivity, heterogeneity, and consistency analyses were performed. RESULTS There was high QoE that infrapopliteal DES significantly reduced restenosis compared with BMS (OR 0.26, 95% CrI 0.12 to 0.51) and BA (OR 0.22, 95% CrI 0.11 to 0.45). Likewise, DES significantly reduced target lesion revascularization (TLR) compared with BA (OR 0.41, 95% CrI 0.22 to 0.75) and BMS (OR 0.26, 95% CrI 0.15 to 0.45). Paclitaxel-coated balloons also reduced TLR compared with BA (OR 0.55, 95% CrI 0.34 to 0.90) and BMS (OR 0.35, 95% CrI 0.18 to 0.67), but QoE was low to moderate. BA had lower TLR than BMS (OR 0.63, 95% CrI 0.40 to 0.99) with high QoE. DES was the only treatment that significantly reduced limb amputations compared with BA (OR 0.58, 95% CrI 0.35 to 0.96), PCB (OR 0.51, 95% CrI 0.26 to 0.98), or BMS (OR 0.38, 95% CrI 0.19 to 0.72) with moderate to high QoE. DES also significantly improved wound healing compared with BA (OR 2.02, 95% CrI 1.01 to 4.07) or BMS (OR 3.45, 95% CrI 1.41 to 8.73) with high QoE. Results were stable on sensitivity and meta-regression analyses without any significant publication bias or inconsistency. CONCLUSION Infrapopliteal DES were associated with significantly lower rates of restenosis, TLR, and amputations and improved wound healing compared to BA and BMS. DES also significantly reduced amputations compared with PCB.
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Affiliation(s)
- Konstantinos Katsanos
- Department of Interventional Radiology, Guy's and St. Thomas' Hospitals, NHS Foundation Trust, King's Health Partners, London, UK
| | - Panagiotis Kitrou
- Department of Interventional Radiology, Patras University Hospital, School of Medicine, Rion, Greece
| | - Stavros Spiliopoulos
- 2nd Department of Radiology, Interventional Radiology Unit, ATTIKO Athens University Hospital, Athens, Greece
| | - Athanasios Diamantopoulos
- Department of Interventional Radiology, Guy's and St. Thomas' Hospitals, NHS Foundation Trust, King's Health Partners, London, UK
| | - Dimitris Karnabatidis
- Department of Interventional Radiology, Patras University Hospital, School of Medicine, Rion, Greece
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21
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Meltzer AJ, Sedrakyan A, Isaacs A, Connolly PH, Schneider DB. Comparative effectiveness of peripheral vascular intervention versus surgical bypass for critical limb ischemia in the Vascular Study Group of Greater New York. J Vasc Surg 2016; 64:1320-1326.e2. [DOI: 10.1016/j.jvs.2016.02.069] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/14/2016] [Indexed: 11/16/2022]
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22
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McBride OM, Mofidi R, Griffiths GD, Dawson AR, Chalmers RT, Stonebridge PA. Development of a Decision Tree to Streamline Infrainguinal Vein Graft Surveillance. Ann Vasc Surg 2016; 36:182-189. [DOI: 10.1016/j.avsg.2016.02.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 02/10/2016] [Accepted: 02/11/2016] [Indexed: 11/24/2022]
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23
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Caradu C, Battut AS, Gonthier C, Midy D, Ducasse E. [Treatment of below the knee lesions: Broadening the limits of vascular surgery]. ACTA ACUST UNITED AC 2016; 41:378-382. [PMID: 27594571 DOI: 10.1016/j.jmv.2016.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 07/22/2016] [Indexed: 11/25/2022]
Abstract
One third of patients with critical limb ischemia (CLI) has below the knee lesions and requires a restoration of direct blood flow into the foot. However, many of these patients are ineligible for open surgery. The primary goals thus become pain relief and limb salvage over patency. The angiosome concept helps determine the target artery to treat in priority. The endovascular approach has decreased morbidity and mortality rates compared to distal bypass surgery; while subintimal retrograde, trans-collateral and loop techniques push the limits of open surgery by reopening the plantar arch, thereby improving run-off. Early restenosis phenomena after angioplasty have been improved by the use of - limus drug eluting balloons and balloon expandable stents in case of flow limiting dissection or recoil with increased limb salvage rates. Moreover, drug-eluting stents have been proposed, and allow a reduction in reintervention and in-stent restenosis rates in short lesions; however, results on amputation rates or survival are limited. Vessel preparation is a key to overcoming some current limitations, including atherectomy, which increases technical success rates and reduces restenosis rates, especially in calcified lesions, chronic total occlusions and restenosis. These advanced techniques in distal endovascular revascularization have revolutionized limb salvage and support the interest of an endovascular first approach in CLI treatment.
