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Gouëffic Y, Piffaretti G, Iqbal K, Dorweiler B, Hyhlik-Dürr A. A Systematic Review and Meta-Analysis of Heparin-Bonded Expanded Polytetrafluoroethylene Grafts for Below-The-Knee Femoral Bypass Surgery. Ann Vasc Surg 2024; 105:236-251. [PMID: 38582218 DOI: 10.1016/j.avsg.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Heparin-bonded expanded polytetrafluoroethylene (hb-ePTFE) synthetic grafts are an alternative to autologous vein grafts (AVG) for surgical bypass interventions in lower limb peripheral arterial disease (LLPAD). However, the clinical benefits of hb-ePTFE grafts have not been reviewed systematically for patients undergoing below-the-knee (BK) surgical bypass. This study aimed to meta-analyze available data on the utility of hb-ePTFE in patients undergoing BK surgical bypass. METHODS Medline, Embase, and Cochrane databases were searched, restricted to material in English with no date restriction. In addition, proceedings from relevant congresses were screened going back 2 years. The search was performed in December 2021. Eligible studies included prospective or retrospective comparative studies or prospective single-arm cohorts with an hb-ePTFE arm. Methodological quality was assessed with the ROBINS-I criteria. Outcomes included primary patency, amputation/limb salvage, and overall survival. Clinical outcomes were expressed as event rates. Studies were compared using meta-analysis to generate a standardized mean event rate for each outcome, with its 95% confidence interval (95% CI), using a random-effects model. RESULTS Following deduplication, 10,263 records were identified and 261 were assessed as full texts. No prospective comparative studies were identified. The level of evidence was uniformly low. Seventeen publications describing data from 9 individual patient cohorts met the inclusion criteria. These cohorts included a total of 1,452 patients undergoing BK surgical bypass with hb-ePTFE. The primary patency rate was 78.9% [95% CI: 72.2-85.7%] at 1 year, 68.2% [95% CI: 62.8-73.6%] at 2 years, decreasing to 48.0% [95% CI: 27.3-68.7%] at 5 years. The secondary patency rate was 84.8% [95% CI: 77.0-92.5%] at 1 year and 68.9% [95% CI: 43.0-94.9%] at 3 years; the 1-year limb salvage rate was 88.3% [95% CI: 79.6-97.1%] at 1 year and 79.0% [95% CI: 56.7-100%] at 3 years. CONCLUSIONS In patients undergoing BK bypass surgery, hb-ePTFE synthetic grafts, compared to uncoated grafts, perform well for patency and limb salvage. However, the quality of the evidence is low, and well-performed randomized clinical trials are needed to inform clinical decision-making on the choice of synthetic graft.
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Affiliation(s)
- Yann Gouëffic
- Department of Vascular and Endovascular Surgery, Paris Saint Joseph Hospital Group, Paris, France.
| | - Gabriele Piffaretti
- Department of Medicine and Surgery, University of Insubria School of Medicine, Varese University Hospital, Varese, Italy
| | - Kashfa Iqbal
- W. L. Gore & Associates (UK) Ltd, Livingstone, Scotland
| | - Bernhard Dorweiler
- Faculty of Medicine and University Hospital Cologne, Department of Vascular and endovascular Surgery, University of Cologne, Cologne, Germany
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Giacoppo D. Untangling the knot of the best endovascular treatment for femoropopliteal artery disease. Int J Cardiol 2024; 407:132108. [PMID: 38692491 DOI: 10.1016/j.ijcard.2024.132108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 04/28/2024] [Indexed: 05/03/2024]
Affiliation(s)
- Daniele Giacoppo
- Division of Cardiology, Policlinico "Rodolico-San Marco", Department of General Surgery and Surgical-Medical Specialties, University of Catania, Via Santa Sofia 78, 95123 Catania, Italy.
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Lei FR, Shen XF, Zhang C, Li XQ, Zhuang H, Sang HF. Clinical efficacy of endovascular revascularization combined with vacuum-assisted closure for the treatment of diabetic foot. World J Diabetes 2024; 15:1499-1508. [DOI: 10.4239/wjd.v15.i7.1499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/25/2024] [Accepted: 05/21/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND The diabetic foot is a common cause of disability and death, and comorbid foot infections usually lead to prolonged hospitalization, high healthcare costs, and a significant increase in amputation rates. And most diabetic foot trauma is complicated by lower extremity arteriopathy, which becomes an independent risk factor for major amputation in diabetic foot patients.
AIM To establish the efficacy and safety of endovascular revascularization (ER) combined with vacuum-assisted closure (VAC) for the treatment of diabetic foot.
METHODS Clinical data were collected from 40 patients with diabetic foot admitted to the Second Affiliated Hospital of Soochow University from April 2018 to April 2022. Diabetic foot lesions were graded according to Wagner’s classification, and blood flow to the lower extremity was evaluated using the ankle-brachial index test and computerized tomography angiography of the lower extremity arteries. Continuous subcutaneous insulin infusion pumps were used to achieve glycemic control. Lower limb revascularization was facilitated by percutaneous tran-sluminal balloon angioplasty (BA) or stenting. Wounds were cleaned by nibbling debridement. Wound granulation tissue growth was induced by VAC, and wound repair was performed by skin grafting or skin flap transplantation.
RESULTS Of the 35 cases treated with lower limb revascularization, 34 were successful with a revascularization success rate of 97%. Of these, 6 cases underwent stenting after BA of the superficial femoral artery, and 1 received popliteal artery stent implantation. In the 25 cases treated with infrapopliteal artery revascularization, 39 arteries were reconstructed, 7 of which were treated by drug-coated BA and the remaining 32 with plain old BA. VAC was performed in 32 wounds. Twenty-four cases of skin grafting and 2 cases of skin flap transplantation were performed. Two patients underwent major amputations, whereas 17 had minor amputations, accounting for a success limb salvage rate of 95%.
CONCLUSION ER in combination with VAC is a safe and effective treatment for diabetic foot that can significantly improve limb salvage rates. The use of VAC after ER simplifies and facilitates wound repair.
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Affiliation(s)
- Feng-Rui Lei
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Xiao-Fei Shen
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Chuang Zhang
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Xin-Qing Li
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Hao Zhuang
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Hong-Fei Sang
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
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Abouzid MR, Vyas A, Kamel I, Anwar J, Elshafei S, Subramaniam V, Bennett W, Lavie CJ, Nwaukwa C, White CJ, Patel RAG. Comparing the efficacy and safety of endovascular therapy versus surgical revascularization for critical limb-threatening ischemia: A systematic review and meta-analysis. Prog Cardiovasc Dis 2024:S0033-0620(24)00096-3. [PMID: 38981532 DOI: 10.1016/j.pcad.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2024] [Accepted: 06/23/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION Critical limb-threatening ischemia (CLTI) is a severe manifestation of peripheral artery disease (PAD) that can lead to limb amputation and significantly reduce the quality of life. In addition to guideline-directed medical therapy (GDMT), endovascular therapy and surgical revascularization are the two revascularization options for CLTI. In recent years, there has been an ongoing debate about the best approach for CLTI patients. The purpose of this meta-analysis is to examine the current evidence and compare the clinical outcomes of endovascular therapy and surgical revascularization for CLTI. METHODS We conducted a systematic search of electronic databases (PubMed, Embase, Cochrane Library, and Web of Science) for studies comparing the outcomes of endovascular therapy versus surgery in patients with CLTI. The primary outcomes were major adverse limb events (MALE) and major adverse cardiovascular events (MACE), while secondary outcomes included risk of bleeding, wound complications, readmission, unplanned reoperation, acute renal failure, and length of hospital stay. Pooled data was analyzed using the fixed-effect model or the random-effect model in Review Manager 5.3. The Newcastle-Ottawa Scale and Cochrane risk of bias assessment tool were used to assess the bias of included studies. RESULTS A total of 16 studies (47,609 patients) were included in this meta-analysis. The overall effect favors surgery over endovascular intervention in terms of MALE [odds ratio (OR) 1.13, 95% CI (1.01-1.28), P = 0.04]. Endovascular therapy is associated with lower MACE rates compared to surgery [OR 0.62, 95% CI (0.51-0.76), P < 0.00001]. Furthermore, the risk of bleeding, wound complications, readmission, unplanned reoperation, acute renal failure as well as the length of hospital stay was lower for endovascular intervention. Finally, there was no statistically significant difference in 30-day mortality between the two groups [OR 0.94, 95% CI 0.79-1.12, P = 0.52; Fig. 3i], and the pooled studies were homogeneous [P = 0.39; I2 = 5%]. CONCLUSION Surgery may be the preferred treatment option for CLTI patients, as it is associated with a lower risk of MALE than endovascular therapy. However, endovascular therapy may be associated with a lower risk of MACE and lower rates of bleeding, wound complications, readmission, unplanned reoperation, acute renal failure, and shorter hospital stays. There was no statistically significant difference in 30-day mortality between the two groups. Ultimately, the decision to use endovascular therapy or surgery as the primary treatment strategy should be based on a multi-disciplinary team approach with careful consideration of patient characteristics and anatomy.
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Affiliation(s)
- Mohamad Riad Abouzid
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont, TX, United States of America
| | - Ankit Vyas
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, United States of America
| | - Ibrahim Kamel
- Department of Internal Medicine, Carney Hospital, Dorchester, MA, United States of America
| | - Junaid Anwar
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont, TX, United States of America
| | - Shorouk Elshafei
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont, TX, United States of America
| | - Venkat Subramaniam
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, United States of America
| | - William Bennett
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, United States of America
| | - Carl J Lavie
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, United States of America
| | - Chima Nwaukwa
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont, TX, United States of America
| | - Christopher J White
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, United States of America
| | - Rajan A G Patel
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, United States of America.
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Krievins DK, Zellans E, Latkovskis G, Kumsars I, Krievina AK, Jegere S, Erglis A, Lacis A, Plopa E, Stradins P, Ivanova P, Zarins CK. Diagnosis and treatment of ischemia-producing coronary stenoses improves 5-year survival of patients undergoing major vascular surgery. J Vasc Surg 2024; 80:240-248. [PMID: 38518962 DOI: 10.1016/j.jvs.2024.02.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/22/2024] [Accepted: 02/24/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE Patients undergoing vascular surgery procedures have poor long-term survival due to coexisting coronary artery disease (CAD), which is often asymptomatic, undiagnosed, and undertreated. We sought to determine whether preoperative diagnosis of asymptomatic (silent) coronary ischemia using coronary computed tomography (CT)-derived fractional flow reserve (FFRCT) together with postoperative ischemia-targeted coronary revascularization can reduce adverse cardiac events and improve long-term survival following major vascular surgery METHODS: In this observational cohort study of 522 patients with no known CAD undergoing elective carotid, peripheral, or aneurysm surgery we compared two groups of patients. Group I included 288 patients enrolled in a prospective Institutional Review Board-approved study of preoperative coronary CT angiography (CTA) and FFRCT testing to detect silent coronary ischemia with selective postoperative coronary revascularization in addition to best medical therapy (BMT) (FFRCT guided), and Group II included 234 matched controls with standard preoperative cardiac evaluation and postoperative BMT alone with no elective coronary revascularization (Usual Care). In the FFRCT group, lesion-specific coronary ischemia was defined as FFRCT ≤0.80 distal to a coronary stenosis, with severe ischemia defined as FFRCT ≤0.75. Results were available for patient management decisions. Endpoints included all-cause death, cardiovascular death, myocardial infarction (MI), and major adverse cardiovascular events (MACE [death, MI, or stroke]) during 5-year follow-up. RESULTS The two groups were similar in age, gender, and comorbidities. In FFRCT, 65% of patients had asymptomatic lesion-specific coronary ischemia, with severe ischemia in 52%, multivessel ischemia in 36% and left main ischemia in 8%. The status of coronary ischemia was unknown in Usual Care. Vascular surgery was performed as planned in both cohorts with no difference in 30-day mortality. In FFRCT, elective ischemia-targeted coronary revascularization was performed in 103 patients 1 to 3 months following surgery. Usual Care had no elective postoperative coronary revascularizations. At 5 years, compared with Usual Care, FFRCT guided had fewer all-cause deaths (16% vs 36%; hazard ratio [HR], 0.37; 95% confidence interval [CI], 0.22-0.60; P < .001), fewer cardiovascular deaths (4% vs 21%; HR, 0.11; 95% CI, 0.04-0.33; P < .001), fewer MIs (4% vs 24%; HR, 0.13; 95% CI, 0.05-0.33; P < .001), and fewer MACE (20% vs 47%; HR, 0.36; 95% CI, 0.23-0.56; P < .001). Five-year survival was 84% in FFRCT compared with 64% in Usual Care (P < .001). CONCLUSIONS Diagnosis of silent coronary ischemia with ischemia-targeted coronary revascularization in addition to BMT following major vascular surgery was associated with fewer adverse cardiovascular events and improved 5-year survival compared with patients treated with BMT alone as per current guidelines.
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Affiliation(s)
- Dainis K Krievins
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia.
| | - Edgars Zellans
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Gustavs Latkovskis
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Indulis Kumsars
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | | | - Sanda Jegere
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Andrejs Erglis
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Aigars Lacis
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | | | - Peteris Stradins
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Riga Stradins University, Riga, Latvia
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Jeffcoate W, Boyko EJ, Game F, Cowled P, Senneville E, Fitridge R. Causes, prevention, and management of diabetes-related foot ulcers. Lancet Diabetes Endocrinol 2024; 12:472-482. [PMID: 38824929 DOI: 10.1016/s2213-8587(24)00110-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 06/04/2024]
Abstract
In this Review, we aim to complement the 2023 update of the guidelines of the International Working Group on the Diabetic Foot. We highlight the complexity of the pathological processes that underlie diabetes-related foot ulceration (DFU) and draw attention to the potential implications for clinical management and outcome. Variation observed in the incidence and outcome of DFUs in different communities might result from differences in study populations and the accessibility of care. Comparing differences in incidence, management, and outcome of DFUs in different communities is an essential component of the quality of disease care. Additionally, these comparisons can also highlight the relationship between DFU incidence, management, and outcome and the structure of local clinical services and the availability of staff with the necessary skills. The clinical outcome is, however, also dependent on the availability of multidisciplinary care and the ability of people with DFUs to gain access to that care.
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Affiliation(s)
| | - Edward J Boyko
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Prue Cowled
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Eric Senneville
- Discipline of Infectious Diseases, The University of Lille, Gustave Dron Hospital, Tourcoing, France
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia; Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, SA, Australia.
