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Ochoa Chaar CI, Malas M, Doros G, Schermerhorn M, Conte MS, Alameddine D, Siracuse JJ, Yadavalli SD, Dake MD, Creager MA, Tan TW, Rosenfield K, Menard MT, Farber A, Hamdan A. The Impact of Diabetes Mellitus on the Outcomes of Revascularization for Chronic Limb-Threatening Ischemia in the BEST-CLI trial. J Vasc Surg 2024:S0741-5214(24)01907-4. [PMID: 39332785 DOI: 10.1016/j.jvs.2024.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Revised: 08/20/2024] [Accepted: 09/19/2024] [Indexed: 09/29/2024]
Abstract
OBJECTIVES Several observational studies have demonstrated an association between diabetes mellitus (DM) and above ankle amputation after lower extremity revascularization (LER). However, data from prospective randomized trials is lacking. This analysis compares the outcomes of patients with and without DM enrolled in the Best Endovascular versus Best Surgical Therapy in patients with Chronic Limb-Threatening Ischemia (CLTI) (BEST-CLI) trial. METHODS Baseline characteristics were compared between patients with and without DM in the BEST-CLI trial. Cox regression was used to determine the association between DM and major outcomes of major adverse limb events (MALE), reintervention, above ankle amputation, and all-cause death. RESULTS Among 1,777 patients who underwent LER, 69.2% had DM. Compared to patients without DM, those with DM were significantly younger, less likely to be White, and more likely to be Hispanic. Patients with DM were more likely to have hypertension, hyperlipidemia, coronary artery disease, congestive heart failure, and renal disease and be on optimal medical therapy (antiplatelets and statins) while patients without DM were significantly more likely to be smokers and have chronic obstructive pulmonary disease. Patients with DM were significantly more likely to present with late Wound Ischemia foot Infection (WIfI) stages (3-4) (73.7% vs 45.9%, P<0.001) that were driven predominantly by differences in wound and infection grade. Conversely, patients without DM had significantly lower ankle pressures and toe pressures and were significantly more likely to have WIfI ischemia grade 3 compared to patients with DM (60% vs 52.5%, P=0.016). At three years, patients with DM exhibited higher rates of above ankle amputation and all-cause death compared to patients without DM. Kaplan-Meier analysis demonstrated significantly higher MALE or all-cause death compared to patients without DM (3-year estimate: 53.5% vs 46.4%, P<0.001). After adjusting for potential confounders, regression analysis demonstrated that DM was independently associated with increased above ankle amputation (1.75 [1.22-2.51]), all-cause death (1.63 [1.31-2.03]), and MALE or all-cause death (1.24 [1.04-1.47]). CONCLUSION Patients with DM undergoing LER for CLTI experienced a greater incidence of MALE or all-cause death compared to patients without DM. The impact of DM seems to be mediated by more severe wounds and infections at the time of presentation, and a higher prevalence of cardiac and renal disease.
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Affiliation(s)
- Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT.
| | - Mahmoud Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Gheorghe Doros
- Boston University School of Public Health, Department of Biostatistics, MA
| | - Marc Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Michael S Conte
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Dana Alameddine
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Jeffrey J Siracuse
- Department of Surgery, Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Sai Divya Yadavalli
- Department of Surgery, Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Mark A Creager
- Heart and Vascular Center, Dartmouth Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Tze-Woei Tan
- Division of Vascular and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Kenneth Rosenfield
- Department of Cardiovascular Diseases, Massachusetts General Hospital, Boston, MA
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alik Farber
- Department of Surgery, Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Allen Hamdan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Alexandrescu VA, Van Overmeire L, Makrygiannis G, Azdad K, Popitiu M, Paquet S, Poppe L, Nodit M. Clinical Implications of Diabetic Peripheral Neuropathy in Primary Infrapopliteal Angioplasty Approach for Neuro-Ischemic Foot Wounds. J Endovasc Ther 2023; 30:920-930. [PMID: 35786131 DOI: 10.1177/15266028221106312] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND To assess the clinical effects of diabetic peripheral neuropathy (DPN) in patients with chronic limb-threatening ischemia (CLTI) treated by primary infrapopliteal angioplasty for neuro-ischemic Rutherford 5, foot wounds. MATERIALS AND METHODS Over a 10-year period (2009-2019), a series of 304 diabetic ischemic limbs adding or not evincible neuropathic affectation were treated by primary infrapopliteal angioplasty and their files were retrospectively reviewed. Mean length of treated arterial lesions was 6.1 cm (range 1-22 cm). Inferior limb vibration perception threshold diagnostic was performed for comparing and scoring detectable DPN in all studied diabetic patients (classed from 0 to 10 points). There were 19% limbs with normal (0-1 points) perception (group 1), 55% others with "mild" and "moderate" (2-6 points) neuropathic impairment (group 2), and 26% limbs showing "severe" (7-10 points) DPN (group 3). RESULTS Primary infrapopliteal angioplasty succeeded in 89% cases in group 1, in 82% in group 2, and in 68% of limbs in group 3. This latest group assembled the heaviest neuropathic affectation and arterial calcifications and proved the lowest clinical benefit at 36 months: 35% (95% confidence interval [CI]=22% to 48%) of primary patency, 36% (95% CI=22% to 50%) wound healing, and 54% (95% CI=39% to 69%) limb preservation rates. A comparison between groups 1 vs 3 and 2 vs 3 of primary patency (p=0.014 and p=0.043), tissue healing (p=0.049 and p=0.01), and limb salvage (p=0.006 and p=0.023) proved significant, yet without statistical weight for group 1 vs 2 (p>0.05). Overall survival was not significantly affected between groups (p=0.34). CONCLUSION The presence of severe DPN may jeopardize the results of infrapopliteal angioplasty in terms of patency, tissue cicatrization, and limb preservation, yet without significance on survival of these patients. When present, DPN requires appropriate stratification as specific indicator in CLTI treatment.