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Affiliation(s)
- C Caradu
- Service de chirurgie vasculaire, université de Bordeaux, hôpital Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - A S Battut
- Service de chirurgie vasculaire, université de Bordeaux, hôpital Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - C Gonthier
- Service de chirurgie vasculaire, université de Bordeaux, hôpital Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - D Midy
- Service de chirurgie vasculaire, université de Bordeaux, hôpital Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - E Ducasse
- Service de chirurgie vasculaire, université de Bordeaux, hôpital Pellegrin, place Amélie-Raba-Léon, 33000 Bordeaux, France.
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Allen LL, Kalmar G, Driver VR. Treatment of a High-Risk Diabetic Patient with Peripheral Vascular Disease and Osteomyelitis. Tech Vasc Interv Radiol 2016; 19:96-100. [PMID: 27423990 DOI: 10.1053/j.tvir.2016.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
We report a case of calcaneal osteomyelitis that was surgically resected from a patient with diabetes and peripheral vascular disease. A 91-year-old male with history of type 2 diabetes, peripheral vascular disease, balloon angioplasty, and recent (2 months ago) stent of the superficial femoral artery presented to the emergency department with a left heel wound infection probed to bone. The patient reported having been on intravenous Zosyn for several months via an outside infectious disease provider for clinical suspicion of osteomyelitis, but noted no improvement. This report includes information regarding the clinical examination and imaging findings, which were used to assess this high-risk patient. Our patient underwent a partial calcanectomy and completed a 6-week course of intravenous antibiotics. The purpose of this case report is to illustrate limb preservation in a high-risk patient with compromised vascular supply who underwent a partial calcanectomy for treatment of calcaneal osteomyelitis. The patient underwent surgical resection of the calcaneus without complications and healed unremarkably with the ability to ambulate while wearing an ankle foot orthosis with a custom shoe. This report was authorized for publication as an educational report to contribute to generalizable knowledge and does not include any patient health information.
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Affiliation(s)
- Latricia L Allen
- Podiatry/Surgical Services, James A. Haley VA Hospital, Tampa, FL; New England VA Medical Center, VA New England Healthcare System, Bedford, MA
| | - Garrett Kalmar
- New England VA Medical Center, VA New England Healthcare System, Bedford, MA
| | - Vickie R Driver
- New England VA Medical Center, VA New England Healthcare System, Bedford, MA; Departmenrt of Orthopedic Surgery, Brown University, Providence, RI; New Indications Discovery Unit, Wound Healing, Novartis Institute for BioMedical Research, Cambridge, MA; Association for the Advancement of Wound Care (AAWC), Malvern, PA; Wound Healing Center, RI Hospital, Providence, RI.
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25
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Hicks CW, Selvarajah S, Mathioudakis N, Sherman RE, Hines KF, Black JH, Abularrage CJ. Burden of Infected Diabetic Foot Ulcers on Hospital Admissions and Costs. Ann Vasc Surg 2016; 33:149-58. [PMID: 26907372 DOI: 10.1016/j.avsg.2015.11.025] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 08/10/2015] [Accepted: 11/22/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Costs related to diabetic foot ulcer (DFU) care are greater than $1 billion annually and rising. We sought to describe the impact of diabetes mellitus (DM) on foot ulcer admissions in the United States, and to investigate potential explanations for rising hospital costs. METHODS The Nationwide Inpatient Sample (2005-2010) was queried using International Classification of Diseases, 9th Revision (ICD-9) codes for a primary diagnosis of foot ulceration. Multivariable analyses were used to compare outcomes and per-admission costs among patients with foot ulceration and DM versus non-DM. RESULTS In total, 962,496 foot ulcer patients were admitted over the study period. The overall rate of admissions was relatively stable over time, but the ratio of DM versus non-DM admissions increased significantly (2005: 10.2 vs. 2010: 12.7; P < 0.001). Neuropathy and infection accounted for 90% of DFU admissions, while peripheral vascular disease accounted for most non-DM admissions. Admissions related to infection rose significantly among DM patients (2005: 39,682 vs. 2010: 51,660; P < 0.001), but remained stable among non-DM patients. Overall, DM accounted for 83% and 96% of all major and minor amputations related to foot ulcers, respectively, and significantly increased cost of care (DM: $1.38 vs. non-DM: $0.13 billion/year; P < 0.001). Hospital costs per DFU admission were significantly higher for patients with infection compared with all other causes ($11,290 vs. $8,145; P < 0.001). CONCLUSIONS Diabetes increases the incidence of foot ulcer admissions by 11-fold, accounting for more than 80% of all amputations and increasing hospital costs more than 10-fold over the 5 years. The majority of these costs are related to the treatment of infected foot ulcers. Education initiatives and early prevention strategies through outpatient multidisciplinary care targeted at high-risk populations are essential to preventing further increases in what is already a substantial economic burden.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Shalini Selvarajah
- Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Nestoras Mathioudakis
- Division of Endocrinology & Metabolism, Department of Medicine, The Johns Hopkins Hospital, Baltimore, MD; Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, MD
| | - Ronald E Sherman
- Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, MD; Department of Orthopedic Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Kathryn F Hines
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD; Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, MD
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD; Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD; Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, MD.