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Morisaki K, Matsuda D, Guntani A, Kinoshita G, Yoshino S, Inoue K, Honma K, Yamaoka T, Mii S, Yoshizumi T. Infra-inguinal bypass surgery vs endovascular revascularization for chronic limb-threatening ischemia in average- and high-risk patients. J Vasc Surg 2024; 80:204-212.e3. [PMID: 38522583 DOI: 10.1016/j.jvs.2024.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/14/2024] [Accepted: 03/15/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVE This study aimed to evaluate treatment outcomes after bypass surgery or endovascular therapy (EVT) in average- and high-risk patients with chronic limb-threatening ischemia (CLTI). METHODS We retrospectively analyzed multicenter data of patients who underwent infra-inguinal revascularization for CLTI between 2015 and 2022. A high-risk patient was defined as one with estimated 30-day mortality rate ≥5% or 2-year survival rate ≤50%, as determined by the Surgical Reconstruction vs Peripheral Intervention in Patients With Critical Limb Ischemia (SPINACH) calculator. The amputation-free survival (AFS), limb salvage (LS), wound healing, and 30-day mortality were compared separately for the average- and high-risk patients between the bypass and EVT with propensity score matching. RESULTS We analyzed 239 and 31 propensity score-matched pairs in the average- and high-risk patients with CLTI. In the average-risk patients, the 2-year AFS and LS rates were 78.1% and 94.4% in the bypass group and 63.0% and 87.7% in the EVT group (P < .001 and P = .007), respectively. The 1-year wound healing rates were 88.6% in the bypass group and 76.8% in the EVT group, respectively (P < .001). The 30-day mortality was 0.8% in the bypass surgery and 0.8% in the EVT group (P = .996). In the high-risk patients, there was no differences in the AFS, LS, and wound healing between the groups (P = .591, P = .148, and P = .074). The 30-day mortality was 3.2% in the bypass group and 3.2% in the EVT group (P = .991). CONCLUSIONS Bypass surgery is superior to EVT with respect to the AFS, LS, and wound healing in the average-risk patients. EVT is a feasible first-line treatment strategy for high-risk patients with CLTI undergoing revascularization, based on the lack of significant differences in the 2-year AFS rate, between the bypass surgery and EVT cohorts.
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Affiliation(s)
- Koichi Morisaki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Daisuke Matsuda
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Atsushi Guntani
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan
| | - Go Kinoshita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinichiro Yoshino
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kentaro Inoue
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenichi Honma
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Shinsuke Mii
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Salm J, Ikker F, Noory E, Beschorner U, Kramer TS, Rieg S, Westermann D, Zeller T. Antimicrobial resistance is not increasing in subsequent cases of ischaemic foot infections, a single-centre cohort from 2012 to 2021. Int Wound J 2024; 21:e14961. [PMID: 38949168 PMCID: PMC11215677 DOI: 10.1111/iwj.14961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 07/02/2024] Open
Abstract
Patients with chronic limb-threatening ischaemia (CLTI) are at risk of foot infections, which is associated with an increase in amputation rates. The use of antibiotics may lead to a higher incidence of antimicrobial resistance (AMR) in subsequent episodes of ischaemic foot infections (IFI). This retrospective single-centre cohort study included 130 patients with IFI undergoing endovascular revascularisation. Staphylococcus aureus and Pseudomonas aeruginosa were the two most common pathogens, accounting for 20.5% and 10.8% of cases, respectively. The prevalence of antimicrobial resistance (AMR) and multi-drug resistance did not significantly increase between episodes (10.2% vs. 13.4%, p = 0.42). In 59% of subsequent episodes, the identified pathogens were unrelated to the previous episode. However, the partial concordance of identified pathogens significantly increased to 66.7% when S. aureus was identified (p = 0.027). Subsequent episodes of IFI in the same patient are likely to differ in causative pathogens. However, in the case of S. aureus, the risk of reinfection, particularly with S. aureus, is increased. Multi-drug resistance does not appear to change between IFI episodes. Therefore, recommendations for empirical antimicrobial therapy should be based on local pathogen and resistance statistics without the need to broaden the spectrum of antibiotics in subsequent episodes.
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Affiliation(s)
- Jonas Salm
- Department of Cardiology and AngiologyUniversity Heart Center FreiburgBad KrozingenGermany
- Medical Center – University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Franziska Ikker
- Department of Cardiology and AngiologyUniversity Heart Center FreiburgBad KrozingenGermany
- Medical Center – University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Elias Noory
- Department of Cardiology and AngiologyUniversity Heart Center FreiburgBad KrozingenGermany
- Medical Center – University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Ulrich Beschorner
- Department of Cardiology and AngiologyUniversity Heart Center FreiburgBad KrozingenGermany
- Medical Center – University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Tobias Siegfried Kramer
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Institute for Hygiene and Environmental MedicineBerlinGermany
- LADR der Laborverbund Dr. Kramer & KollegenGeesthachtGermany
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine IIMedical Center – University of Freiburg, Faculty of Medicine, University of FreiburgFreiburgGermany
| | - Dirk Westermann
- Department of Cardiology and AngiologyUniversity Heart Center FreiburgBad KrozingenGermany
- Medical Center – University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Thomas Zeller
- Department of Cardiology and AngiologyUniversity Heart Center FreiburgBad KrozingenGermany
- Medical Center – University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburgGermany
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Vosgin-Dinclaux V, Bertucat P, Dari L, Webster C, Foussard N, Mohammedi K, Ducasse E, Caradu C. Predictors of major adverse lower limb events in patients with tissue loss secondary to critical limb-threatening ischemia. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 64:34-41. [PMID: 38350775 DOI: 10.1016/j.carrev.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND Chronic limb-threatening ischemia (CLTI) is the end-stage of peripheral arterial disease (PAD) posing a high risk for limb loss and mortality. This study aims to evaluate and list possible predictors of major adverse limb events (MALEs) in CLTI patients with tissue loss. METHODS This retrospective study included all Rutherford-Becker stage 5 or 6 patients who required foot debridement and revascularization in our department from January 2016 to December 2018. The limbs were classified according to the TASC II, GLASS and WiFI grading systems. The primary composite outcome was MALEs at 2 years. The secondary outcomes included all-cause mortality, primary patency, freedom from reintervention, and major amputation. Kaplan-Meier estimates were used to determine the event rates, and Cox proportional hazards model with the index MALE as a time-dependent covariate was used to search for MALEs predictors. RESULTS Of 241 included patients, 19 underwent open surgeries (7.9 %) 207 had endovascular interventions (85.9 %) and 15 required a hybrid approach (6.2 %). On univariate analysis, patients who experienced MALEs (n = 111) more often required hemodialysis (25 vs 15; p = .02), presented with more complex lesions (TASC D on femoropopliteal (p = .05) or below the knee (BTK) arteries (p = .006) with increasing infra-inguinal GLASS Stage (p < .0001)), a history of index limb open (p = .009) or endovascular (p = .049) revascularization, an occluded tibial artery (p = .002 for the posterior tibial and p = .052 for the anterior tibial), or a "desert foot" (p = .02). The CRP level was also higher at admission (p = .001). Technical success of BTK revascularization significantly reduced MALEs (p < .0001) along with the number of patent BTK vessels (p = .0007). Independent predictors of MALEs included hemodialysis (HR = 2.00; 95%CI: 1.14 to 3.39), pulsatile arterial pressure (HR = 1.01; 95%CI: 1.00 to 1.03) and the infra-inguinal GLASS Stage (HR = 2.50; 95%CI: 1.17 to 5.82). We could not correlate our results with the WiFI scores for amputation risk and revascularization benefit. CONCLUSION For patients with CLTI at the stage of trophic disorders, with or without a history of index limb revascularization, the GLASS successfully predicted MALEs. Hemodialysis and high pulsatile arterial pressure increased the risk of MALEs. The WiFI score did not demonstrate its interest in this subgroup of patients.
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Affiliation(s)
| | - Paul Bertucat
- Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
| | - Loubna Dari
- Bordeaux University Hospital, Hôpital Saint-André, Vascular Medicine Department, Bordeaux, France
| | - Claire Webster
- Imperial College London, Department of Vascular Surgery, London, UK
| | - Ninon Foussard
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France
| | - Kamel Mohammedi
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France
| | - Eric Ducasse
- Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
| | - Caroline Caradu
- Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France.
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10
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Nyman J, Acosta S, Svensson-Björk R, Monsen C, Hasselmann J. Prospective Comparison of Wound Complication Rates after Elective Open Peripheral Vascular Surgery - Endovascular Versus Open Vascular Surgeons. Ann Vasc Surg 2024; 104:63-70. [PMID: 37473836 DOI: 10.1016/j.avsg.2023.07.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Skill and experience of surgeons are likely to influence the incidence of surgical wound complications (SWC) after open lower limb revascularization. Differences in SWC between surgeons with predominantly endovascular or open vascular surgical profiles could be expected. The aim of this study was to compare SWC rates after elective open vascular surgery between primarily endovascular and primarily open vascular surgeons. METHODS Prospective data from patients undergoing elective surgery for peripheral artery disease (PAD) was collected between 2013 and 2019. Senior surgeons were assigned to the open-surgeon or the endo-surgeon group based on the percentage of their open surgical case load during the 6 year study period. SWC was measured by their clinical impact scale (grade 1-outpatient treatment to grade 6-death). Surgical site infection was defined by Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of deep tissues, Isolation of bacteria, and Stay (ASEPSIS) criteria. Propensity score adjusted analysis (PSAA) was used to account for differences in baseline and perioperative characteristics and expressed as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS The proportion of chronic limb-threatening ischemia (P = 0.001), ipsilateral foot wound (P = 0.012) and femoro-popliteal bypass procedures (P < 0.001) were higher in the open-surgeon group. A lower incidence of SWC according to ASEPSIS criteria (25.6% vs. 38.6%, respectively, P = 0.042) and SWC grade ≥1 (33.7% vs. 51.0%, respectively, P = 0.010) was found in the endo-surgeon group (n = 86) compared to the open-surgeon group (n = 153). These differences disappeared after PSAA (OR 0.63, 95% CI 0.27-1.44, and OR 0.60, 95% CI 0.27-1.33, respectively). CONCLUSIONS Patients operated by endo-surgeons had less advanced PAD and lower incidence of SWC compared to those treated by open-surgeons. No difference in SWC remained after PSAA.
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Affiliation(s)
- Johan Nyman
- Department of Cardiothoracic and Vascular Surgery, Vascular Center, Skane University Hospital, Malmö, Sweden; Department of Clinical Sciences, Lund University, Malmö, Sweden.
| | - Stefan Acosta
- Department of Cardiothoracic and Vascular Surgery, Vascular Center, Skane University Hospital, Malmö, Sweden; Department of Clinical Sciences, Lund University, Malmö, Sweden
| | | | - Christina Monsen
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Allied Health Professions, Skane University Hospital, Malmö, Sweden
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11
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Nordanstig J, Menard MT. Do We Lose on the Swings What We Gain on the Roundabouts? Eur J Vasc Endovasc Surg 2024; 68:108-109. [PMID: 38360132 DOI: 10.1016/j.ejvs.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 02/17/2024]
Affiliation(s)
- Joakim Nordanstig
- Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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12
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Bradley NA, Walter A, Roxburgh CSD, McMillan DC, Guthrie GJK. The Relationship between Clinical Frailty Score, CT-Derived Body Composition, Systemic Inflammation, and Survival in Patients with Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2024; 104:18-26. [PMID: 37356659 DOI: 10.1016/j.avsg.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/23/2023] [Accepted: 06/06/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Frailty is a chronic condition with complex etiology and impaired functional performance that has been associated with altered body composition and chronic inflammation. Chronic limb-threatening ischemia (CLTI) carries significant morbidity and mortality and is associated with poor quality of life. The present study aims to examine these relationships and their prognostic value in patients with CLTI. METHODS Consecutive patients presenting as unscheduled admissions to a single tertiary center with CLTI were included over a 12-month period. Frailty was diagnosed using the Clinical Frailty Scale (CFS). Body composition was assessed using computerised tomography (CT) at the L3 vertebral level (CT-BC) to generate visceral and subcutaneous fat indices, skeletal muscle index, and skeletal muscle density. Skeletal muscle index and skeletal muscle density were combined to form the CT-sarcopenia score (CT-SS). Systemic inflammation was assessed by the modified Glasgow prognostic score (mGPS). The primary outcome was overall mortality. RESULTS There were 190 patients included with a median (interquartile range) follow-up of 22 (6) months (range 15-32 months) and 79 deaths during the follow-up period. One hundred patients (53%) had a CFS >4. CFS >4 (hazard ratio [HR] 2.14, 95% confidence interval [CI] 1.25-3.66, P < 0.01), CT-SS (HR 1.47, 95% CI 1.03-2.09, P < 0.05), and mGPS (HR 1.54, 95% CI 1.11-2.13, P < 0.01) were independently associated with increased mortality. CT-SS (odds ratio 1.88, 95% CI 1.09-3.24, P < 0.01) was independently associated with CFS >4. Patients with CT-SS 0 and CFS ≤4 had 90% (standard error [SE] 5%) 1-year survival, compared with 35% (SE 9%) in patients with CT-SS 2 and CFS >4 (P < 0.001). Patients with mGPS 0 and CFS ≤4 had 94% (SE 4%) 1-year survival compared with 44% (SE 6%) in the mGPS 2 and CFS >4 subgroup (P < 0.001). CONCLUSIONS Frailty assessed by CFS was associated with CT-BC. CFS, CT-SS, and mGPS were associated with poorer survival in patients presenting as unscheduled admissions with CLTI. CT-SS and mGPS may contribute to part of frailty and prognostic assessment in this patient cohort.
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Affiliation(s)
- Nicholas A Bradley
- Clinical Research Fellow, University of Glasgow, Glasgow, Scotland, United Kingdom.
| | - Amy Walter
- Clinical Fellow, NHS Tayside, Dundee, Scotland, United Kingdom
| | | | - Donald C McMillan
- Professor of Surgical Science, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Graeme J K Guthrie
- Consultant Vascular Surgeon, NHS Tayside, Honorary Clinical Senior Lecturer, University of Glasgow, Glasgow, Scotland, United Kingdom
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13
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Muñoz A, Muñoz D, Cardozo A. Saphenous vein ablation a word of caution. J Vasc Surg Venous Lymphat Disord 2024; 12:101728. [PMID: 38244858 DOI: 10.1016/j.jvsv.2023.101728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 11/19/2023] [Indexed: 01/22/2024]
Affiliation(s)
- Alberto Muñoz
- Vascular and Endovascular Surgery Unit, National University Hospital, Bogotá, Colombia; Clínica Vascular de Bogotá, Bogotá, Colombia.
| | - Daniel Muñoz
- Facultad de Medicina, Universidad de los Andes, Bogotá, Colombia
| | - Andrés Cardozo
- Facultad de Medicina, Universidad de los Andes, Bogotá, Colombia
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Komai H. Vascular Disease and Diabetes. Ann Vasc Dis 2024; 17:109-113. [PMID: 38919320 PMCID: PMC11196175 DOI: 10.3400/avd.ra.24-00010] [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: 02/01/2024] [Accepted: 02/07/2024] [Indexed: 06/27/2024] Open
Abstract
The most important vascular lesion associated with diabetes is arteriosclerosis obliterans (ASO). Differential diagnosis from diabetic foot lesions that produce neurogenic ulcers is important, and the presence of ischemia must be diagnosed as soon as possible. It has been reported that diabetes makes ASO more severe and often leads to lower extremity amputation. In addition to the need for appropriate early control of diabetes, vascular surgeons are required to perform immediate revascularization in cases of ulcer and necrosis, and to aggressively use surgical treatment with good long-term prognosis. (This is a translation of Jpn J Vasc Surg 2023; 32: 105-109.).
