Limb salvage in women

Aggressive infrainguinal revascularization in renal transplant patients is justifiable

While studies demonstrate poor outcomes of lower extremity revascularization in patients with end-stage renal disease, little is known about results in renal transplant patients. We analyzed 2-year primary patency and limb salvage outcomes and associated risk factors of transplant (n = 202) and nontransplant patients (n = 25 274) in the Vascular Quality Initiative database undergoing infrainguinal bypass from 2003 to 2016. Multivariable Cox regression analysis and coarsened exact matching with many-to-one were used. Transplant patients were more likely to have critical limb ischemia and revascularization of more distal arteries and to receive vein conduits. Primary patency was similar between transplant and nontransplant patients at 1 year (80.8% vs 77.5%) and 2 years (67.9% vs 63.7%, P = .079). Amputation-free survival was higher for nontransplant patients (1 year: 82.4% vs 75.3%, 2 years: 68.8% vs 58.2%, P = .0060), although overall survival was equivalent (2 years: 84.6% vs 87.2%, 4 years: 75.9% vs 79.6%, P = .35). Risk factors for primary patency loss included being female, critical limb ischemia, prior bypass, and distal bypass. Age, diabetes, prior contralateral amputation, critical limb ischemia, prosthetic conduit, and more distal bypass were associated with limb loss. This is the largest series of infrainguinal revascularization in transplant patients. Outcomes for transplant patients are not inferior, and aggressive approaches at limb salvage are justifiable in appropriately selected patients.

Comparison of Lower Extremity Endovascular Intervention Outcomes in Women Versus Men

This study examined a gender difference in 12-month patient outcomes after endovascular intervention for symptomatic peripheral artery disease (PAD) utilizing propensity score-matched Excellence in Peripheral Artery Disease registry data. Mortality and repeat intervention outcomes after endovascular treatment in women compared with men in the existing literature are inconsistent and confounded by other risk factors. The study included 1,084 patients who underwent 1,702 endovascular procedures, at 8 non-Veterans Administration hospitals from January 2005 to October 2015. Frailty hazard ratios by gender for time-to-event analysis were estimated. Women made up about 40% of the study population. After propensity score matching, 449 women and 449 men were included in the analysis, in which women had similar baseline patient and lesion characteristics, laboratory data, procedural characteristics, and medical therapy as men. Within 12-month postintervention, women were at a lower risk of mortality than men (p = 0.05); however, they underwent significantly more frequent repeat revascularization procedures (p = 0.04). In subgroup analysis, women with superficial femoral artery disease were also at higher risk of 12-month repeat intervention than men (p <0.01) and had a higher mortality risk, albeit with an attenuated significance (p = 0.07). Women with PAD are at a higher risk of 12-month repeat intervention than men.

Angiosome-targeted revascularisation in diabetic foot ulcers

Peripheral vascular disease is a common complication of type 2 diabetes and is often more severe and diffuse than in non-diabetic individuals with a higher risk of major amputations in the lower limbs. Diabetic foot revascularisation using both traditional bypass surgery and endovascular therapy are often burdened by the failure and the inevitable subsequent massive amputation. In this study, we examined the clinical response of diabetic patients with critical limb ischaemia and extended ischaemic wounds, treated with a new angiosome-based revascularisation technique. In a 3-year period, nine diabetic patients with imminent amputation threatening and foot ulcers with no feasible arterial revascularisation options were treated by the angiosome-based surgical technique by means of deep vein arterialisation. The postoperative tcPO2 evaluation showed a mean increase in the cutaneous oxygen tension in all patients treated. The overall survival rates were 88·88%, 88·88% and 77·77% at 12, 24 and 36 months, respectively. Limb salvage was 100% at 1 year and steady at 88·88% thereafter. Surgical deep venous arterialisation might be considered as an extreme alternative to attempt tissue preservation in limbs unfit for conventional arterial revascularisations. This technique would give advantages to the patients in terms of better compliance to the minor amputations and thus avoiding major limb amputations.