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26
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Drug delivering technology for endovascular management of infrainguinal peripheral artery disease. JACC Cardiovasc Interv 2016; 7:827-39. [PMID: 25147028 DOI: 10.1016/j.jcin.2014.05.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 04/07/2014] [Accepted: 05/08/2014] [Indexed: 11/21/2022]
Abstract
Endovascular intervention has become a well-recognized treatment modality for peripheral artery disease; however, mid- and long-term outcomes have been plagued by limited durability. Plain balloon angioplasty and bare-metal stents have historically suffered from high restenosis rates leading to the need for frequent repeat revascularization procedures. The innovation of locally administered, drug-delivering balloons and stents has been a direct result of technological innovations directed toward prevention and treatment of this limitation. Over the last 5 years, numerous clinical trials investigating the use of drug-coated stents and drug-coated balloons indicate a significant improvement in endovascular treatment durability and outcomes. This review provides an up-to-date assessment of the current evidence for the use of drug-coated stents and drug-coated balloons in the treatment of femoropopliteal and infrapopliteal peripheral artery disease. Additionally, it provides an overview of the development of this technology, highlights landmark ongoing and completed clinical trials, examines evidence to support the use of drug-coated technologies in combination with other modalities, and examines promising new technological developments. Last, it summarizes the challenges and safety concerns that have delayed U.S. Food and Drug Administration approval of these devices.
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Reifsnyder T, Arhuidese IJ, Hicks CW, Obeid T, Massada KE, Khaled A, Qazi U, Malas MB. Contemporary Outcomes for Open Infrainguinal Bypass in the Endovascular Era. Ann Vasc Surg 2016; 30:52-8. [DOI: 10.1016/j.avsg.2015.10.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 09/09/2015] [Accepted: 10/27/2015] [Indexed: 11/16/2022]
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28
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Park YY, Joh JH, Han SA, Kim SH, Cho S, Park HC, Ahn HJ. National trends for the treatment of peripheral arterial disease in Korea between 2004 and 2013. Ann Surg Treat Res 2015; 89:319-24. [PMID: 26665127 PMCID: PMC4672096 DOI: 10.4174/astr.2015.89.6.319] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/07/2015] [Accepted: 06/24/2015] [Indexed: 11/30/2022] Open
Abstract
Purpose Peripheral arterial disease (PAD) has been a major public health issue in the elderly. Advances in endovascular surgery have led to a substantial shift in the management of PAD. Although the nationwide trend of PAD treatment in the Western countries was reported, limited data have been available on this in Korea. This study examined the national trend in the treatment of PAD in Korea over the past decade. Methods Health Insurance Review and Assessment Service data were used. We sought to analyze trends in the open and endovascular surgery for the treatment of PAD in Medicare beneficiaries between 2004 and 2013. We also analyzed trends in each types of surgery in the lower extremity. A linear-by-linear association was performed to determine the changes of PAD treatment for this period. Results The rate of open surgery per 100,000 Medicare beneficiaries decreased significantly from 8 procedures in 2004 to 6 in 2013. At the same time, endovascular surgery increased from 23 procedures in 2004 to 59 in 2013. Endovascular surgery in the lower extremity increased more than twofold, while the open surgery decreased by 39%. The rate of balloon angioplasty among endovascular surgery was increased by almost threefold, while the bypass surgery using artificial graft decreased by half. Conclusion Endovascular surgery is now performed more commonly than open surgery for PAD treatment. Balloon angioplasty increased by almost threefold, while the bypass surgery using artificial graft decreased by about 50%.
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Affiliation(s)
- Youn Young Park
- Department of Surgery, Graduate School, Kyung Hee University, Seoul, Korea
| | - Jin Hyun Joh
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sang-Ah Han
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sang Hyun Kim
- Department of Surgery, Graduate School, Kyung Hee University, Seoul, Korea
| | - Sungsin Cho
- Department of Surgery, Graduate School, Kyung Hee University, Seoul, Korea
| | - Ho-Chul Park
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Hyung Joon Ahn
- Department of Surgery, Kyung Hee University Medical Center, Kyung Hee University School of Medicine, Seoul, Korea
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Tartaglia E, Lejay A, Georg Y, Roussin M, Thaveau F, Chakfe N. Results of isolated infrapopliteal percutaneous transluminal angioplasty for critical limb ischemia in high-risk diabetic patients. Vascular 2015; 24:515-22. [PMID: 26603863 DOI: 10.1177/1708538115619265] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM Infrapopliteal occlusive arterial lesions mostly characterize diabetic patients arteriopathy. Diabetic patients are prone to multiple comorbidities that make them candidates for low-invasive therapeutic options. The aim of this study was to evaluate the safety of infrapopliteal angioplasty in high-risk diabetic patients. METHODS We undertook a study (retrospective study of a prospectively collected database) of all infrapopliteal endovascular revascularizations performed for critical limb ischemia in high-risk (≥3 major comorbidities) diabetic patients in our institution between 2008 and 2010. Study end points were safety, technical success rate, healing rate, overall 1-year survival, primary patency, secondary patency and limb salvage rates. RESULTS A total of 101 high-risk diabetic patients (160 arterial lesions: 94 stenosis and 66 occlusions) underwent infrapopliteal endovascular surgery. No major adverse cardiovascular or cerebrovascular event was recorded within 30 days. Two major adverse limb events (two thromboses requiring major amputation) and seven minor adverse events were recorded. Technical and healing rates were, respectively, 83% and 78%. The 1-year survival, primary patency, secondary patency and limb salvage rates were, respectively, 86%, 67%, 83% and 84%. CONCLUSION Infrapopliteal angioplasty can be considered as a safe and feasible option for high-risk diabetic patients with critical limb ischemia.