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Affiliation(s)
- Hiroyoshi Komai
- Department of Vascular Surgery, Kansai Medical University Medical Center, Osaka, Osaka, Japan
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15
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Espinola-Klein C. [Lower extremity arterial disease (LEAD)]. Herz 2024:10.1007/s00059-024-05252-3. [PMID: 38916707 DOI: 10.1007/s00059-024-05252-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/26/2024]
Abstract
Peripheral arterial occlusive disease (PAOD) is a frequent manifestation of atherosclerosis with a high risk of cardiovascular events (myocardial infarction, stroke, amputation, cardiovascular death). A distinction is made between the stable form of intermittent claudication and chronic limb-threatening ischemia (CLTI, pain at rest, wounds). The most frequent risk factors are diabetes mellitus and smoking. As the disease is often asymptomatic early diagnostic necessary. Measurement of the ankle-brachial index (ABI) is suitable for screening. Consistent treatment of cardiovascular risk factors and antithrombotic medication are important. At the stage of intermittent claudication, exercise training should be performed. In CLTI early endovascular or surgical revascularization must be performed to avoid amputation of the extremity.
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Affiliation(s)
- Christine Espinola-Klein
- Kardiologie III - Angiologie, Zentrum für Kardiologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland.
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16
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Heindel P, Fitzgibbon JJ, McKie K, Goudreau B, Dieffenbach BV, Aicher BO, Belkin M, Farber A, Menard MT, Hussain MA. Real-World Vein Mapping Practice Patterns Before Endovascular Treatment of Limb Ischemia. J Surg Res 2024; 301:62-70. [PMID: 38917575 DOI: 10.1016/j.jss.2024.05.011] [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: 01/07/2024] [Revised: 05/02/2024] [Accepted: 05/08/2024] [Indexed: 06/27/2024]
Abstract
INTRODUCTION The Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trial results suggest that in patients with chronic limb-threatening ischemia (CLTI) and adequate single-segment great saphenous vein (SSGSV) by preoperative duplex ultrasonography, a surgical-first treatment strategy is superior to an endovascular-first strategy. However, the utilization of vein mapping prior to endovascular-first revascularization for CLTI in actual clinical practice is not known. METHODS Data from a multicenter clinical data warehouse (2008-2019) were linked to Medicare claims data for patients undergoing endovascular-first treatment of infra-inguinal CLTI. Only patients who would have otherwise been eligible for enrollment in BEST-CLI were included. Adequate SSGSV was defined as healthy vein >3.0 mm in diameter from the groin through the knee. Logistic regression was used to estimate associations between preprocedure characteristics and vein mapping. Survival methods were used to estimate the risk of major adverse limb events and death. RESULTS A total of 142 candidates for either surgical or endovascular treatment underwent endovascular-first management of CLTI. Ultrasound assessment for SSGSV was not performed in 76% of patients prior to endovascular-first revascularization. Of those who underwent preprocedure vein mapping, 44% had adequate SSGSV for bypass. Within one year postprocedure, 12.0% (95% confidence interval 7.4-18.0%) of patients underwent open surgical bypass and 54.7% (95% confidence interval 45.3-62.4%) experienced a major adverse limb event or death. CONCLUSIONS In a real-world cohort of BEST-CLI-eligible patients undergoing endovascular-first intervention for infra-inguinal CLTI, three-quarters of patients had no preprocedure ultrasound assessment of great saphenous vein conduit. Practice patterns for vein conduit assessment in the real-world warrant reconsideration in the context of BEST-CLI trial results.
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Affiliation(s)
- Patrick Heindel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - James J Fitzgibbon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kerri McKie
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bernadette Goudreau
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Brittany O Aicher
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mohamad A Hussain
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
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17
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Korosoglou G, Feld J, Langhoff R, Lichtenberg M, Stausberg J, Hoffmann U, Rammos C, Malyar N. Safety and Effectiveness of Debulking for the Treatment of Infrainguinal Peripheral Artery Disease. Data From the Recording Courses of vascular Diseases Registry in 2910 Patients. Angiology 2024:33197241263381. [PMID: 38904281 DOI: 10.1177/00033197241263381] [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: 06/22/2024]
Abstract
We investigated the safety and efficacy of debulking infrainguinal lesions in patients with peripheral artery disease (PAD) undergoing endovascular revascularization (EVR) as part of the RECording Courses of vascular Diseases (RECCORD) registry. Patient and lesion specific characteristics, including the lesion complexity score (LCS) were analyzed. The primary endpoint encompassed: (i) clinical improvement in Rutherford categories, (ii) index limb re-interventions, and (iii) major amputations during follow-up. The secondary endpoint included the need for bail-out stenting. Overall, 2910 patients were analyzed; 2552 without and 358 with debulking-assisted EVR. Patients were 72 (interquartile range (IQR) = 15) years old and 1027 (35.3%) had diabetes. Overall complication rates were similarly low in the debulking vs the non-debulking group (4.7 vs 3.2%, P = .18). However, peripheral embolizations rates were low but more frequent with debulking vs. non-debulking procedures (3.9 vs 1.1%, P < .001). After adjustment for clinical and lesion-specific parameters, including LCS, no differences were noted for the primary endpoint (odds ration (OR) = 0.99, 95%CI = 0.69-1.41, P = .94). Bail-out stenting was less frequently performed in patients with debulking-assisted EVR (OR = 0.5, 95%CI = 0.38-0.65, P < .0001). Debulking-assisted EVR is currently used in ∼12% of EVR with infrainguinal lesions and is associated with lower bail-out stent rates but higher peripheral embolization rates; no differences were found regarding index limb re-intervention and amputation rates.
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Affiliation(s)
| | - Jannik Feld
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Ralf Langhoff
- Department of Angiology, Sankt-Gertrauden-Krankenhaus, Berlin, Germany
| | | | | | - Ulrich Hoffmann
- Division of Vascular Medicine, Medical Clinic and Policlinic IV, University Hospital Munich, Munich, Germany
| | - Christos Rammos
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University of Duisburg-Essen, Duisburg, Germany
| | - Nasser Malyar
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiology, Münster, Germany
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18
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Aridi HD, Sansone J, Ramchandani N, Gutwein AR, Rowe VL, Zheng X, Mao J, Goodney PP, Motaganahalli RL. Long-term outcomes of great saphenous vein harvest techniques for infrainguinal arterial bypass in a Medicare-matched registry database. J Vasc Surg 2024:S0741-5214(24)01215-1. [PMID: 38912996 DOI: 10.1016/j.jvs.2024.05.036] [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: 04/15/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 06/25/2024]
Abstract
OBJECTIVE Long-term outcomes for harvesting techniques for great saphenous vein (GSV) and its impact on the outcomes of infrainguinal arterial bypass remains largely unknown. Endoscopic GSV harvesting (EVH) has emerged as a less invasive alternative to conventional open techniques. Using the Vascular Quality initiative Vascular Implant Surveillance & Interventional Outcomes Network (VQI-VISION) database, we compared the long-term outcomes of infrainguinal arterial bypass using open and endoscopic GSV harvest techniques. METHODS Patients who underwent infrainguinal GSV bypass between 2010 and 2019 were identified in the VQI-VISION Medicare linked database. Long-term outcomes of major/minor amputations, and reinterventions up to 5 years of follow-up were compared between continuous incisions, skip incision, and EVH, with continuous incisions being the reference group. Secondary outcomes included 30- and 90-day readmission, in addition to surgical site infections and patency rates at 6 months to 2 years postoperatively. Survival analysis using Kaplan-Meier curves and Cox regression hazard models were utilized to compare outcomes between groups. To adjust for multiple comparisons between the study groups, a P value of 2.5% was considered significant. RESULTS Among the 8915 patients included in the study, continuous and skip vein harvest techniques were used in 44.4% and 43.4% of cases each, whereas 12.3% underwent EVH. The utilization of EVH remained relatively stable at around 12% throughout the study period. Compared with GSV harvest using continuous incisions, EVH was associated with higher rates of reintervention at 1 year (46.5% vs 41.3%; adjusted hazard ratio [aHR], 1.22; 95% confidence interval [CI], 1.06-1.41; P = .01]. However, no significant difference was observed between EVH and continuous incisions, and between skip and continuous incisions in terms of long-term reintervention or major and minor amputations on adjusted analysis. Compared with continuous incision vein harvest, both EVH and skip incisions were associated with lower surgical site infection rates within the first 6 months post-bypass (aHR, 0.53; 95% CI, 0.35-0.82 and aHR, 0.68; 95% CI, 0.53-0.87, respectively). Loss of primary, primary-assisted, and secondary patency was higher after EVH compared with continuous incision vein harvest. Among surgeons performing EVH, comparable long-term outcomes were observed regardless of low (<4 cases/year), medium (4-7 cases/year), or high procedural volumes (>7 cases/year). CONCLUSIONS Despite higher 1-year reintervention rates, EVH for infrainguinal arterial bypass is not associated with a significant difference in long-term reintervention or amputation rates compared with other harvesting techniques. These outcomes are not influenced by procedural volumes for EVH technique.
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Affiliation(s)
- Hanaa D Aridi
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Jack Sansone
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Neal Ramchandani
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Ashley R Gutwein
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Vincent L Rowe
- Division of Vascular Surgery and Endovascular Therapy, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Xinyan Zheng
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Jialin Mao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN.
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Giles KA, Farber A, Menard MT, Conte MS, Nolan BW, Siracuse JJ, Strong M, Doros G, Venermo M, Azene E, Rosenfield K, Powell RJ. Surgery or Endovascular Therapy for Patients with Chronic Limb-threatening Ischemia Requiring Infrapopliteal Interventions. J Vasc Surg 2024:S0741-5214(24)01228-X. [PMID: 38908805 DOI: 10.1016/j.jvs.2024.05.049] [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: 04/24/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVE The recent publication of randomized trials comparing open bypass surgery to endovascular therapy in chronic limb threatening ischemia (CLTI) patients, BEST-CLI and BASIL-2, has resulted in potentially contradictory findings. The trials differed significantly with respect to anatomic disease patterns and primary endpoints. We performed an analysis of BEST-CLI patients with significant infrapopliteal disease undergoing open tibial bypass or endovascular tibial interventions to formulate a relevant comparator to the outcomes reported from BASIL-2. METHODS The study population consisted of BEST-CLI patients with adequate single segment saphenous vein conduit randomized to open bypass or endovascular intervention (Cohort 1) who additionally had significant infrapopliteal disease and underwent tibial level intervention. The primary outcome was major adverse limb event (MALE) or all-cause death. MALE included any major limb amputation or major re-intervention. Outcomes were evaluated using Cox proportional regression models. RESULTS The analyzed subgroup included a total of 665 patients with 326 in the open tibial bypass group and 339 in the tibial endovascular intervention group. The primary outcome of MALE or all cause death at 3 years was significantly lower in the surgical group at 48.5% compared to 56.7% in the endovascular group (p=0.0018). Mortality was similar between groups (35.5% open vs. 35.8% endovascular; p=0.94 whereas MALE events were lower in the surgical group (23.3% vs. 35.0%; p<0.0001). This included a lower rate of major reinterventions in the surgical group (10.9%) compared to the endovascular group (20.2%; p=0.0006). Freedom from above ankle amputation or all-cause death was similar between treatment arms at 43.6% in the surgical group compared to 45.3% the endovascular group (p=0.30) however there were fewer above ankle amputations in the surgical group (13.5%) compared to the endovascular group (19.3%; p=0.0205). Perioperative (30-day) death was similar between treatment groups (2.5% open vs 2.4% endovascular; p=0.93) as was 30-day MACE (5.3% open vs 2.7% endovascular; p=0.12). CONCLUSIONS Among patients with suitable single segment great saphenous vein who underwent infrapopliteal revascularization for CLTI, open bypass surgery was associated with a lower incidence of MALE or death and less major amputation compared to endovascular intervention. Amputation free survival was similar between the groups. Further investigations into differences in comorbidities, anatomic extent, and lesion complexity are needed to explain differences between the BEST-CLI and BASIL-2 reported outcomes.
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Affiliation(s)
- Kristina A Giles
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, ME.
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Woman's Hospital, Boston, MA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California San Francisco, CA
| | - Brian W Nolan
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, ME
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | | | - Gheorghe Doros
- Department of Biostatistics, Boston University, School of Public Health, Boston, MA
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki Finland
| | - Ezana Azene
- Department of Interventional Radiology, Gundersen Health System, La Crosse, WI
| | - Kenneth Rosenfield
- Vascular Medicine and Intervention, Massachusetts General Hospital, Boston, MA
| | - Richard J Powell
- Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
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20
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Kobayashi T, Hamamoto M, Okazaki T, Okusako R, Takahashi S. Learning curve in tibial and pedal bypass with autologous vein graft. Vascular 2024:17085381241263909. [PMID: 38896848 DOI: 10.1177/17085381241263909] [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: 06/21/2024]
Abstract
OBJECTIVES The 2019 Global Vascular Guidelines recommended open bypass for patients at average risk with greater limb severity and anatomical complexity. However, the outcomes of tibial and pedal bypass (TPB) are inferior to those of above-the-knee surgical revascularization. This may be due to the technical difficulty and need for development of skills to perform TPB. However, there is a limited knowledge on the learning curve in TPB. Thus, the aim of the study is to assess this learning curve in a single-center retrospective analysis. METHODS Cases treated with TPB with an autologous vein conduit in patients with chronic limb-threatening ischemia (CLTI) at a Japanese single center from 2009 to 2022 were analyzed retrospectively. The primary endpoint was the learning curve for TPB. RESULTS The study included 449 TPB procedures conducted by a single main surgeon in patients with CLTI (median age, 75 years; 309 males; diabetes mellitus, 73%; end stage renal failure with hemodialysis, 44%). The operative time decreased significantly as the number of cases accumulated (p < .001). Using the cumulative sum (CUSUM) operative time, the learning curve was estimated to be phase 1 (initial learning curve) for 134 cases (1-134); phase 2 (competent period) for 179 cases (135-313); and phase 3 (mastery and challenging period) for 136 cases (314-449). The mean follow-up period was 34 ± 31 months. The 1- and 3-year limb salvage rates of 97% and 96% in phase 3 were significantly higher than those in phases 1 and 2 (p < .001, p = .029). Major adverse limb events (MALE) occurred in 117 (26%) patients, and the 1- and 3-year MALE rates of 10% and 17% in phase 3 were significantly lower than those in phases 1 and 2 (p < .001, p = .009). CONCLUSIONS In the study, vascular surgeon required a learning curve of 134 TPB cases to Overcoming the learning curve for bypass was associated with improvement of medium-term outcomes for limb salvage and freedom from MALE.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Ryo Okusako
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University, Hiroshima, Japan
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Campbell DB, Gutta G, Sobol CG, Atway SA, Haurani MJ, Chen XP, Rowe VL, Stacy MR, Go MR. How multidisciplinary clinics may mitigate socioeconomic barriers to care for chronic limb-threatening ischemia. J Vasc Surg 2024:S0741-5214(24)01212-6. [PMID: 38906429 DOI: 10.1016/j.jvs.2024.05.033] [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: 04/07/2024] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE Although multidisciplinary clinics improve outcomes in chronic limb-threatening ischemia (CLTI), their role in addressing socioeconomic disparities is unknown. Our institution treats patients with CLTI at both traditional general vascular clinics and a multidisciplinary Limb Preservation Program (LPP). The LPP is in a minority community, providing expedited care at a single facility by a consistent team. We compared outcomes within the LPP with our institution's traditional clinics and explored patients' perspectives on barriers to care to evaluate if the LPP might address them. METHODS All patients undergoing index revascularization for CLTI from 2014 to 2023 at our institution were stratified by clinic type (LPP or traditional). We collected clinical and socioeconomic variables, including Area Deprivation Index (ADI). Patient characteristics were compared using χ2, Student t, or Mood median tests. Outcomes were compared using log-rank and multivariable Cox analysis. We also conducted semi-structured interviews to understand patient-perceived barriers. RESULTS From 2014 to 2023, 983 limbs from 871 patients were revascularized; 19.5% of limbs were treated within the LPP. Compared with traditional clinic patients, more LPP patients were non-White (43.75% vs 27.43%; P < .0001), diabetic (82.29% vs 61.19%; P < .0001), dialysis-dependent (29.17% vs 13.40%; P < .0001), had ADI in the most deprived decile (29.38% vs 19.54%; P = .0061), resided closer to clinic (median 6.73 vs 28.84 miles; P = .0120), and had worse Wound, Ischemia, and foot Infection (WIfI) stage (P < .001). There were no differences in freedom from death, major adverse limb event (MALE), or patency loss. Within the most deprived subgroup (ADI >90), traditional clinic patients had earlier patency loss (P = .0108) compared with LPP patients. Multivariable analysis of the entire cohort demonstrated that increasing age, heart failure, dialysis, chronic obstructive pulmonary disease, and increasing WIfI stage were independently associated with earlier death, and male sex was associated with earlier MALE. Ten traditional clinic patients were interviewed via convenience sampling. Emerging themes included difficulty understanding their disease, high visit frequency, transportation barriers, distrust of the health care system, and patient-physician racial discordance. CONCLUSIONS LPP patients had worse comorbidities and socioeconomic deprivation yet had similar outcomes to healthier, less deprived non-LPP patients. The multidisciplinary clinic's structure addresses several patient-perceived barriers. Its proximity to disadvantaged patients and ability to conduct multiple appointments at a single visit may address transportation and visit frequency barriers, and the consistent team may facilitate patient education and improve trust. Including these elements in a multidisciplinary clinic and locating it in an area of need may mitigate some negative impacts of socioeconomic deprivation on CLTI outcomes.
