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Alameddine D, Satam K, Slade M, Wang H, Mena-Hurtado C, Turner J, Inzucchi SE, Ochoa Chaar CI. Insulin Requirement and Infrainguinal Bypass Outcomes in Patients with Peripheral Arterial Disease. Ann Vasc Surg 2024; 102:25-34. [PMID: 38307234 DOI: 10.1016/j.avsg.2023.11.044] [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: 08/12/2023] [Revised: 11/24/2023] [Accepted: 11/24/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Diabetes mellitus (DM) is a major risk factor for peripheral artery disease. The association of DM with major adverse limb events (MALE) after lower extremity revascularization remains controversial, as patients with diabetes are typically analyzed as a single, homogenous group. Using a large national database, this study examines the impact of insulin use and glycemic control on the outcomes following infrainguinal bypass. The hypothesis is that prevalent insulin therapy and elevated hemoglobin A1c (HbA1c) are associated with an increased risk of MALEs after infrainguinal bypass in patients with DM and could therefore be used for risk stratification. METHODS The Vascular Quality Initiative database files for infrainguinal bypass (2007-2021) were retrospectively reviewed. Patients with DM undergoing bypass for peripheral artery disease were included. Patients on dialysis or with prior kidney transplantation were excluded. The characteristics and outcomes of patients with insulin-requiring diabetes mellitus (IRDM) were compared to those of patients not requiring insulin (noninsulin-requiring diabetes mellitus [NIRDM]) prior to the bypass procedure. RESULTS A total of 9,686 patients with DM (56% IRDM) underwent bypass. Patients with IRDM were significantly younger than patients with NIRDM, more likely to be female (P < 0.01), African American (P < 0.01), and Hispanic (P = 0.031), and more likely to have comorbidities and be categorized into American Society of Anesthesiologist classes IV-V. They were more likely to be treated for chronic limb-threatening ischemia (P < 0.001). Patients with IRDM had significantly higher perioperative complications with no difference in perioperative mortality between the 2 groups. Beyond the perioperative period, with a mean follow-up of 427 days, patients with IRDM had significantly lower crude rates of primary patency and higher crude rates of major amputation, MALE, and mortality compared to patients with NIRDM. Regression analyses demonstrated that insulin requirement, but not HbA1c, was independently associated with a higher risk of MALE (hazard ratio = 1.17 [1.06-1.29]) and mortality (hazard ratio = 1.28 [1.16-1.43]). CONCLUSIONS Insulin requirement, but not HbA1c, is significantly associated with MALEs and survival after infrainguinal bypass in the Vascular Quality Initiative. Stratification of patients with DM based on their prevalent insulin use prior to infrainguinal bypass surgery could improve the prediction of outcomes of peripheral arterial bypass surgery in patients with diabetes.
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Affiliation(s)
- Dana Alameddine
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT.
| | - Keyuree Satam
- Department of Vascular Surgery, Stanford Hospital, Palo Alto, CA
| | - Martin Slade
- Department of Epidemiology and Public Health, Yale University, New Haven, CT
| | - He Wang
- Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Jeffrey Turner
- Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Silvio E Inzucchi
- Section of Endocrinology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT
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Zhao GF, Pan T, Yan R, Deng G, Wang Z, Qin YL, Ji JJ, Bai ZB, Li R, Teng GJ. Endovascular Denervation for the Improvement of Limb Ischemia in Patients with Peripheral Artery Disease: A Randomized Clinical Trial. Ann Vasc Surg 2024; 100:39-46. [PMID: 38104925 DOI: 10.1016/j.avsg.2023.10.011] [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: 07/18/2023] [Revised: 10/13/2023] [Accepted: 10/13/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND To evaluate the safety and efficacy of endovascular denervation (EDN) as an adjunct to percutaneous vascular intervention (PVI) for peripheral artery disease (PAD). METHODS From August 2019 to April 2021, 38 eligible patients with PAD enrolled in this study were randomly and equally assigned into 2 groups: the PVI group and the PVI + EDN group treated with EDN at the iliac and femoral arteries before PVI. The primary endpoint was the improvement in the ankle brachial index at 6 months after the procedure. The secondary endpoints were transcutaneous oxygen pressure (TcPO2), Rutherford category, numerical rating scale score, and safety. RESULTS The technical success rates of PVI and EDN were 100%, and no device-related or procedure-related major adverse events occurred in either group. Compared with PVI alone, PVI + EDN demonstrated a significant improvement in limb hemodynamics at 6 months (Δ ankle brachial index 0.44 ± 0.31 vs. 0.24 ± 0.15, P = 0.018). Microcirculatory perfusion of PAD was significantly better at 6 months in the PVI + EDN group (ΔTcPO2, 15.68 ± 16.72 vs. 4.95 ± 13.43, P = 0.036). The Rutherford category was significantly improved in the PVI + EDN group in comparison with the PVI group at the 3-month follow-up (100.00% vs. 68.42%, P = 0.02). The decrease in the numerical rating scale score in the PVI + EDN group was greater than that in the PVI group at 1 week following the procedure (3 [2-5] vs. 4 [4-6], P = 0.022). CONCLUSIONS In this single-center pilot analysis of a heterogeneous cohort of patients with PAD, PVI with EDN demonstrated a significant improvement in limb ischemia at 6 months compared with PVI alone.
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Affiliation(s)
- Guo-Feng Zhao
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Tao Pan
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Rong Yan
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Gang Deng
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Zhi Wang
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Yong-Lin Qin
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Jia-Jie Ji
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Zhi-Bin Bai
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Rui Li
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Gao-Jun Teng
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China.
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Cáceres-Farfán L, Moreno-Loaiza M, Cubas WS. Ankle-brachial index: more than a diagnostic test? ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2021; 2:254-262. [PMID: 37727667 PMCID: PMC10506545 DOI: 10.47487/apcyccv.v2i4.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/20/2021] [Indexed: 09/21/2023]
Abstract
The ankle-brachial index (ABI) is the relationship between the systolic blood pressure taken at the ankle level and the brachial artery. A pathological ABI (<0.90 or >1.40) indicates the presence of peripheral artery disease (PAD). Many studies indicate the great utility of this test in the diagnosis of PAD due to its ease of use, reproducibility, low cost, and high cost-effectiveness. This evaluation can be directly correlated with cardiovascular morbidity and mortality; however, it has recently been confirmed that a low ABI can be a predictor of major cardiovascular events, as it is related to diabetes mellitus, chronic coronary disease, stroke, and more. The objective of this work was to review the current evidence on the importance of ABI in the diagnosis of PAD and its main role as a predictor of cardiovascular morbidity and mortality.
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Affiliation(s)
- Ludwig Cáceres-Farfán
- Service of Vascular and Endovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Edgardo Rebagliati Martins National Hospital, Lima, Peru. Service of Vascular and Endovascular Surgery Department of Thoracic and Cardiovascular Surgery Edgardo Rebagliati Martins National Hospital Lima Peru
| | - Milagros Moreno-Loaiza
- Service of Vascular and Endovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Edgardo Rebagliati Martins National Hospital, Lima, Peru. Service of Vascular and Endovascular Surgery Department of Thoracic and Cardiovascular Surgery Edgardo Rebagliati Martins National Hospital Lima Peru
| | - W Samir Cubas
- Service of Vascular and Endovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Edgardo Rebagliati Martins National Hospital, Lima, Peru. Service of Vascular and Endovascular Surgery Department of Thoracic and Cardiovascular Surgery Edgardo Rebagliati Martins National Hospital Lima Peru
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