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Affiliation(s)
- E Tartaglia
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - A Lejay
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Y Georg
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - M Roussin
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - F Thaveau
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - N Chakfe
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
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Diabetic foot infections: what have we learned in the last 30 years? Int J Infect Dis 2015; 40:81-91. [DOI: 10.1016/j.ijid.2015.09.023] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 09/29/2015] [Accepted: 09/30/2015] [Indexed: 12/21/2022] Open
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Han SM, Wu B, Eichler CM, Reilly LM, Vartanian SM, Conte MS, Hiramoto J. Risk Factors for 30-Day Hospital Readmission in Patients Undergoing Treatment for Peripheral Artery Disease. Vasc Endovascular Surg 2015; 49:69-74. [DOI: 10.1177/1538574415593498] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Early hospital readmission among vascular surgery patients is a focus of Medicare’s new reimbursement structure. We aim to identify factors associated with 30-day readmission after lower extremity interventions to treat peripheral artery disease (PAD). Retrospective analysis of 174 consecutive patients discharged from the vascular surgery service between January 1, 2011, and July 31, 2012, after procedures for lower extremity PAD was performed. Of 174 patients, 37 were readmitted within 30 days of discharge. There were no significant differences in baseline characteristics between the readmitted and the nonreadmitted groups. In a multivariate logistic regression model, urgent operation and advanced chronic kidney disease (CKD) were associated with increased risk of 30-day readmission. The most common reasons for readmission were infection of the surgical site or index limb (18 of 37), followed by unresolved limb symptoms (13 of 37). The 30-day readmission is frequent after lower extremity interventions to treat PAD. Urgent operative intervention and advanced CKD appear to be risk factors for early hospital readmission.
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Affiliation(s)
- Sukgu M. Han
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Bian Wu
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Charles M. Eichler
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Linda M. Reilly
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Shant M. Vartanian
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Michael S. Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Jade Hiramoto
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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Lower-extremity arterial revascularization: Is there any evidence for diabetic foot ulcer-healing? DIABETES & METABOLISM 2015; 42:4-15. [PMID: 26072053 DOI: 10.1016/j.diabet.2015.05.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 05/13/2015] [Accepted: 05/14/2015] [Indexed: 12/21/2022]
Abstract
The presence of peripheral arterial disease (PAD) is an important consideration in the management of diabetic foot ulcers. Indeed, arteriopathy is a major factor in delayed healing and the increased risk of amputation. Revascularization is commonly performed in patients with critical limb ischaemia (CLI) and diabetic foot ulcer (DFU), but also in patients with less severe arteriopathy. The ulcer-healing rate obtained after revascularization ranges from 46% to 91% at 1 year and appears to be improved compared to patients without revascularization. However, in those studies, healing was often a secondary criterion, and there was no description of the initial wound or its management. Furthermore, specific alterations associated with diabetes, such as microcirculation disorders, abnormal angiogenesis and glycation of proteins, can alter healing and the benefits of revascularization. In this review, critical assessment of data from the literature was performed on the relationship between PAD, revascularization and healing of DFUs. Also, the impact of diabetes on the effectiveness of revascularization was analyzed and potential new therapeutic targets described.