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Affiliation(s)
- Drayson B Campbell
- The Ohio State University College of Medicine, Columbus, OH; Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Goutam Gutta
- The Ohio State University College of Medicine, Columbus, OH; Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Carly G Sobol
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin, Madison, WI
| | - Said A Atway
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH
| | - Mounir J Haurani
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Xiaodong P Chen
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Mitchel R Stacy
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH; Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Michael R Go
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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22
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Li B, Shaikh F, Zamzam A, Syed MH, Abdin R, Qadura M. The Identification and Evaluation of Interleukin-7 as a Myokine Biomarker for Peripheral Artery Disease Prognosis. J Clin Med 2024; 13:3583. [PMID: 38930112 PMCID: PMC11205196 DOI: 10.3390/jcm13123583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/13/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
Background/Objectives: Myokines have been demonstrated to be associated with cardiovascular diseases; however, they have not been studied as biomarkers for peripheral artery disease (PAD). We identified interleukin-7 (IL-7) as a prognostic biomarker for PAD from a panel of myokines and developed predictive models for 2-year major adverse limb events (MALEs) using clinical features and plasma IL-7 levels. Methods: A prognostic study was conducted with a cohort of 476 patients (312 with PAD and 164 without PAD) that were recruited prospectively. Their plasma concentrations of five circulating myokines were measured at recruitment, and the patients were followed for two years. The outcome of interest was two-year MALEs (composite of major amputation, vascular intervention, or acute limb ischemia). Cox proportional hazards analysis was performed to identify IL-7 as the only myokine that was associated with 2-year MALEs. The data were randomly divided into training (70%) and test sets (30%). A random forest model was trained using clinical characteristics (demographics, comorbidities, and medications) and plasma IL-7 levels with 10-fold cross-validation. The primary model evaluation metric was the F1 score. The prognostic model was used to classify patients into low vs. high risk of developing adverse limb events based on the Youden Index. Freedom from MALEs over 2 years was compared between the risk-stratified groups using Cox proportional hazards analysis. Results: Two-year MALEs occurred in 28 (9%) of patients with PAD. IL-7 was the only myokine that was statistically significantly correlated with two-year MALE (HR 1.56 [95% CI 1.12-1.88], p = 0.007). For the prognosis of 2-year MALEs, our model achieved an F1 score of 0.829 using plasma IL-7 levels in combination with clinical features. Patients classified as high-risk by the predictive model were significantly more likely to develop MALEs over a 2-year period (HR 1.66 [95% CI 1.22-1.98], p = 0.006). Conclusions: From a panel of myokines, IL-7 was identified as a prognostic biomarker for PAD. Using a combination of clinical characteristics and plasma IL-7 levels, we propose an accurate predictive model for 2-year MALEs in patients with PAD. Our model may support PAD risk stratification, guiding clinical decisions on additional vascular evaluation, specialist referrals, and medical/surgical management, thereby improving outcomes.
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Affiliation(s)
- Ben Li
- Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada;
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health Toronto, University of Toronto, 30 Bond Street, Suite 7-076, Toronto, ON M5B 1W8, Canada; (F.S.); (A.Z.); (M.H.S.)
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A1, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Farah Shaikh
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health Toronto, University of Toronto, 30 Bond Street, Suite 7-076, Toronto, ON M5B 1W8, Canada; (F.S.); (A.Z.); (M.H.S.)
| | - Abdelrahman Zamzam
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health Toronto, University of Toronto, 30 Bond Street, Suite 7-076, Toronto, ON M5B 1W8, Canada; (F.S.); (A.Z.); (M.H.S.)
| | - Muzammil H. Syed
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health Toronto, University of Toronto, 30 Bond Street, Suite 7-076, Toronto, ON M5B 1W8, Canada; (F.S.); (A.Z.); (M.H.S.)
| | - Rawand Abdin
- Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Mohammad Qadura
- Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada;
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health Toronto, University of Toronto, 30 Bond Street, Suite 7-076, Toronto, ON M5B 1W8, Canada; (F.S.); (A.Z.); (M.H.S.)
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A1, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, ON M5B 1W8, Canada
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23
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Gottsäter A. Bypassing Amputations in BEST-CLI. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00493-3. [PMID: 38906367 DOI: 10.1016/j.ejvs.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 06/16/2024] [Indexed: 06/23/2024]
Affiliation(s)
- Anders Gottsäter
- Department of Internal Medicine, Clinical Research Unit, Lund University, Skåne University Hospital, Malmö, Sweden.
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24
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2497-2604. [PMID: 38752899 DOI: 10.1016/j.jacc.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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25
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Mohamad Yusoff F, Kajikawa M, Yamaji T, Kishimoto S, Maruhashi T, Nakashima A, Tsuji T, Higashi Y. Low-intensity pulsed ultrasound improves symptoms in patients with Buerger disease: a double-blinded, randomized, and placebo-controlled study. Sci Rep 2024; 14:13704. [PMID: 38871832 DOI: 10.1038/s41598-024-64118-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 06/05/2024] [Indexed: 06/15/2024] Open
Abstract
Here we report the effects of low-intensity pulsed ultrasound (LIPUS) on symptoms in peripheral arterial disease patients with Buerger disease. A double-blinded and randomized study with active and inactive LIPUS was conducted. We assessed symptoms in leg circulation during a 24-week period of LIPUS irradiation in 12 patients with Buerger disease. Twelve patients without LIPUS irradiation served as controls. The pain intensity on visual analog score was significantly decreased after 24-week LIPUS treatment. Skin perfusion pressure was significantly increased in patients who received LIPUS treatment. There was no significant difference in symptoms and perfusion parameters in the control group. No severe adverse effects were observed in any of the patients who underwent LIPUS treatment. LIPUS is noninvasive, safe and effective option for improving symptoms in patients with Buerger disease.
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Affiliation(s)
- Farina Mohamad Yusoff
- Department of Regenerative Medicine, Division of Radiation Medical Science, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Masato Kajikawa
- Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Takayuki Yamaji
- Department of Regenerative Medicine, Division of Radiation Medical Science, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Shinji Kishimoto
- Department of Regenerative Medicine, Division of Radiation Medical Science, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Tatsuya Maruhashi
- Department of Regenerative Medicine, Division of Radiation Medical Science, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan
| | - Ayumu Nakashima
- Department of Nephrology, Graduate School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Toshio Tsuji
- Graduate School of Engineering, Hiroshima University, Hiroshima, Japan
| | - Yukihito Higashi
- Department of Regenerative Medicine, Division of Radiation Medical Science, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8551, Japan.
- Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan.
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26
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Cifuentes S, Sen I, DeMartino RR, Mendes BC, Shuja F, Colglazier JJ, Kalra M, Schaller MS, Morrison JJ, Rasmussen TE. Comparative outcomes of arterial bypass using the human acellular vessel and great saphenous vein in patients with chronic limb ischemia. J Vasc Surg 2024:S0741-5214(24)01189-3. [PMID: 38904582 DOI: 10.1016/j.jvs.2024.05.012] [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: 04/20/2024] [Revised: 05/10/2024] [Accepted: 05/11/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE The Human Acellular Vessel (HAV) is a novel, off-the-shelf biologic conduit being evaluated for arterial reconstructions. Regulatory studies in peripheral arterial disease (PAD) to date have consisted of single-arm cohorts with no comparator groups to contrast performance against established standards. This study aimed to compare outcomes of the HAV with autologous great saphenous vein (GSV) in patients with advanced PAD undergoing infrageniculate bypass. METHODS Patients with advanced PAD and no autologous conduit who underwent bypass with the 6-mm diameter HAV (Group 1; n = 34) (March 2021-February 2024) were compared with a multicenter historical cohort who had bypass with single-segment GSV (group 2; n = 88) (January 2017-December 2022). The HAV was used under an Investigational New Drug protocol issued by the Food and Drug Administration (FDA) under the agency's Expanded Access Program. RESULTS Demographics were comparable between groups (mean age 69 ± 10 years; 71% male). Group 1 had higher rates of tobacco use (37 pack-years vs 28 pack-years; P = .059), coronary artery disease (71% vs 43%; P = .007), and prior coronary artery bypass grafting (38% vs 14%; P = .003). Group 1 had more patients classified as wound, ischemia, and foot infection clinical stage 4 (56% vs 33%; P = .018) and with previous index leg revascularizations (97% vs 53%; P < .001). Both groups had a similar number of patients with chronic limb-threatening ischemia (Rutherford class 4-6) (88% vs 86%; P = .693) and Global Anatomic Staging System stage III (91% vs 96%; P = .346). Group 1 required a composite conduit (two HAV sewn together) in 85% of bypasses. The tibial vessels were the target in 79% of group 1 and 100% of group 2 (P < .001). Group 1 had a lower mean operative time (364 minutes vs 464 minutes; P < .001). At a median of 12 months, major amputation-free survival (73% vs 81%; P = .55) and overall survival (84% vs 88%; P = .20) were comparable. Group 1 had lower rates of primary patency (36% vs 50%; P = .044), primary-assisted patency (45% vs 72%; P = .002), and secondary patency (64% vs 72%; P = .003) compared with group 2. CONCLUSIONS Implanted under Food and Drug Administration Expanded Access provisions, the HAV was more likely to be used in redo operations and cases with more advanced limb ischemia than GSV. Despite modest primary patency, the HAV demonstrated resilience in a complex cohort with no autologous conduit options, achieving good secondary patency and providing major amputation-free survival comparable with GSV at 12 months.
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Affiliation(s)
| | - Indrani Sen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Fahad Shuja
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jill J Colglazier
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Melinda S Schaller
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Todd E Rasmussen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
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27
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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28
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Haga M, Shindo S, Nitta J, Kimura M, Motohashi S, Inoue H, Akasaka J. Anatomical and clinical factors associated with infrapopliteal arterial bypass outcomes in patients with chronic limb-threatening ischemia. Heart Vessels 2024:10.1007/s00380-024-02421-6. [PMID: 38842587 DOI: 10.1007/s00380-024-02421-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 05/23/2024] [Indexed: 06/07/2024]
Abstract
The aim of this study was to identify anatomical and clinical factors associated with limb-based patency (LBP) loss, major adverse limb events (MALEs), and poor amputation-free survival (AFS) after an infrapopliteal arterial bypass (IAB) surgery according to the Global Limb Anatomic Staging System. A retrospective analysis of patients undergoing IAB surgery between January 2010 and December 2021 at a single institution was performed. Two-year AFS, freedom from LBP loss, and freedom from MALEs were assessed using the Kaplan-Meier method. Anatomical and clinical predictors were assessed using multivariate analysis. The total number of risk factors was used to calculate risk scores for subsequent categorization into low-, moderate-, and high-risk groups. IABs were performed on 103 patients. The rates of two-year freedom from LBP loss, freedom from MALEs, and AFS were 71.3%, 76.1%, and 77.0%, respectively. The multivariate analysis showed that poor run-off beyond the ankle and a bypass vein caliber of < 3 mm were significantly associated with LBP loss and MALEs. Moreover, end-stage renal disease, non-ambulatory status, and a body mass index of < 18.5 were significantly associated with poor AFS. The rates of freedom from LBP loss and MALEs and the AFS rate were significantly lower in the high-risk group than in the other two groups (12-month low-risk rates: 92.2%, 94.8%, and 94.4%, respectively; 12-month moderate-risk rates: 58.6%, 84.6%, and 78.3%, respectively; 12-month high-risk rates: 11.1%, 17.6%, and 56.2%, respectively; p < 0.001, p < 0.001, and p < 0.001, respectively). IAB is associated with poor clinical outcomes in terms of LBP, MALEs, and AFS in high-risk patients. Risk stratification based on these predictors is useful for long-term prognosis.
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Affiliation(s)
- Makoto Haga
- Department of Cardiovascular Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi-chou, Hachioji-shi, Tokyo, 193-0944, Japan.
| | - Shunya Shindo
- Center for Preventive Medicine, Yamanashi Kosei Hospital, Yamanashi, Japan
| | - Jun Nitta
- Department of Cardiovascular Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi-chou, Hachioji-shi, Tokyo, 193-0944, Japan
| | - Mitsuhiro Kimura
- Department of Cardiovascular Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi-chou, Hachioji-shi, Tokyo, 193-0944, Japan
| | - Shinya Motohashi
- Department of Cardiovascular Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi-chou, Hachioji-shi, Tokyo, 193-0944, Japan
| | - Hidenori Inoue
- Department of Cardiovascular Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi-chou, Hachioji-shi, Tokyo, 193-0944, Japan
| | - Junetsu Akasaka
- Department of Cardiovascular Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi-chou, Hachioji-shi, Tokyo, 193-0944, Japan
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29
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Matthay ZA, Pace WA, Smith EJ, Gutierrez RD, Gasper WJ, Hiramoto JS, Reilly LM, Conte MS, Iannuzzi JC. Predictors of amputation-free survival and wound healing after infrainguinal bypass with alternative conduits. J Vasc Surg 2024; 79:1447-1456.e2. [PMID: 38310981 DOI: 10.1016/j.jvs.2024.01.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 01/24/2024] [Accepted: 01/28/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVE Inadequate vein quality or prior harvest precludes use of autologous single segment greater saphenous vein (ssGSV) in many patients with chronic limb-threatening ischemia (CLTI). Predictors of patient outcome after infrainguinal bypass with alternative (non-ssGSV) conduits are not well-understood. We explored whether limb presentation, bypass target, and conduit type were associated with amputation-free survival (AFS) after infrainguinal bypass using alternative conduits. METHODS A single-center retrospective study (2013-2020) was conducted of 139 infrainguinal bypasses performed for CLTI with cryopreserved ssGSV (cryovein) (n = 71), polytetrafluoroethylene (PTFE) (n = 23), or arm/spliced vein grafts (n = 45). Characteristics, Wound, Ischemia, and foot Infection (WIfI) stage, and outcomes were recorded. Multivariable Cox proportional hazards and classification and regression tree analysis modeled predictors of AFS. RESULTS Within 139 cases, the mean age was 71 years, 59% of patients were male, and 51% of cases were nonelective. More patients undergoing bypass with cryovein were WIfI stage 4 (41%) compared with PTFE (13%) or arm/spliced vein (27%) (P = .04). Across groups, AFS at 2 years was 78% for spliced/arm, 79% for PTFE, and 53% for cryovein (adjusted hazard ratio for cryovein, 2.5; P = .02). Among cases using cryovein, classification and regression tree analysis showed that WIfI stage 3 or 4, age >70 years, and prior failed bypass were predictive of the lowest AFS at 2 years of 36% vs AFS of 58% to 76% among subgroups with less than two of these factors. Although secondary patency at 2 years was worse in the cryovein group (26% vs 68% and 89% in arm/spliced and PTFE groups; P < .01), in patients with tissue loss there was no statistically significant difference in wound healing in the cryovein group (72%) compared with other bypass types (72% vs 87%, respectively; P = .12). CONCLUSIONS In patients with CLTI lacking suitable ssGSV, bypass with autogenous arm/spliced vein or PTFE has superior AFS compared with cryovein, although data were limited for PTFE conduits for distal targets. Despite poor patency with cryovein, wound healing is achieved in a majority of cases, although it should be used with caution in older patients with high WIfI stage and prior failed bypass, given the low rates of AFS.
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Affiliation(s)
- Zachary A Matthay
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - William A Pace
- Department of Surgery, University of California, San Francisco, San Francisco, CA.
| | - Eric J Smith
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Richard D Gutierrez
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade S Hiramoto
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Linda M Reilly
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
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30
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Biroš E, Staffa R, Krejčí M, Novotný T, Skotáková M, Bobák R. Autologous Alternative Vein Grafts for Infrainguinal Bypass in the Absence of Single-Segment Great Saphenous Vein: A Single-Center Study. Ann Vasc Surg 2024; 103:133-140. [PMID: 38428452 DOI: 10.1016/j.avsg.2023.12.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 10/29/2023] [Accepted: 12/10/2023] [Indexed: 03/03/2024]
Abstract
BACKGROUND Alternative autologous veins can be used as a conduit when adequate great saphenous vein is unavailable. We analyzed the results of our infrainguinal bypasses after adopting upper extremity veins in our practice. METHODS This is a single-center observational study involving all patients whose infrainguinal bypass involved the use of upper extremity veins between April 2019, when we began using arm veins, and February 2023. RESULTS During the study period, 49 bypasses were done in 48 patients; mean age 68.1 ± 9.8; men 32 (66.7%); body mass index 28.0 ± 4.8; indications for surgery: chronic limb threatening ischemia 41 (83.7%); acute limb ischemia 3 (6.1%); complications of previous prosthetic 3 (6.1%), or autologous 2 (4.1%) bypass grafts. Vein splicing was used in 43 (87.8%) bypasses with 3-segment grafts being the most common (26; 53.1%). There were 24 (49.0%) femorotibial, 11 (22.4%) femoropopliteal, 9 (18.4%) femoropedal, and 5 (10.2%) extension jump bypass procedures. Eighteen (36.7%) operations were redo surgeries. Twenty-one (42.9%) bypasses were formed using only arm veins. The median follow-up was 12.9 months (4.5-24.2). Two bypasses occluded during the first 30 postoperative days (2/49; 4.1%). Overall 30-day, 1-year, and 2-year primary patency rates were 93.7% ± 3.5%, 84.8% ± 5.9%, and 80.6% ± 6.9%, and secondary patency (SP) rates were 95.8% ± 2.9%, 89.2% ± 5.3%, and 89.2% ± 5.3%. One-segment grafts had better patencies than 2-, 3-, and 4-segment grafts (1-year SP 100% ± 0% vs 87.6% ± 6.0%). Two-year amputation-free survival was 86.8% ± 6.5%; 2-year overall survival was 88.2% ± 6.6%. CONCLUSIONS Integration of arm vein grafts in infrainguinal bypass practice can be done safely with low incidences of perioperative graft failure. One-segment grafts had better patencies than spliced vein grafts. The achieved early patency and amputation-free survival rates strongly encourage their use. In the absence of a single-segment great saphenous vein, upper extremity vein grafts should be the preferred conduit choice.
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Affiliation(s)
- Ernest Biroš
- 2nd Department of Surgery, Centre for Vascular Disease, Faculty of Medicine, Masaryk University and St. Anne's University Hospital, Brno, Czech Republic.
| | - Robert Staffa
- 2nd Department of Surgery, Centre for Vascular Disease, Faculty of Medicine, Masaryk University and St. Anne's University Hospital, Brno, Czech Republic
| | - Miroslav Krejčí
- 2nd Department of Surgery, Centre for Vascular Disease, Faculty of Medicine, Masaryk University and St. Anne's University Hospital, Brno, Czech Republic
| | - Tomáš Novotný
- 2nd Department of Surgery, Centre for Vascular Disease, Faculty of Medicine, Masaryk University and St. Anne's University Hospital, Brno, Czech Republic
| | - Monika Skotáková
- Biostatistics, International Clinical Research Centre of St. Anne's University Hospital, Brno, Czech Republic
| | - Robert Bobák
- 2nd Department of Surgery, Centre for Vascular Disease, Faculty of Medicine, Masaryk University and St. Anne's University Hospital, Brno, Czech Republic
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Spinella G, Pisa FR, Boschetti GA, Finotello A, Pane B, Pratesi G, Lanzarone E. Reconsidering the Impact of Endovascular Repair on Short-Term and Mid-Term Outcomes in Peripheral Arterial Disease: A Retrospective Analysis. Ann Vasc Surg 2024; 103:141-150. [PMID: 38395344 DOI: 10.1016/j.avsg.2023.12.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/25/2023] [Accepted: 12/10/2023] [Indexed: 02/25/2024]
Abstract
BACKGROUND The aim of the study is to compare the short-term and medium-term outcomes in patients who underwent open repair (OR) or endovascular repair (ER) for peripheral arterial disease (PAD) also including stratifications based on severity and year of the first intervention. METHODS We conducted an observational retrospective single-center cohort study. We evaluated patients with PAD that primarily underwent ER, OR, minor, and major amputations in a single center from 2005 to 2020. The patients were then subdivided according to the type of intervention (OR versus ER), and stratified according to the International Classification of Diseases 9 code reported in the operating documents and to the year intervention. Mortality, minor, and major amputation rates occurring at 30 days, 2 years, and 5 years after the first intervention were evaluated as primary outcomes and compared between patient groups in both stratifications. Moreover, Kaplan-Maier curves were analyzed for these outcomes. RESULTS One thousand four hundred ninety two patients (67.0% males) with PAD were evaluated. Their clinical presentations were intermittent claudication in 51.4% of cases, rest pain in 16.8%, ulcers in 10.3%, and gangrene in 21.5%. Nine hundred ninety seven (66.8%) underwent OR and 495 (33.2%) ER as first intervention for PAD. No statistical differences were observed in terms of mortality in the 2 groups (OR versus ER, P = 1,000, P = 0.357, and P = 0.688 at 30 days, 2 years, and 5 years, respectively). The rate of minor amputations was significantly higher (P < 0.012, P < 0.002, and P < 0.007 at 30 days, 2 years, and 5 years, respectively) for ER group in any of the observed follow-up periods. Also, we have observed that OR and ER do not have any significant short-term and medium-term major amputation rate differences. CONCLUSIONS In our experience, the impact of ER does not significantly change short-term and mid-term major outcomes in patients with PAD.
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Affiliation(s)
- Giovanni Spinella
- Department of Surgical and Integrated Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Vascular and Endovascular Surgery Clinic, Genoa, Italy.
| | - Fabio Riccardo Pisa
- Department of Surgical and Integrated Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy
| | - Gian Antonio Boschetti
- Vascular Surgery Unit, AULSS 2 Marca Trevigiana, Treviso Regional Hospital, Treviso, Italy
| | | | - Bianca Pane
- Department of Surgical and Integrated Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Vascular and Endovascular Surgery Clinic, Genoa, Italy
| | - Giovanni Pratesi
- Department of Surgical and Integrated Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Vascular and Endovascular Surgery Clinic, Genoa, Italy
| | - Ettore Lanzarone
- Department of Management, Information and Production Engineering, University of Bergamo, Bergamo, Italy
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Feliz JD, Heindel P, Fitzgibbon JJ, Ozaki CK, Gravereaux E, Nguyen LL, Menard M, Belkin M, Hussain MA. Descriptive Analysis of Amputation-Free Survival After First Time Infra-Inguinal Bypass Occlusion. J Surg Res 2024; 300:263-271. [PMID: 38824856 DOI: 10.1016/j.jss.2024.05.010] [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: 02/23/2023] [Revised: 05/05/2024] [Accepted: 05/08/2024] [Indexed: 06/04/2024]
Abstract
INTRODUCTION Occlusion after infra-inguinal bypass surgery for peripheral artery disease is a major complication with potentially devastating consequences. In this descriptive analysis, we sought to describe the natural history and explore factors associated with long-term major amputation-free survival following occlusion of a first-time infra-inguinal bypass. METHODS Using a prospective database from a tertiary care vascular center, we conducted a retrospective cohort study of all patients with peripheral artery disease who underwent a first-time infra-inguinal bypass and subsequently suffered a graft occlusion (1997-2021). The primary outcome was longitudinal rate of major amputation-free survival after bypass occlusion. Cox proportional hazard models were used to generate hazard ratios (HRs) and 95% confidence intervals (CIs) to explore predictors of outcomes. RESULTS Of the 1318 first-time infra-inguinal bypass surgeries performed over the study period, 255 bypasses occluded and were included in our analysis. Mean age was 66.7 (12.6) years, 40.4% were female, and indication for index bypass was chronic limb threatening ischemia (CLTI) in 89.8% (n = 229). 48.2% (n = 123) of index bypass conduits used great saphenous vein, 29.0% (n = 74) prosthetic graft, and 22.8% (n = 58) an alternative conduit. Median (interquartile range) time to bypass occlusion was 6.8 (2.3-19.0) months, and patients were followed for median of 4.3 (1.7-8.1) years after bypass occlusion. Following occlusion, 38.04% underwent no revascularization, 32.94% graft salvage procedure, 25.1% new bypass, and 3.92% native artery recanalization. Major amputation-free survival following occlusion was 56.9% (50.6%-62.8%) at 1 y, 37.1% (31%-43.3%) at 5 y, and 17.2% (11.9%-23.2%) at 10 y. In multivariable analysis, factors associated with lower amputation-free survival were older age, female sex, advanced cardiorenal comorbidities, CLTI at index procedure, CLTI at time of occlusion, and distal index bypass outflow. Initial treatment after occlusion with both a new surgical bypass (HR 0.44, CI: 0.29-0.67) or a graft salvage procedure (HR 0.56, CI: 0.38-0.82) showed improved amputation-free survival. One-year rate of major amputation or death were 59.8% (50.0%-69.6%) for those who underwent no revascularization, 37.9% (28.7%-49.0%) for graft salvage, and 26.7% (17.6%-39.5%) for new bypass. CONCLUSIONS Long-term major amputation-free survival is low after occlusion of a first-time infra-inguinal bypass. While several nonmodifiable risk factors were associated with lower amputation-free survival, treatment after graft occlusion with either a new bypass or a graft salvage procedure may improve longitudinal outcomes.
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Affiliation(s)
- Jessica Dominique Feliz
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Patrick Heindel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - James J Fitzgibbon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Edwin Gravereaux
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Louis L Nguyen
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Matthew Menard
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Mohamad A Hussain
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts; Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts.
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Rammos C, Zeller T, Piorkowski M, Deloose K, Hertting K, Sesselmann V, Tepe G, Gaines P, Lichtenberg M. The BioMimics 3D Helical Centreline Nitinol Stent in Chronic Limb Threatening Ischaemia and Complex Lesions: Three Year Outcomes of the MIMICS-3D Registry. Eur J Vasc Endovasc Surg 2024; 67:923-932. [PMID: 38447693 DOI: 10.1016/j.ejvs.2024.02.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 02/01/2024] [Accepted: 02/29/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE There is a need for improved outcomes in the endovascular treatment of patients suffering from chronic limb threatening ischaemia (CLTI), highly calcified lesions, and chronic total occlusions (CTOs). The helical centreline self expanding BioMimics 3D stent might be particularly useful in these high risk subsets, combining flexibility and fracture resistance with radial strength. Herein, the performance of the BioMimics 3D stent was assessed in these high risk subsets. METHODS MIMICS-3D is a prospective, multicentre, European real world registry. This was a post hoc analysis, comparing patients with CLTI vs. intermittent claudication (IC), lesions with bilateral calcification vs. those without (peripheral arterial calcium scoring system [PACSS] 3,4 vs. PACSS 0 - 2), and CTO vs. no CTO. Propensity score matching was performed to reduce the impact of baseline variables. The 36 month endpoints were clinically driven target lesion revascularisation (CD-TLR), death, major target limb amputation, and stent patency. RESULTS A total of 507 patients were enrolled. At 36 months, patients with CLTI had lower freedom from major amputation than patients with IC (92.6% vs. 100%, p < .001). In terms of primary patency, patients with CTO had lower patency rates than those without (63.9% vs. 77.8%, p = .003), but the difference reduced after propensity score matching (70.5% vs. 76.8%, p = .43). Primary patency was not impaired for patients with PACSS 3,4 or patients with CLTI. Freedom from CD-TLR was not significantly different among the groups and was 73.8% for CLTI vs. 78.9% for IC (p = .15), 77.6% for PACSS 3,4 vs. 78.7% for PACSS 0 - 2 (p = .55), and 75.6% for CTO vs. 81.0% for no CTO (p = .11). CONCLUSIONS The outcome of the MIMICS-3D registry suggests that the BioMimics 3D stent is effective in the endovascular treatment of complex femoropopliteal lesions and in CLTI. Future randomised controlled trials should confirm its non-inferiority or superiority compared with existing alternatives.