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Goodney PP, Tarulli M, Faerber AE, Schanzer A, Zwolak RM. Fifteen-year trends in lower limb amputation, revascularization, and preventive measures among medicare patients. JAMA Surg 2015; 150:84-6. [PMID: 25409197 DOI: 10.1001/jamasurg.2014.1007] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire2VA Outcomes Group, White River Junction, Vermont3Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, New Hampshire
| | - Massimo Tarulli
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Adrienne E Faerber
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, New Hampshire
| | - Andreas Schanzer
- Section of Vascular Surgery, University of Massachusetts School of Medicine, Worcester
| | - Robert M Zwolak
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire2VA Outcomes Group, White River Junction, Vermont
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Courtois MC, Sapoval M, Del Giudice C, Ducloux R, Mirault T, Messas E. [Distal revascularization in diabetic patients with chronic limb ischemia]. ACTA ACUST UNITED AC 2015; 40:24-36. [PMID: 25596672 DOI: 10.1016/j.jmv.2014.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 12/04/2014] [Indexed: 12/01/2022]
Abstract
Diabetes mellitus is an independent risk factor for peripheral artery disease. Life expectancy is 41 months for diabetic patients with an ischemic ulcer. The characteristics of diabetic arteriopathy make its treatment more difficult than in non-diabetic patients. Few data are available about the surgical treatment of arteriopathy in diabetic patients (including angioplasty or bypass), especially in case of distal arteriopathy. The choice of the procedure depends on multiple factors such as the disease localization, its extent, distal blood flow and vascular disease-related surgical risk. The principal aim of revascularisation is to restore direct flow to the foot in order to ensure wound healing and limb salvage. With percutaneous endoluminal angioplasty, limb salvage can be achieved in more than 80% of patients at 1-3 years. The percutaneous procedure is less invasive than open surgery, there are fewer complications, and morbidity and mortality rates are reduced; moreover, a second procedure remains possible in the future. With bypass surgery, the rate of limb salvage exceeds 80% at five years. Nevertheless, peri-operative mortality reaches 3% and arterial anatomy, patient-related risks factors or venous graft availability may be limitations. New endovascular techniques especially designed for the distal arteries of the lower limbs enable very distal revascularization with morbidity and mortality rates lower than with surgery.
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Affiliation(s)
- M-C Courtois
- Unité de médecine vasculaire, service de médecine vasculaire, université Paris-Descartes, hôpital européen George-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France
| | - M Sapoval
- Service de radiologie interventionnelle vasculaire et oncologique, université Paris-Descartes, hôpital européen George-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France
| | - C Del Giudice
- Service de radiologie interventionnelle vasculaire et oncologique, université Paris-Descartes, hôpital européen George-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France
| | - R Ducloux
- Service de diabétologie, université Paris-Descartes, hôpital européen George-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France
| | - T Mirault
- Service de réadaptation vasculaire, université Paris-Descartes, hôpital Corentin-Celton, 4, parvis Corentin-Celton, 92130 Issy-les-Moulineaux, France
| | - E Messas
- Unité de médecine vasculaire, service de médecine vasculaire, université Paris-Descartes, hôpital européen George-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France.
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Jung H, Cho J, Kim HK, Kim J, Huh S. Long-term outcomes of infrainguinal bypass surgery for patients with diabetes mellitus and tissue loss. Ann Surg Treat Res 2014; 88:35-40. [PMID: 25553323 PMCID: PMC4279985 DOI: 10.4174/astr.2015.88.1.35] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 07/04/2014] [Accepted: 07/30/2014] [Indexed: 12/30/2022] Open
Abstract
Purpose To determine the long-term outcomes of patients with diabetes mellitus (DM) and tissue loss who have undergone infrainguinal bypass surgery (IBS). Methods We retrospectively reviewed the medical records of 91 patients with DM and tissue loss who underwent IBS between July 2003 and December 2013. We determined the rates of overall survival (OS), amputation-free survival (AFS), limb salvage (LS), and graft patency (GP). In addition, we evaluated data to identify risk factors that affected long-term outcomes. Results The mean age of patients was 66 ± 8 years, and 78 patients (85.7%) were men. The locations of tissue loss were toe on 76 limbs (71.6%), heel on 6 limbs (5.7%) and others on 24 limbs (22.6%). Single lesions were found in 81 limbs (76.4%). According to categorization by distal anastomosis artery, there were 57 popliteal (53.8%) and 49 infrapopliteal bypasses (46.2%). Among infrapopliteal bypasses, 5 cases (10.2%) were sequential bypasses. The OS at 1, 3, and 5 years was 90.5%, 70.9%, and 44.2%, respectively. At 1, 3, and 5 years, the LS was 92.1%, 88.9%, 88.9%, respectively; and AFS was 84.4%, 67.6%, 45.7%, respectively. At 1, 3, and 5 years, the GP was 84.8%, 74.5%, and 69.8%, respectively. Renal failure was a negative predictor for OS, and female gender was a negative predictor for GP. Conclusion IBS for patients with DM and tissue loss led to acceptable OS, AFS, LS, and GP. Active revascularization for patients with DM and tissue loss can reduce the risk of major amputation.