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Affiliation(s)
- Christos Rammos
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Centre Essen, University Hospital Essen, Germany.
| | - Thomas Zeller
- Universitätsklinikum Freiburg Herzzentrum, Bad Krozingen, Germany
| | | | - Koen Deloose
- Department of Vascular Surgery, AZ Sint-Blasius Dendermonde, Dendermonde, Belgium
| | - Klaus Hertting
- Department of Cardiology and Angiology, Krankenhaus Buchholz und Winsen GmbH, Buchholz, Germany
| | - Volker Sesselmann
- Department of Angiology, SRH Zentralklinikum Suhl GmbH, Suhl, Germany
| | - Gunnar Tepe
- Department of Diagnostic and Interventional Radiology, RoMed Klinikum Rosenheim, Rosenheim, Germany
| | - Peter Gaines
- Vascular Institute, Sheffield Hallam University, Sheffield, UK
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Lyden SP, Soukas PA, De A, Tedder B, Bowman J, Mustapha JA, Armstrong EJ. DETOUR2 trial outcomes demonstrate clinical utility of percutaneous transmural bypass for the treatment of long segment, complex femoropopliteal disease. J Vasc Surg 2024; 79:1420-1427.e2. [PMID: 38367850 DOI: 10.1016/j.jvs.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 01/29/2024] [Accepted: 02/09/2024] [Indexed: 02/19/2024]
Abstract
OBJECTIVE Percutaneous transmural arterial bypass (PTAB) using the DETOUR system aims to create a percutaneous, endovascular femoropopliteal bypass for the treatment of long segment, complex superficial femoral and proximal popliteal artery disease. The goal of the DETOUR2 study is to investigate the safety and effectiveness of the therapy in comparison with pre-established performance goals. METHODS The DETOUR2 investigational device exemption study is a prospective, single-arm, multicenter, international trial of symptomatic peripheral arterial disease patients (Rutherford classes 3-5) undergoing the DETOUR procedure for long segment (>20 cm) superficial femoral artery disease. Prespecified end points included primary safety (composite of major adverse events) at 30 days, and effectiveness (primary patency defined as freedom from restenosis or clinically driven target lesion revascularization) at 1 year. RESULTS We enrolled 202 patients at 32 sites with 200 treated with the DETOUR system. The mean lesion length was 32.7 cm, of which 96% were chronic total occlusions (CTO) and 70% were severely calcified. Technical success was achieved in 100% of treated patients. The primary safety end point was met with a 30-day freedom from major adverse event rate of 93.0%. The 1-year primary effectiveness end point was met with 72.1% primary patency at 12 months. Primary-assisted and secondary patency were 77.7% and 89.0%, respectively, at 12 months. The 12 month deep venous thrombosis incidence was 4.1% with no pulmonary emboli reported. Venous quality-of-life scores showed no significant changes from baseline. There was a Rutherford improvement of at least one class through 12 months in 97.2% of patients. The mean ankle-brachial index also improved from 0.61 to 0.95 during this period. There were marked improvements in quality-of-life and functional status measures. CONCLUSIONS The DETOUR2 study met both the primary safety and effectiveness end points, demonstrating clinical usefulness of this novel therapeutic strategy in long femoropopliteal lesions.
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Affiliation(s)
- Sean P Lyden
- Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
| | - Peter A Soukas
- The Miriam Hospital/Brown Medical School, Providence, RI
| | - Ajanta De
- El Camino Hospital, Mountain View, CA
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Liu IH, El Khoury R, Hiramoto JS, Gasper WJ, Schneider PA, Vartanian SM, Conte MS. Relevance of BEST-CLI trial endpoints in a tertiary care limb preservation program. J Vasc Surg 2024; 79:1438-1446.e2. [PMID: 38401777 DOI: 10.1016/j.jvs.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVE Major adverse limb event-free survival (MALE-FS) differed significantly by initial revascularization approach in the BEST-CLI randomized trial. The BEST-CLI trial represented a highly selected subgroup of patients seen in clinical practice; thus, we examined the endpoint of MALE-FS in an all-comers tertiary care practice setting. METHODS This is a single-center retrospective study of consecutive, unique patients who underwent technically successful infrainguinal revascularization for chronic limb-threatening ischemia (2011-2021). MALE was major amputation (transtibial or above) or major reintervention (new bypass, open bypass revision, thrombectomy, or thrombolysis). RESULTS Among 469 subjects, the mean age was 70 years, and 34% were female. Characteristics included diabetes (68%), end-stage renal disease (ESRD) (16%), Wound, Ischemia, and foot Infection (WIfI) stage 4 (44%), Global Limb Anatomic Staging System (GLASS) stage 3 (62%), and high pedal artery calcium score (pMAC) (22%). Index revascularization was autogenous vein bypass (AVB) (30%), non-autogenous bypass (NAB) (13%), or endovascular (ENDO) (57%). The composite endpoint of MALE or death occurred in 237 patients (51%) at a median time of 189 days from index revascularization. In an adjusted Cox model, factors independently associated with MALE or death included younger age, ESRD, WIfI stage 4, higher GLASS stage, and moderate-severe pMAC, whereas AVB was associated with improved MALE-FS. Freedom from MALE-FS, MALE, and major amputation at 30 days were 90%, 92%, and 95%; and at 1 year were 63%, 70%, and 83%, respectively. MALE occurred in 144 patients (31%) and was associated with ESRD, WIfI stage, GLASS stage, pMAC score, and index revascularization approach. AVB had superior durability, with adjusted 2-year freedom from MALE of 72%, compared with 66% for ENDO and 51% for NAB. Within the AVB group, spliced vein conduit had higher MALE compared with single-segment vein (hazard ratio, 1.8; 95% confidence interval, 0.9-3.7; P = .008 after inverse propensity weighting), but there was no statistically significant difference in major amputation. Of the 144 patients with any MALE, the first MALE was major reintervention in 47% and major amputation in 53%. Major amputation as first MALE was associated with non-AVB index approach. Indications for major reintervention were symptomatic stenosis/occlusion (54%), lack of clinical improvement (28%), asymptomatic graft stenosis (16%), and iatrogenic events (3%). Conversion to bypass occurred after 6% of ENDO cases, two-thirds of which involved distal bypass targets at the ankle or foot. CONCLUSIONS In this consecutive, all-comers cohort, disease complexity was associated with procedural selection and MALE-FS. AVB independently provided the greatest MALE-FS and freedom from MALE and major amputation. Compared with the BEST-CLI randomized trial, MALE after ENDO in this series was more frequently major amputation, with relatively few conversions to open bypass.
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Affiliation(s)
- Iris H Liu
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Rym El Khoury
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Jade S Hiramoto
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Warren J Gasper
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Peter A Schneider
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Shant M Vartanian
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA
| | - Michael S Conte
- University of California, San Francisco Department of Surgery, Division of Vascular and Endovascular Surgery, San Francisco, CA.
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Saini N, Marrone L, Desai S, Herman KC, Rundback JH. Comparison of outcomes of percutaneous deep venous arterialization in multiple practice settings. J Vasc Surg 2024:S0741-5214(24)01230-8. [PMID: 38830436 DOI: 10.1016/j.jvs.2024.05.051] [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: 02/19/2024] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVE We compared the efficacy of percutaneous deep venous arterialization (pDVA) in patients with no-option chronic limb-threatening ischemia in the hospital vs in office-based laboratory (OBL) settings. METHODS A retrospective chart review was performed of all patients who underwent pDVA using off-the-shelf devices from January 2018 to March 2023 in a hospital and an OBL. We identified 73 eligible patients, 41 from a hospital setting (59% male; median age, 72 years; interquartile range, 18 years) and 32 from an OBL setting (59% males; 67 years; interquartile range, 16 years). All eligible patients were deemed to have no-option critical limb ischemia, had at least one patent proximal tibial artery available for the creation of an arteriovenous anastomosis, and were classified as having Rutherford classification IV or higher peripheral arterial disease. Patients were ineligible if classified as Rutherford classification III or lower, had active infection, did not have at least one appropriate venous target, and/or had rapidly progressing wounds requiring immediate major amputation. The primary outcome was major amputation-free survival (AFS). Secondary outcomes included technical success, limb salvage, survival, primary patency, reintervention rate, adverse events, and partial and complete wound healing. Outcomes were evaluated using Kaplan-Meier method, log-rank, and two-stage procedure tests. RESULTS Technical success was achieved in 70 patients (96%) with 1 hospital (2.4%) and 2 OBL (6.3%) patients lost to follow-up. Major AFS estimates at 6 months, 1 year, and 2 years were 51.4%, 40.4%, and 30.2% in the hospital group and 69.4%, 54.0%, and 49.5% in the OBL group, respectively. Partial wound healing estimates at 6 months, 1 year, and 2 years were 27.5%, 71.7%, and 81.2% in the hospital group and 62.7% at all time points in the OBL group. Complete wound healing estimates at 6 months, 1 year, and 2 years were 6.7%, 33.3%, and 33.3% in the hospital group and 5.3%, 37.7%, and 41.6% in the OBL group, respectively. There was no significant difference in major AFS (P = .13), limb salvage (P = .07), survival (P = .69), primary patency (P = .53), partial (P = .08), or complete wound healing (P = .79) between groups. Reintervention was performed in 8 hospital (20.5%) and 14 OBL (45.2%) patients. CONCLUSIONS pDVA is a feasible and safe procedure for no-option critical limb ischemia in the hospital and OBL setting without significant differences in outcomes at ≤2 years.
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Affiliation(s)
- Neginder Saini
- Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, NY
| | | | - Sanket Desai
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY
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Houghton JSM, Saratzis AN, Sayers RD, Haunton VJ. New Horizons in Peripheral Artery Disease. Age Ageing 2024; 53:afae114. [PMID: 38877714 PMCID: PMC11178507 DOI: 10.1093/ageing/afae114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Indexed: 06/16/2024] Open
Abstract
Peripheral artery disease (PAD) is the lower limb manifestation of systemic atherosclerotic disease. PAD may initially present with symptoms of intermittent claudication, whilst chronic limb-threatening ischaemia (CLTI), the end stage of PAD, presents with rest pain and/or tissue loss. PAD is an age-related condition present in over 10% of those aged ≥65 in high-income countries. Guidelines regarding definition, diagnosis and staging of PAD and CLTI have been updated to reflect the changing patterns and presentations of disease given the increasing prevalence of diabetes. Recent research has changed guidelines on optimal medical therapy, with low-dose anticoagulant plus aspirin recommended in some patients. Recently published randomised trials highlight where bypass-first or endovascular-first approaches may be optimal in infra-inguinal disease. New techniques in endovascular surgery have increased minimally invasive options for ever more complex disease. Increasing recognition has been given to the complexity of patients with CLTI where a high prevalence of both frailty and cognitive impairment are present and a significant burden of multi-morbidity and polypharmacy. Despite advances in minimally invasive revascularisation techniques and reduction in amputation incidence, survival remains poor for many with CLTI. Shared decision-making is essential, and conservative management is often appropriate for older patients. There is emerging evidence of the benefit of specialist geriatric team input in the perioperative management of older patients undergoing surgery for CLTI. Recent UK guidelines now recommend screening for frailty, cognitive impairment and delirium in older vascular surgery patients as well as recommending all vascular surgery services have support and input from specialist geriatrics teams.
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Affiliation(s)
- John S M Houghton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre—The Glenfield Hospital, Leicester, UK
| | - Athanasios N Saratzis
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre—The Glenfield Hospital, Leicester, UK
| | - Rob D Sayers
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre—The Glenfield Hospital, Leicester, UK
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Conte MS, Azene E, Doros G, Gasper WJ, Hamza T, Kashyap VS, Guzman R, Mena-Hurtado C, Menard MT, Rosenfield K, Rowe VL, Strong M, Farber A. Secondary interventions following open vs endovascular revascularization for chronic limb threatening ischemia in the BEST-CLI trial. J Vasc Surg 2024; 79:1428-1437.e4. [PMID: 38368997 DOI: 10.1016/j.jvs.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/02/2024] [Accepted: 02/11/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVES Patients undergoing revascularization for chronic limb-threatening ischemia experience a high burden of target limb reinterventions. We analyzed data from the Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) randomized trial comparing initial open bypass (OPEN) and endovascular (ENDO) treatment strategies, with a focus on reintervention-related study endpoints. METHODS In a planned secondary analysis, we examined the rates of major reintervention, any reintervention, and the composite of any reintervention, amputation, or death by intention-to-treat assignment in both trial cohorts (cohort 1 with suitable single-segment great saphenous vein [SSGSV], n = 1434; cohort 2 lacking suitable SSGSV, n = 396). We also compared the cumulative number of major and all index limb reinterventions over time. Comparisons between treatment arms within each cohort were made using univariable and multivariable Cox regression models. RESULTS In cohort 1, assignment to OPEN was associated with a significantly reduced hazard of a major limb reintervention (hazard ratio [HR], 0.37; 95% confidence interval [CI], 0.28-0.49; P < .001), any reintervention (HR, 0.63; 95% CI, 0.53-0.75; P < .001), or any reintervention, amputation, or death (HR, 0.68; 95% CI, 0.60-0.78; P < .001). Findings were similar in cohort 2 for major reintervention (HR, 0.53; 95% CI, 0.33-0.84; P = .007) or any reintervention (HR, 0.71; 95% CI, 0.52-0.98; P = .04). In both cohorts, early (30-day) limb reinterventions were notably higher for patients assigned to ENDO as compared with OPEN (14.7% vs 4.5% of cohort 1 subjects; 16.6% vs 5.6% of cohort 2 subjects). The mean number of major (mean events per subject ratio [MR], 0.45; 95% CI, 0.34-0.58; P < .001) or any target limb reinterventions (MR, 0.67; 95% CI, 0.57-0.80; P < .001) per year was significantly less in the OPEN arm of cohort 1. The mean number of reinterventions per limb salvaged per year was lower in the OPEN arm of cohort 1 (MR, 0.45; 95% CI, 0.35-0.57; P < .001 and MR, 0.66; 95% CI, 0.55-0.79; P < .001 for major and all, respectively). The majority of index limb reinterventions occurred during the first year following randomization, but events continued to accumulate over the duration of follow-up in the trial. CONCLUSIONS Reintervention is common following revascularization for chronic limb-threatening ischemia. Among patients deemed suitable for either approach, initial treatment with open bypass, particularly in patients with available SSGSV conduit, is associated with a significantly lower number of major and minor target limb reinterventions.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA.
| | - Ezana Azene
- Department of Interventional Radiology, Gundersen Health System, La Crosse, WI
| | | | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | | | - Vikram S Kashyap
- Frederik Meijer Heart and Vascular Institute, Corewell Health, Grand Rapids, MI
| | - Randy Guzman
- Section of Vascular Surgery, Hospital St. Boniface, Winnipeg, Manitoba, Canada
| | | | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kenneth Rosenfield
- Section of Vascular Medicine and Intervention, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Vincent L Rowe
- Division of Vascular Surgery and Endovascular Therapy, University of California, Los Angeles, CA
| | - Michael Strong
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
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Thomas B, Hackenberg RK, Krasniqi D, Eisa A, Böcker A, Gazyakan E, Bigdeli AK, Kneser U, Harhaus-Wähner L. [Modern concepts of interdisciplinary extremity reconstruction in open fractures]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:469-480. [PMID: 38739196 DOI: 10.1007/s00113-024-01437-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 05/14/2024]
Abstract
The orthoplastic approach involves the collaboration of orthopedic/trauma surgeons, vascular surgeons and reconstructive microsurgeons. In cases of complex limb fractures, the aims are to optimize blood flow, restore bone stability, reconstruct soft tissue defects, and enhance function and sensitivity. The early administration of antibiotics and a timely, high-quality debridement after initial interdisciplinary assessment are carried out. This is followed by fracture stabilization and temporary wound coverage in order to plan the definitive interdisciplinary procedure. This includes definitive osteosynthesis and soft tissue reconstruction, using local tissue transfer if feasible, or free tissue transfer in cases of extensive trauma zones. The orthoplastic approach allows for faster definitive stabilization, fewer operations, shorter hospital stays, lower complication and revision rates, higher cost-effectiveness and improved long-term function.
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Affiliation(s)
- Benjamin Thomas
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland.
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland.
| | - Roslind K Hackenberg
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Demir Krasniqi
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Amr Eisa
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Arne Böcker
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Emre Gazyakan
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Amir K Bigdeli
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Ulrich Kneser
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
| | - Leila Harhaus-Wähner
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
- Klinik für Plastische Chirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland
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Chaney M, Joshi G, Cataneo Serrato JL, Rashid M, Jacobs A, Jacobs CE, White JV, Schwartz LB, El Khoury R. The natural history of isolated common femoral endarterectomy for chronic limb-threatening ischemia. J Vasc Surg 2024:S0741-5214(24)01229-1. [PMID: 38823529 DOI: 10.1016/j.jvs.2024.05.050] [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: 01/29/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVE Occlusive disease of the common femoral artery can generate profound lower extremity ischemia as the normal collateral pathways from the profunda to the superficial femoral artery cannot adequately develop. In patients with lifestyle-limiting claudication, isolated common femoral endarterectomy (CFE) is highly effective. Because CFE does not provide direct, in-line flow to the plantar arch, it has been felt to provide inadequate revascularization to patients with chronic limb-threatening ischemia (CLTI). The purpose of this retrospective clinical study was to report and assess the natural history of selected patients with CLTI treated with isolated CFE (without concomitant infrainguinal revascularization). METHODS Consecutive CFEs performed in a large, urban hospital for CLTI between 2014 and 2021 were reviewed. Patient characteristics, limb, and anatomical stages using the Wound, Ischemia, foot Infection (WIfI) and Global Limb Anatomic Staging System were tabulated. Limb-specific and survival-related end points were analyzed. RESULTS Fifty-eight patients presenting with CLTI underwent isolated CFE (mean age, 74 ± 10 years; 62% male, 90% current or prior smoker). Comorbidities included diabetes (52%), coronary artery disease (55%), congestive heart failure (22%), and end-stage renal failure on hemodialysis (5%). Patients presented with either rest pain (36%) or tissue loss (64%); the latter group exhibited advanced limb threat (68% in WIfI stage 3 or 4). The majority of patients had associated severe infrainguinal disease (50% Global Limb Anatomic Staging Systems 3). After a median follow-up of 17 months (range, 10-29 months), vascular reintervention was required in 7 patients (12%). One patient (2%) required major limb amputation after presentation in WIfI stage 4 (W3I3fI0). Indeed, WIfI stage 4 was a significant univariate predictor of the need for subsequent infrainguinal bypass (P = .034). CONCLUSIONS Isolated CFE as primary therapy in highly selected patients with CLTI was safe and effective. Index limb stage is predictive of the need for associated infrainguinal revascularization in this complex population.
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Affiliation(s)
- Michael Chaney
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI
| | - Gaurang Joshi
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | | | - Mohammed Rashid
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Abraham Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Chad E Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Lewis B Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Rym El Khoury
- Department of Surgery, Division of Vascular Surgery, NorthShore University Health System, Evanston, IL.
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Abdul-Malak OM, Semaan DB, Madigan MC, Sridharan ND, Chaer RA, Siracuse JJ, Eslami MH. Midterm Outcomes and Predictors of Failure of Lower Extremity Bypass to Para-Malleolar and Pedal Targets. Ann Vasc Surg 2024; 106:227-237. [PMID: 38815913 DOI: 10.1016/j.avsg.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/25/2024] [Accepted: 04/09/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND The frequency of distal lower extremity bypass (LEB) for infrapopliteal critical limb threatening ischemia (IP-CLTI) has significantly decreased. Our goal was to analyze the contemporary outcomes and factors associated with failure of LEB to para-malleolar and pedal targets. METHODS We queried the Vascular Quality Initiative infrainguinal database from 2003 to 2021 to identify LEB to para-malleolar or pedal/plantar targets. Primary outcomes were graft patency, major adverse limb events [vascular reintervention, above ankle amputation] (MALE), and amputation-free survival at 2 years. Standard statistical methods were utilized. RESULTS We identified 2331 LEB procedures (1,265 anterior tibial at ankle/dorsalis pedis, 783 posterior tibial at ankle, 283 tarsal/plantar). The prevalence of LEB bypasses to distal targets has significantly decreased from 13.37% of all LEB procedures in 2003-3.51% in 2021 (P < 0.001). The majority of cases presented with tissue loss (81.25. Common postoperative complications included major adverse cardiac events (8.9%) and surgical site infections (3.6%). Major amputations occurred in 16.8% of patients at 1 year. Postoperative mortality at 1 year was 10%. On unadjusted Kaplan-Meier survival analysis at 2 years, primary patency was 50.56% ± 3.6%, MALE was 63.49% ± 3.27%, and amputation-free survival was 71.71% ± 0.98%. In adjusted analyses [adjusted for comorbidities, indication, conduit type, urgency, prior vascular interventions, graft inflow vessel (femoral/popliteal), concomitant inflow procedures, surgeon and center volume] conduits other than great saphenous vein (P < 0.001) were associated with loss of primary patency and increased MALE. High center volume (>5 procedures/year) was associated with improved primary patency (P = 0.015), and lower MALE (P = 0.021) at 2 years. CONCLUSIONS Despite decreased utilization, open surgical bypass to distal targets at the ankle remains a viable option for treatment of IP-CLTI with acceptable patency and amputation-free survival rates at 2 years. Bypasses to distal targets should be performed at high volume centers to optimize graft patency and limb salvage and minimize reinterventions.
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Affiliation(s)
- Othman M Abdul-Malak
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA; MedStar Heart and Vascular Institute, Baltimore, MD.
| | - Dana B Semaan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Michael C Madigan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Natalie D Sridharan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University, Boston, MA
| | - Mohammad H Eslami
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Charleston Area Medical Center, Charleston, WV
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Rajan A, Sima RR, Natarajan S. Endovascular Management of Chronic Limb-Threatening Ischemia (CLTI) in the Elderly: A Focus on Frailty, Wound Healing, and Outcomes. Ann Vasc Surg 2024; 106:321-332. [PMID: 38815902 DOI: 10.1016/j.avsg.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 02/27/2024] [Accepted: 03/07/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND In India, a significant scarcity of published data exists regarding chronic limb-threatening ischemia (CLTI) and its management, especially among the elderly population. CLTI, often accompanied by frailty poses a significant healthcare challenge. While endovascular interventions offer hope, there remains a dearth of outcome data for this age group. This study seeks to address this critical gap by investigating the impact of frailty on outcomes, emphasizing amputation-free survival (AFS), wound healing, and health-related quality of life (HRQoL). METHODS Our study included 131 elderly CLTI patients aged ≥70 years who underwent infrainguinal endovascular interventions between April 2018 and August 2021, with a follow-up period of 2 years. Among the patients, 93.9% had diabetes mellitus and 82.4% had hypertension. Clinical frailty was assessed using the clinical frailty scale (CFS). Patients were categorized into group 1 (CFS 1-5) and group 2 (CFS 6-9). Primary outcomes were AFS, wound healing, HRQoL, and their association with frailty. Secondary outcomes included technical success, procedure-related complications, major adverse limb events, major adverse cardiac events, vessel patency, re-intervention rates, and mortality rates including periprocedural and overall mortality. RESULTS Technical success was achieved in 86.3% of patients, with frailty significantly influencing this outcome. Group 2 exhibited reduced technical success (80.8%) compared to group 1 (93.1%). The major amputation rate was 9.2%, with higher rates in group 2 [univariate hazard ratio: 5.20; P = 0.033]. Similarly, group 2 showed elevated overall mortality [univariate hazard ratio: 5.18; P < 0.001]. AFS at 1 and 2 years were 67.9% and 55%, respectively, with higher rates in group 1. Wound healing was achieved in 76.1% of patients (83/109), with frailty significantly associated with delayed wound healing (P < 0.001). Vessel patency at 1 year was observed in 88.8% of patients. HRQoL significantly improved postintervention, with vascular quality of life questionnaire-6 (VascuQol-6) scores increasing from an average of 9 of 24 at baseline to 20 of 24 at 2 years. Frailty score significantly correlated with VascuQol-6 scores at 1 and 2 years (P < 0.0012). Group 1 exhibited higher VascuQol-6 scores than group 2, indicating improved HRQoL during follow-up. CONCLUSIONS Successful endovascular treatments in high-risk CLTI patients promote improved wound healing and post-treatment quality of life. Frailty should be assessed before endovascular interventions as it correlates with adverse outcomes, including amputations and mortality. While revascularization holds promise, caution is advised for frailer patients, emphasizing the importance of personalized care and tailored treatments for elderly CLTI patients.
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Affiliation(s)
- Archana Rajan
- Department of Vascular and Endovascular Surgery, Kauvery Hospital, Chennai, India.
| | - Rahul Ralph Sima
- Department of Vascular and Endovascular Surgery, Kauvery Hospital, Chennai, India
| | - Sekar Natarajan
- Department of Vascular and Endovascular Surgery, Kauvery Hospital, Chennai, India
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Brahmandam A, Kim TI, Parziale S, Deng Y, Setia O, Tonnessen BH, Ochoa Chaar CI, Guzman RJ, Aboian E. Intravascular Ultrasound Use is Associated with Improved Patency in Lower Extremity Peripheral Arterial Interventions. Ann Vasc Surg 2024; 106:410-418. [PMID: 38810722 DOI: 10.1016/j.avsg.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Intravascular ultrasound (IVUS) facilitates detailed visualization of endoluminal anatomy not adequately appreciated on conventional angiography. However, it is unclear if IVUS use improves clinical outcomes of peripheral vascular interventions (PVIs) for peripheral arterial disease. This study aimed to evaluate the impact of IVUS on 1-year outcomes of PVI in the vascular quality initiative (VQI). METHODS The VQI-PVI modules were reviewed (2016-2020). All patients with available 1-year follow-up after lower extremity PVI were included and grouped as IVUS-PVI or non-IVUS PVI based on use of IVUS. Propensity matching (1:1) was performed using demographics and comorbidities. One-year major amputation and patency rates were compared. A generalized estimating equation model was used to identify predictors of 1-year outcomes. Subgroup analysis based on Trans-Atlantic Intersociety Consensus (TASC) classification, treatment length and treatment modalities were performed using same modeling approaches. RESULTS There were 56,633 procedures (non-IVUS PVI = 55,302 vs. IVUS-PVI = 1,331) in 44,042 patients. Propensity matching yielded a total cohort of 1,854 patients matched (1:1), with no baseline differences. Lower extremity revascularization for claudication was performed in 60.4%, while one-third (33.9%) had chronic limb threatening ischemia (CLTI). IVUS was more commonly used for lesions >15 cm in length (46.6% vs. 43.3%) and for aortoiliac disease (31.8% vs. 27.2%). Rates of atherectomy and stenting were significantly higher with IVUS-PVI (21.1% vs. 16.8%), while balloon angioplasty was less common (13.5% vs. 24.4%). One-year patency was better with IVUS-PVI (97.7% vs. 95.2%, P = 0.004). On subgroup analysis, IVUS (odds ratio [OR] 2.20, 95% confidence interval [CI] 1.29-3.75) was associated with improved patency in CLTI patients, TASC C or D lesions, and treatment length >15 cm. Adjunctive IVUS use during PVI did not significantly impact 1-year amputation (OR 1.7, 95% CI 0.78-3.91). On multivariable regression, adjunctive use of IVUS (OR 2.46 95% CI 1.43-4.25) and aortoiliac interventions (OR 2.91, 95% CI 1.09-7.75) were independent predictors of patency. Treatment modalities such as atherectomy, stenting or balloon angioplasty did not significantly impact patency at 1-year. CONCLUSIONS IVUS during lower extremity PVI is associated with improved 1-year patency, when compared to angiography alone. Certain subgroups, such as CLTI patients, lesions>15 cm, and TASC C or D lesions might benefit from adjunctive use of IVUS.
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Affiliation(s)
- Anand Brahmandam
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Tanner I Kim
- Department of Surgery, University of Hawaii John A. Burns School of Medicine, Honolulu, HI
| | - Stephen Parziale
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT
| | - Ocean Setia
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Britt H Tonnessen
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Raul J Guzman
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Edouard Aboian
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT.
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Smeltz AM, Newton EJ, Kumar PA, Isaak RS, Doyal A, Fernando RJ, Vanneman MW, Augoustides JGT. 2023 Update on Vascular Anesthesia. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00321-5. [PMID: 38862283 DOI: 10.1053/j.jvca.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/11/2024] [Indexed: 06/13/2024]
Abstract
The authors thank thank the editors for this opportunity to review the recent literature on vascular surgery and anesthesia and provide this clinical update. The last in a series of updates on this topic was published in 2019.1 This review explores evolving discussions and current trends related to vascular surgery and anesthesia that have been published since then. The focus is on the major points discussed in the recent literature in the following areas: carotid artery surgery, infrarenal aortic surgery, peripheral vascular surgery, and the preoperative evaluation of vascular surgical patients.
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Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily J Newton
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Priya A Kumar
- Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS; Outcomes Research Consortium, Cleveland, OH
| | - Robert S Isaak
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Alexander Doyal
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Wake Forest University, Winston-Salem, NC
| | - Matthew W Vanneman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
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Marcaccio CL, Schermerhorn ML. Using Administrative Data to Better Treat Chronic Limb Threatening Ischemia. Ann Vasc Surg 2024:S0890-5096(24)00204-8. [PMID: 38754578 DOI: 10.1016/j.avsg.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 01/17/2024] [Indexed: 05/18/2024]
Abstract
Chronic limb threatening ischemia (CLTI) is the most severe manifestation of peripheral arterial disease and represents a particularly high-risk subgroup of patients. As such, efforts to better understand this complex patient population through well-designed clinical research studies are critical to improving CLTI care. Prospective randomized clinical trials (RCTs) remain the gold standard in clinical research, but these trials are resource-intensive and have highly selective patient populations, which limit their feasibility and generalizability. Alternatively, retrospective studies are less expensive than RCTs, have a larger sample size, and are more generalizable owing to a broader patient population. Health care administrative data provide rich sources of information that may be used for research purposes and are increasingly being used for the study of vascular surgery conditions, including CLTI. Although administrative data are collected for billing purposes, they may be leveraged to study a broad range of topics in vascular surgery including those related to health care delivery, epidemiology, health disparities, and outcomes. This review provides an overview of administrative data available for CLTI research, the strengths and limitations of these data sources, current areas of investigation, and future opportunities for further study with the goal of improving outcomes in this high-risk population.
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Affiliation(s)
- Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Rumba R, Krievins D, Ezite N, Lacis A, Mouttet L, Vavere AL, Zarins CK. Endovascular Transvenous versus Open Femoropopliteal Bypass. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:777. [PMID: 38792960 PMCID: PMC11123046 DOI: 10.3390/medicina60050777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/18/2024] [Accepted: 05/05/2024] [Indexed: 05/26/2024]
Abstract
Background and Objectives: Lower extremity arterial disease is one of the most prevalent manifestations of atherosclerosis. The results from numerous studies regarding the best revascularization method of an occluded superficial femoral artery have been conflicting. The aim of this study was to compare the patency of transvenous endovascular with open femoropopliteal bypass, both with vein and prosthetic grafts. To our knowledge, a direct patency comparison between transvenous endovascular and open femoropopliteal bypass has not been published. This could help elucidate which method is preferable and in which cases. Materials and Methods: Patients with complex TASC-C and D SFA lesions were offered endovascular transvenous or open bypass. A total of 384 consecutive patients with PAD requiring surgical treatment were evaluated for inclusion in this study. Three-year follow-up data were collected for 52 endovascular procedures, 80 prosthetic grafts, and 44 venous bypass surgeries. Bypass patency was investigated by Duplex US every 6 months. Kaplan-Meier plots were used to analyze primary, primary-assisted, and secondary patency for endovascular transvenous, autovenous, and prosthetic bypasses. Results: Primary, primary-assisted, and secondary patency in venous group at 3 years was 70.5%, 77.3%, and 77.3%, respectively. In the endovascular transvenous group, primary, primary-assisted, and secondary patency at 3 years was 46.2%, 69.2%, and 76.9%, respectively. The lowest patency rates at 3 years were noted in the prosthetic graft group with 22.5% primary, 26.6% primary-assisted, and 28.2% secondary patency. Conclusions: The saphenous vein is the best graft to perform in above-the-knee femoropopliteal bypass. Transvenous endovascular bypass is a viable option with comparable primary-assisted and secondary patency. Primary patency is substantially lower for endovascular transvenous compared to venous bypass. Patients treated with endovascular transvenous bypass will require a significant number of secondary procedures to provide optimal patency. Prosthetic grafts should only be used if no other option for bypass is available.