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Affiliation(s)
- Heekyung Jung
- Division of Transplantation and Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jayun Cho
- Division of Transplantation and Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hyung-Kee Kim
- Division of Transplantation and Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jihye Kim
- Division of Transplantation and Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Seung Huh
- Division of Transplantation and Vascular Surgery, Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
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Akgül EA, Karakaya J, Aydın S. Role of comorbidities as limiting factors to the effect of hyperbaric oxygen in diabetic foot patients: a retrospective analysis. Diabetes Ther 2014; 5:535-44. [PMID: 25273365 PMCID: PMC4269652 DOI: 10.1007/s13300-014-0085-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION The effectiveness of hyperbaric oxygen therapy (HBOT) on selected diabetic foot wounds continues to be controversial. A holistic approach to diabetes and its comorbidities may be beneficial in the discussion of the proper application of this treatment modality. The aim of the current study is to evaluate the efficacy of HBOT on diabetic foot wounds and provide clinical data that may support this knowledge. METHODS The present study was a retrospective analysis of the effect of HBOT on diabetic foot lesions ranging 3-5 on the Wagner Grading System. Patients had been treated with HBOT and monitored for 12 months. The results were analyzed in relation to age, gender, diabetes duration and type, microangiopathic complications, peripheral arterial disease (PAD), history of coronary artery disease, stroke, hypertension, smoking habits, glycated hemoglobin, blood sedimentation rate, C-reactive protein, and number of HBOT sessions. Microangiopathies were evaluated as retinopathy, nephropathy, and neuropathy. PAD was determined by available color Doppler ultrasonography and/or angiographic data depending on a modified scoring system. The data of arteries from the aorta to the dorsal pedal artery were scored singly. Average scores of aorto-iliac, femoral, popliteal and pedal levels were also evaluated with this system to compare the healing results in relation to PAD. RESULTS One hundred and seventeen patients with 126 diabetic foot wounds were treated. Histories of coronary artery disease, stroke, and non-proliferative or proliferative retinopathy had negative effects on HBOT (P = 0.002, P = 0.015, P = 0.022, respectively). Depending on the scorings of PAD, the single arterial scores and average scores of aorto-iliac, popliteal and pedal levels had no relation to outcomes, while the average scores of the femoral arterial level affected the results (P = 0.048). CONCLUSIONS Diabetic foot patients with histories of coronary artery diseases or stroke and non-proliferative or proliferative retinopathy might resist HBOT. PAD at the femoral arterial level has been shown to have a significant negative effect on HBOT outcomes that should be first considered for surgery. In contrast, PAD below the knee does not seem to be an obstacle to the efficacy of HBOT.
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Affiliation(s)
- Esra A Akgül
- Fora Hyperbaric Oxygen Therapy Center, Ziyabey C. 1413. S. NO: 4B/5 06520 Balgat, Ankara, Turkey,
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Yamamoto S, Hosaka A, Okamoto H, Shigematsu K, Miyata T, Watanabe T. Efficacy of revascularization for critical limb ischemia in patients with end-stage renal disease. Eur J Vasc Endovasc Surg 2014; 48:316-24. [PMID: 24980076 DOI: 10.1016/j.ejvs.2014.05.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 05/16/2014] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To evaluate the outcomes of surgical revascularization for critical limb ischemia in patients with end-stage renal disease (ESRD). PATIENTS AND METHODS From 2004 to 2010, 184 patients with 213 critically ischaemic limbs caused by arteriosclerosis were admitted to The University of Tokyo Hospital. The outcomes of primarily surgical revascularization-based treatments were retrospectively compared in patients with ESRD (ESRD group: 79 patients, 101 limbs) and without ESRD (non-ESRD group: 105 patients, 112 limbs) during the same period. RESULTS Arterial reconstruction was performed on 56 limbs in 46 patients in the ESRD group and 78 limbs in 73 patients in the non-ESRD group (55% vs. 70%; p = .03). Major amputation was performed in 6 of 48 limbs with patent grafts in the ESRD group because of uncontrolled infection or progression of necrosis. The limb salvage rate after arterial reconstruction was significantly lower in the ESRD group than in the non-ESRD group (p = .0019). The postoperative survival rate was lower in the ESRD group than in the non-ESRD group, although this difference was not significant (p = .052). Associated cardiovascular disease and systemic infection were the most frequent causes of death in the ESRD group. There was no significant difference in graft patency between the two groups after distal bypass surgery; however, the limb salvage rate was significantly lower in the ESRD group than in the non-ESRD group (p = .03). CONCLUSIONS Critical limb ischemia associated with ESRD has a poor prognosis. Infection control is particularly important for achievement of good treatment outcomes.
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Affiliation(s)
- S Yamamoto
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - A Hosaka
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - H Okamoto
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - K Shigematsu
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - T Miyata
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - T Watanabe
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Zeller T, Baumgartner I, Scheinert D, Brodmann M, Bosiers M, Micari A, Peeters P, Vermassen F, Landini M. IN.PACT Amphirion paclitaxel eluting balloon versus standard percutaneous transluminal angioplasty for infrapopliteal revascularization of critical limb ischemia: rationale and protocol for an ongoing randomized controlled trial. Trials 2014. [PMID: 24552184 DOI: 10.1186/1745-6215-15-63.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The effectiveness and durability of endovascular revascularization therapies for chronic critical limb ischemia (CLI) are challenged by the extensive burden of infrapopliteal arterial disease and lesion-related characteristics (e.g., severe calcification, chronic total occlusions), which frequently result in poor clinical outcomes. While infrapopliteal vessel patency directly affects pain relief and wound healing, sustained patency and extravascular care both contribute to the ultimate "patient-centric" outcomes of functional limb preservation, mobility and quality of life (QoL). METHODS/DESIGN IN.PACT DEEP is a 2:1 randomized controlled trial designed to assess the efficacy and safety of infrapopliteal arterial revascularization between the IN.PACT Amphirion™ paclitaxel drug-eluting balloon (IA-DEB) and standard balloon angioplasty (PTA) in patients with Rutherford Class 4-5-6 CLI. DISCUSSION This multicenter trial has enrolled 358 patients at 13 European centers with independent angiographic core lab adjudication of the primary efficacy endpoint of target lesion late luminal loss (LLL) and clinically driven target lesion revascularization (TLR) in major amputation-free surviving patients through 12-months. An independent wound core lab will evaluate all ischemic wounds to assess the extent of healing and time to healing at 1, 6, and 12 months. A QoL questionnaire including a pain scale will assess changes from baseline scores through 12 months. A Clinical Events Committee and Data Safety Monitoring Board will adjudicate the composite primary safety endpoints of all-cause death, major amputation, and clinically driven TLR at 6 months and other trial endpoints and supervise patient safety throughout the study. All patients will be followed for 5 years. A literature review is presented of the current status of endovascular treatment of CLI with drug-eluting balloon and standard PTA. The rationale and design of the IN.PACT DEEP Trial are discussed. IN.PACT DEEP is a milestone, prospective, randomized, robust, independent core lab-adjudicated CLI trial that will evaluate the role of a new infrapopliteal revascularization technology, the IA-DEB, compared to PTA. It will assess the overall impact on infrapopliteal artery patency, limb salvage, wound healing, pain control, QoL, and patient mobility. The 1-year results of the adjudicated co-primary and secondary endpoints will be available in 2014. TRIAL REGISTRATION NCT00941733.
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Affiliation(s)
- Thomas Zeller
- Department of Angiology, Universitäts Herzzentrum Freiburg Bad Krozingen, Bad Krozingen, Germany.
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Zeller T, Baumgartner I, Scheinert D, Brodmann M, Bosiers M, Micari A, Peeters P, Vermassen F, Landini M. IN.PACT Amphirion paclitaxel eluting balloon versus standard percutaneous transluminal angioplasty for infrapopliteal revascularization of critical limb ischemia: rationale and protocol for an ongoing randomized controlled trial. Trials 2014; 15:63. [PMID: 24552184 PMCID: PMC3936931 DOI: 10.1186/1745-6215-15-63] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 01/28/2014] [Indexed: 11/10/2022] Open
Abstract
Background The effectiveness and durability of endovascular revascularization therapies for chronic critical limb ischemia (CLI) are challenged by the extensive burden of infrapopliteal arterial disease and lesion-related characteristics (e.g., severe calcification, chronic total occlusions), which frequently result in poor clinical outcomes. While infrapopliteal vessel patency directly affects pain relief and wound healing, sustained patency and extravascular care both contribute to the ultimate “patient-centric” outcomes of functional limb preservation, mobility and quality of life (QoL). Methods/Design IN.PACT DEEP is a 2:1 randomized controlled trial designed to assess the efficacy and safety of infrapopliteal arterial revascularization between the IN.PACT Amphirion™ paclitaxel drug-eluting balloon (IA-DEB) and standard balloon angioplasty (PTA) in patients with Rutherford Class 4-5-6 CLI. Discussion This multicenter trial has enrolled 358 patients at 13 European centers with independent angiographic core lab adjudication of the primary efficacy endpoint of target lesion late luminal loss (LLL) and clinically driven target lesion revascularization (TLR) in major amputation-free surviving patients through 12-months. An independent wound core lab will evaluate all ischemic wounds to assess the extent of healing and time to healing at 1, 6, and 12 months. A QoL questionnaire including a pain scale will assess changes from baseline scores through 12 months. A Clinical Events Committee and Data Safety Monitoring Board will adjudicate the composite primary safety endpoints of all-cause death, major amputation, and clinically driven TLR at 6 months and other trial endpoints and supervise patient safety throughout the study. All patients will be followed for 5 years. A literature review is presented of the current status of endovascular treatment of CLI with drug-eluting balloon and standard PTA. The rationale and design of the IN.PACT DEEP Trial are discussed. IN.PACT DEEP is a milestone, prospective, randomized, robust, independent core lab-adjudicated CLI trial that will evaluate the role of a new infrapopliteal revascularization technology, the IA-DEB, compared to PTA. It will assess the overall impact on infrapopliteal artery patency, limb salvage, wound healing, pain control, QoL, and patient mobility. The 1-year results of the adjudicated co-primary and secondary endpoints will be available in 2014. Trial registration NCT00941733
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Affiliation(s)
- Thomas Zeller
- Department of Angiology, Universitäts Herzzentrum Freiburg Bad Krozingen, Bad Krozingen, Germany.