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Affiliation(s)
- Roberts Rumba
- Vascular Surgery Department, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (R.R.)
| | - Dainis Krievins
- Vascular Surgery Department, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (R.R.)
| | - Natalija Ezite
- Diagnostic Radiology, Diagnostic and Interventional Radiology Centre, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia
| | - Aigars Lacis
- Vascular Surgery Department, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (R.R.)
| | - Ludovic Mouttet
- Department of Surgical and Interventional Sciences, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G 2M1, Canada
| | - Anda L. Vavere
- Faculty of Medicine, University of Latvia, 1004 Riga, Latvia
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47
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Fanaroff AC, Dayoub EJ, Yang L, Schultz K, Ramadan OI, Wang GJ, Damrauer SM, Genovese EA, Secemsky EA, Parikh SA, Nathan AS, Kohi MP, Weinberg MD, Jaff MR, Groeneveld PW, Giri JS. Association Between Diagnosis-to-Limb Revascularization Time and Clinical Outcomes in Outpatients With Chronic Limb-Threatening Ischemia: Insights From the CLIPPER Cohort. J Am Heart Assoc 2024; 13:e033898. [PMID: 38639376 PMCID: PMC11179943 DOI: 10.1161/jaha.123.033898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/18/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND The extent and consequences of ischemia in patients with chronic limb-threatening ischemia (CLTI) may change rapidly, and delays from diagnosis to revascularization may worsen outcomes. We sought to describe the association between time from diagnosis to endovascular lower extremity revascularization (diagnosis-to-limb revascularization [D2L] time) and clinical outcomes in outpatients with CLTI. METHODS AND RESULTS In the CLIPPER cohort, comprising patients between 66 and 86 years old diagnosed with CLTI betweeen 2010 and 2019, we used Medicare claims data to identify patients who underwent outpatient endovascular revascularization within 180 days of diagnosis. We described the risk-adjusted association between D2L time and clinical outcomes. Among 1 130 065 patients aged between 66 and 86 years with CLTI, 99 221 (8.8%) underwent outpatient endovascular lower extremity revascularization within 180 days of their CLTI diagnosis. Among patients with D2L time <30 days, there was no association between D2L time and all-cause death or major lower extremity amputation. However, among patients with D2L time >30 days, each additional 10-day increase in D2L time was associated with a 2.5% greater risk of major amputation (hazard ratio, 1.025 [95% CI, 1.014-1.036]). There was no association between D2L time and all-cause death. CONCLUSIONS A delay of >30 days from CLTI diagnosis to lower extremity endovascular revascularization was associated with an increased risk of major lower extremity amputation among patients undergoing outpatient endovascular revascularization. Improving systems of care to reduce D2L time could reduce amputations.
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Affiliation(s)
- Alexander C. Fanaroff
- Cardiovascular Medicine Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Penn Center for Health Incentives and Behavioral EconomicsUniversity of PennsylvaniaPhiladelphiaPA
| | - Elias J. Dayoub
- Cardiovascular Medicine Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
| | - Lin Yang
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
| | - Kaitlyn Schultz
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
| | - Omar I. Ramadan
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Grace J. Wang
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Scott M. Damrauer
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Department of Genetics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
| | - Elizabeth A. Genovese
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Eric A. Secemsky
- Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical SchoolHarvard UniversityBostonMA
| | - Sahil A. Parikh
- Division of Cardiology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNY
| | - Ashwin S. Nathan
- Cardiovascular Medicine Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
| | - Maureen P. Kohi
- Department of RadiologyUniversity of North CarolinaChapel HillNC
| | | | | | - Peter W. Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
- General Internal Medicine Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Jay S. Giri
- Cardiovascular Medicine Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
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Li B, Aljabri B, Verma R, Beaton D, Hussain MA, Lee DS, Wijeysundera DN, de Mestral C, Mamdani M, Al‐Omran M. Predicting Outcomes Following Lower Extremity Endovascular Revascularization Using Machine Learning. J Am Heart Assoc 2024; 13:e033194. [PMID: 38639373 PMCID: PMC11179886 DOI: 10.1161/jaha.123.033194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 03/01/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Lower extremity endovascular revascularization for peripheral artery disease carries nonnegligible perioperative risks; however, outcome prediction tools remain limited. Using machine learning, we developed automated algorithms that predict 30-day outcomes following lower extremity endovascular revascularization. METHODS AND RESULTS The National Surgical Quality Improvement Program targeted vascular database was used to identify patients who underwent lower extremity endovascular revascularization (angioplasty, stent, or atherectomy) for peripheral artery disease between 2011 and 2021. Input features included 38 preoperative demographic/clinical variables. The primary outcome was 30-day postprocedural major adverse limb event (composite of major reintervention, untreated loss of patency, or major amputation) or death. Data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, 6 machine learning models were trained using preoperative features. The primary model evaluation metric was area under the receiver operating characteristic curve. Overall, 21 886 patients were included, and 30-day major adverse limb event/death occurred in 1964 (9.0%) individuals. The best performing model for predicting 30-day major adverse limb event/death was extreme gradient boosting, achieving an area under the receiver operating characteristic curve of 0.93 (95% CI, 0.92-0.94). In comparison, logistic regression had an area under the receiver operating characteristic curve of 0.72 (95% CI, 0.70-0.74). The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.09. The top 3 predictive features in our algorithm were (1) chronic limb-threatening ischemia, (2) tibial intervention, and (3) congestive heart failure. CONCLUSIONS Our machine learning models accurately predict 30-day outcomes following lower extremity endovascular revascularization using preoperative data with good discrimination and calibration. Prospective validation is warranted to assess for generalizability and external validity.
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Affiliation(s)
- Ben Li
- Department of SurgeryUniversity of TorontoCanada
- Division of Vascular SurgerySt. Michael’s Hospital, Unity Health Toronto, University of TorontoTorontoCanada
- Institute of Medical Science, University of TorontoTorontoCanada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T‐CAIREM)University of TorontoTorontoCanada
| | - Badr Aljabri
- Department of SurgeryKing Saud UniversityRiyadhSaudi Arabia
| | - Raj Verma
- School of Medicine, Royal College of Surgeons in IrelandUniversity of Medicine and Health SciencesDublinIreland
| | - Derek Beaton
- Data Science & Advanced Analytics, Unity Health TorontoUniversity of TorontoTorontoCanada
| | - Mohamad A. Hussain
- Division of Vascular and Endovascular Surgery and the Center for Surgery and Public Health, Brigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Douglas S. Lee
- Division of Cardiology, Peter Munk Cardiac CentreUniversity Health NetworkTorontoCanada
- Institute of Health Policy, Management and Evaluation, University of TorontoTorontoCanada
- ICES, University of TorontoTorontoCanada
| | - Duminda N. Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of TorontoTorontoCanada
- ICES, University of TorontoTorontoCanada
- Department of AnesthesiaSt. Michael’s Hospital, Unity Health TorontoTorontoCanada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health TorontoTorontoCanada
| | - Charles de Mestral
- Department of SurgeryUniversity of TorontoCanada
- Division of Vascular SurgerySt. Michael’s Hospital, Unity Health Toronto, University of TorontoTorontoCanada
- Institute of Health Policy, Management and Evaluation, University of TorontoTorontoCanada
- ICES, University of TorontoTorontoCanada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health TorontoTorontoCanada
| | - Muhammad Mamdani
- Institute of Medical Science, University of TorontoTorontoCanada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T‐CAIREM)University of TorontoTorontoCanada
- Data Science & Advanced Analytics, Unity Health TorontoUniversity of TorontoTorontoCanada
- Institute of Health Policy, Management and Evaluation, University of TorontoTorontoCanada
- ICES, University of TorontoTorontoCanada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health TorontoTorontoCanada
- Leslie Dan Faculty of PharmacyUniversity of TorontoTorontoCanada
| | - Mohammed Al‐Omran
- Department of SurgeryUniversity of TorontoCanada
- Division of Vascular SurgerySt. Michael’s Hospital, Unity Health Toronto, University of TorontoTorontoCanada
- Institute of Medical Science, University of TorontoTorontoCanada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T‐CAIREM)University of TorontoTorontoCanada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health TorontoTorontoCanada
- Department of SurgeryKing Faisal Specialist Hospital and Research CenterRiyadhSaudi Arabia
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49
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Zarrintan S, Rahgozar S, Ross EG, Farber A, Menard MT, Conte MS, Malas MB. Endovascular therapy versus bypass for chronic limb-threatening ischemia in a real-world practice. J Vasc Surg 2024:S0741-5214(24)01093-0. [PMID: 38718850 DOI: 10.1016/j.jvs.2024.04.067] [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: 11/09/2023] [Revised: 04/26/2024] [Accepted: 04/29/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE The recent Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) study showed that bypass was superior to endovascular therapy (ET) in patients with chronic limb-threatening ischemia (CLTI) deemed suitable for either approach who had an available single-segment great saphenous vein (GSV). However, the superiority of bypass among those lacking GSV was not established. We aimed to examine comparative treatment outcomes from a real-world CLTI population using the Vascular Quality Initiative-Medicare-linked database. METHODS We queried the Vascular Quality Initiative-Medicare-linked database for patients with CLTI who underwent first-time lower extremity revascularization (2010-2019). We performed two one-to-one propensity score matchings (PSMs): ET vs bypass with GSV (BWGSV) and ET vs bypass with a prosthetic graft (BWPG). The primary outcome was amputation-free survival. Secondary outcomes were freedom from amputation and overall survival (OS). RESULTS Three cohorts were queried: BWGSV (N = 5279, 14.7%), BWPG (N = 2778, 7.7%), and ET (N = 27,977, 77.6%). PSM produced two sets of well-matched cohorts: 4705 pairs of ET vs BWGSV and 2583 pairs of ET vs BWPG. In the matched cohorts of ET vs BWGSV, ET was associated with greater hazards of death (hazard ratio [HR] = 1.34, 95% confidence interval [CI], 1.25-1.43; P < .001), amputation (HR = 1.30, 95% CI, 1.17-1.44; P < .001), and amputation/death (HR = 1.32, 95% CI, 1.24-1.40; P < .001) up to 4 years. In the matched cohorts of ET vs BWPG, ET was associated with greater hazards of death up to 2 years (HR = 1.11, 95% CI, 1.00-1.22; P = .042) but not amputation or amputation/death. CONCLUSIONS In this real-world multi-institutional Medicare-linked PSM analysis, we found that BWGSV is superior to ET in terms of OS, freedom from amputation, and amputation-free survival up to 4 years. Moreover, BWPG was superior to ET in terms of OS up to 2 years. Our study confirms the superiority of BWGSV to ET as observed in the BEST-CLI trial.
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Affiliation(s)
- Sina Zarrintan
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of California San Diego (UCSD), San Diego, CA
| | - Shima Rahgozar
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of California San Diego (UCSD), San Diego, CA
| | - Elsie G Ross
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of California San Diego (UCSD), San Diego, CA
| | - Alik Farber
- Department of Surgery, Division of Vascular & Endovascular Surgery, Boston University School of Medicine, Boston, MA
| | - Matthew T Menard
- Department of Surgery, Division of Vascular & Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael S Conte
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of California San Francisco (UCSF), San Francisco, CA
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of California San Diego (UCSD), San Diego, CA.
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50
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Das TS, Shammas NW, Yoho JA, Martinez-Clark P, Ramaiah V, Leon LR, Pacanowski JP, Tai Z, Ali V, Arslan B, Rundback J. Solid state, pulsed-wave 355 nm UV laser atherectomy debulking in the treatment of infrainguinal peripheral arterial disease: The Pathfinder Registry. Catheter Cardiovasc Interv 2024; 103:949-962. [PMID: 38566525 DOI: 10.1002/ccd.31023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 02/07/2024] [Accepted: 03/19/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Atherectomy is an important option for debulking atherosclerotic plaque from diseased arteries in patients with infrainguinal arterial disease. Laser atherectomy uses a high-powered laser to remove the plaque from the arteries to restore blood flow. AIMS The Pathfinder multicenter registry was initiated to evaluate the safety and efficacy of the 355 nm laser atherectomy system in a real-world setting for the treatment of de novo, re-stenotic and in-stent restenosis (ISR) lesions in infrainguinal arteries of patients with peripheral artery disease (PAD). METHODS The study was a prospective, single-arm, multicenter, open-label registry study for patients treated with the 355 nm laser system. Clinical and lesion characteristics, procedural safety and efficacy data, and baseline, 6-, and 12-month outcomes data, including Ankle Brachial Index (ABI), Rutherford class, and Walking Impairment Questionnaires (WIQ), were collected. The primary efficacy endpoint was the achievement of ≤30% final residual stenosis at the index lesion postatherectomy and adjunctive therapy evaluated by an angiographic Core Lab. The primary safety endpoint was the percentage of subjects who did not experience periprocedural major adverse events (PPMAEs) before discharge. RESULTS One hundred and two subjects with 121 lesions treated with the 355 nm laser device at 10 centers were included in the analysis. Mean age was 68.4 ± 10.21 years, 61.8% of subjects were male, 44.6% had critical limb ischemia (CLI), and 47.3% had tibial lesions. The mean residual stenosis at the end of the procedure was 24.4 ± 15.5 with 69 lesions (69.0%) achieving technical procedural success (<30% stenosis); similar rates were observed for subjects with ISR (25.5 ± 14.9), chronic total occlusion (CTO) (28.1 ± 17.0), and severe calcification (36.5 ± 21.6) lesions. Mean ABI, Rutherford, and WIQ scores were improved at both 6 and 12 months. Ninety-seven of 102 subjects (95.1%) met the primary safety endpoint of not experiencing a PPMAE before discharge. CONCLUSIONS The initial data from the Pathfinder Registry demonstrates the 355 nm laser system is safe and effective in a real-world setting for performing atherectomy in patients with infrainguinal PAD.
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Affiliation(s)
- Tony S Das
- The Heart Hospital Baylor Plano, Plano, Texas, USA
| | | | - Jason A Yoho
- The Texas Cardiac and Vascular Institute, Corpus Christi, Texas, USA
| | | | | | - Luis R Leon
- Pima Heart and Vascular, Tucson, Arizona, USA
| | | | - Zaheed Tai
- Comprehensive Cardiovascular Specialists, Winter Haven, Florida, USA
| | - Vaqar Ali
- First Coast Cardiovascular Institute, Jacksonville, Florida, USA
| | - Bulent Arslan
- Rush University Medical Center, Chicago, Illinois, USA
| | - John Rundback
- NJ Endovascular and Amputation Prevention, West Orange, New Jersey, USA
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