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Affiliation(s)
- Guanghong Jia
- Division of Endocrinology, Diabetes and Metabolism and the Diabetes Cardiovascular Center, University of Missouri School of Medicine, Columbia, MO
- Harry S. Truman Memorial Veterans' Hospital, Columbia, MO
| | - James R. Sowers
- Division of Endocrinology, Diabetes and Metabolism and the Diabetes Cardiovascular Center, University of Missouri School of Medicine, Columbia, MO
- Harry S. Truman Memorial Veterans' Hospital, Columbia, MO
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, MO
- Department of Internal Medicine, University of Missouri, Columbia, MO
- Corresponding author: James R. Sowers,
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Systematic Review on Health-Related Quality of Life After Revascularization and Primary Amputation in Patients With Critical Limb Ischemia. Ann Vasc Surg 2013; 27:1105-14. [DOI: 10.1016/j.avsg.2013.01.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 01/19/2013] [Accepted: 01/28/2013] [Indexed: 11/17/2022]
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Diabetic foot: surgical approach in emergency. Int J Vasc Med 2013; 2013:296169. [PMID: 24260718 PMCID: PMC3821940 DOI: 10.1155/2013/296169] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 09/10/2013] [Indexed: 12/30/2022] Open
Abstract
Introduction. Critical limb lschemia (CLI) and particularly diabetic foot (DF) are still considered “Cinderella” in our departments. Anyway, the presence of arterial obstructive disease increases the risk of amputation by itself; when it is associated with foot infection, the risk of amputation is greatly increased. Methods. From January 2007 to December 2011, 375 patients with DF infection and CLI have been admitted to our Unit; from 2007 to 2009, 192 patients (Group A) underwent surgical debridement of the lesion followed by a delayed revascularization; from 2010 to 2011, 183 patients (Group B) were treated following a new 4-step protocol: (1) early diagnosis with a 24 h on call DF team; (2) urgent treatment of severe foot infection with an aggressive surgical debridement; (3) early revascularization within 24 hours; (4) definitive treatment: wound healing, reconstructive surgery, and orthesis. We reported rates of mortality, major amputation, and foot healing at 6 months of followup. Results. The majority of patients in both groups were male; no statistical differences in medical history and clinical condition were reported at the baseline. The main difference between the two groups was the mean time from debridement to revascularization (3 days in Group A and 24 hours in Group B). After 6 months of follow-up, mortality was 11% in Group A versus 4.4% in Group B. Major amputation rate was 39.6% and 24.6% in Groups A and B, respectively. Wound healing was achieved in 17.8% in Group A and 20.8% in Group B. Conclusions. This protocol requires a lot of professional skills that should to reach the goal to avoid major amputations in patients with DF. Only an interdisciplinary integrated DF team and an early intervention may significantly impact the outcome of our patients: “Time is Tissue”!
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Serra R, Grande R, Scarcello E, Buffone G, de Franciscis S. Angiosome-targeted revascularisation in diabetic foot ulcers. Int Wound J 2013; 12:555-8. [PMID: 24118695 DOI: 10.1111/iwj.12162] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 08/29/2013] [Indexed: 12/01/2022] Open
Abstract
Peripheral vascular disease is a common complication of type 2 diabetes and is often more severe and diffuse than in non-diabetic individuals with a higher risk of major amputations in the lower limbs. Diabetic foot revascularisation using both traditional bypass surgery and endovascular therapy are often burdened by the failure and the inevitable subsequent massive amputation. In this study, we examined the clinical response of diabetic patients with critical limb ischaemia and extended ischaemic wounds, treated with a new angiosome-based revascularisation technique. In a 3-year period, nine diabetic patients with imminent amputation threatening and foot ulcers with no feasible arterial revascularisation options were treated by the angiosome-based surgical technique by means of deep vein arterialisation. The postoperative tcPO2 evaluation showed a mean increase in the cutaneous oxygen tension in all patients treated. The overall survival rates were 88·88%, 88·88% and 77·77% at 12, 24 and 36 months, respectively. Limb salvage was 100% at 1 year and steady at 88·88% thereafter. Surgical deep venous arterialisation might be considered as an extreme alternative to attempt tissue preservation in limbs unfit for conventional arterial revascularisations. This technique would give advantages to the patients in terms of better compliance to the minor amputations and thus avoiding major limb amputations.
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Affiliation(s)
- Raffaele Serra
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Raffaele Grande
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Edoardo Scarcello
- Unit of Vascular and Endovascular Surgery, Regional Hospital of Cosenza, Catanzaro, Italy
| | - Gianluca Buffone
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Stefano de Franciscis
- Department of Surgical and Medical Science, University Magna Graecia of Catanzaro, Catanzaro, Italy
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