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Affiliation(s)
- Vlad Adrian Alexandrescu
- Department of Thoracic and Vascular Surgery, Princess Paola Hospital, Vivalia, Marche-en-Famenne, Belgium
| | - Lionel Van Overmeire
- Department of Nephrology and Internal Medicine, Princess Paola Hospital, Vivalia, Marche-en-Famenne, Belgium
| | - Georgios Makrygiannis
- Department of Thoracic and Vascular Surgery, Princess Paola Hospital, Vivalia, Marche-en-Famenne, Belgium
| | - Khalid Azdad
- Department of Radiology, Princess Paola Hospital, Vivalia, Marche-en-Famenne, Belgium
| | - Mircea Popitiu
- Department of Vascular Surgery and Reconstructive Microsurgery, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Séverine Paquet
- Department of Thoracic and Vascular Surgery, Princess Paola Hospital, Vivalia, Marche-en-Famenne, Belgium
| | - Laura Poppe
- Department of Thoracic and Vascular Surgery, Princess Paola Hospital, Vivalia, Marche-en-Famenne, Belgium
| | - Mihaela Nodit
- Department of Geriatric Care and Internal Medicine, Princess Paola Hospital, Vivalia, Marche-en-Famenne, Belgium
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An TJ, Cochran RL, Di Capua J, Reid N, Walker TG. Insulin-Dependent Status Influences Post-Procedural Outcomes in Diabetic Patients Following Lower Extremity Endovascular Intervention for Peripheral Arterial Disease. Cardiovasc Intervent Radiol 2021; 44:1165-1173. [PMID: 33855582 DOI: 10.1007/s00270-021-02830-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/22/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Diabetic patients are at increased risk of developing lower extremity peripheral arterial disease (PAD) requiring revascularization. This study assessed the effect of insulin dependence in diabetics on post-procedural outcomes following infra-inguinal endovascular intervention. MATERIALS AND METHODS The American College of Surgeon's National Surgical Quality Improvement Program database was used to identify 8022 patients undergoing infra-inguinal endovascular interventions between 2014 and 2017. Thirty-day post-procedural outcomes for patients without diabetes, with non-insulin-dependent diabetes mellitus (NIDDM), and with insulin-dependent diabetes mellitus (IDDM) were compared. RESULTS At presentation, IDDM patients were more likely to present with critical limb ischemia compared to NIDDM and non-diabetic patients. In propensity score-weighted logistic regression analysis, IDDM status was an independent predictor for increased renal complication (odds ratio [OR] = 3.08, confidence interval [CI] = 1.44-6.65), sepsis (OR = 1.68, CI = 1.13-2.48), wound complication (OR = 1.57, CI = 1.09-2.25, p = 0.006), UTI (OR = 2.07, CI = 1.09-3.94, p = 0.03), and readmission (OR = 1.21, CI = 1.03-1.42). NIDDM status was an independent predictor for increased risk of renal complications (OR = 2.80, CI = 1.18-6.63). CONCLUSIONS IDDM status is an independent predictor for increased risk of 30-day post-procedural complications and readmission compared to both NIDDM and non-diabetic status in patients undergoing lower extremity endovascular interventions for PAD.
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Affiliation(s)
- Thomas J An
- MGH Department of Radiology, Division of Interventional Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Harvard Medical School, Boston, USA
| | - Rory L Cochran
- MGH Department of Radiology, Division of Interventional Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Harvard Medical School, Boston, USA
| | - John Di Capua
- MGH Department of Radiology, Division of Interventional Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Harvard Medical School, Boston, USA
| | | | - T Gregory Walker
- MGH Department of Radiology, Division of Interventional Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, USA.
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Giannopoulos S, Palena LM, Armstrong EJ. Technical Success and Complication Rates of Retrograde Arterial Access for Endovascular Therapy for Critical Limb Ischaemia: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2020; 61:270-279. [PMID: 33358346 DOI: 10.1016/j.ejvs.2020.11.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/26/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Antegrade crossing techniques via transfemoral access are often challenging and may be associated with technical and clinical failure when treating patients with critical limb ischaemia (CLI). The objective of this study was to summarise all available literature regarding retrograde endovascular treatment of patients with CLI and to investigate the technical success and complication rate of retrograde access. METHODS A systematic literature search was performed in PubMed, Scopus, and Cochrane Central until May 2020. A meta-analysis of 31 observational studies (29 retrospective and two prospective; 26 and five studies with low and moderate risk of bias, respectively) was conducted with random effects modelling. The incidence of adverse events peri-procedurally and during follow up were calculated. RESULTS The 31 studies enrolled 1 910 patients who were treated endovascularly for femoropopliteal and/or infrapopliteal lesions causing CLI. Most of the patients had diabetes while more than half of the overall population had coronary artery disease and dyslipidaemia. All lesions were located in the infra-inguinal segment and most were chronic total occlusions (96%; 95% CI 85%-100%). Seven studies reported moderate or severe calcification in approximately half of the cases (45%; 95% CI 30%-60%). The overall technical success of the retrograde approach was 96% (18 studies; 95% CI 92%-100%). Perforation, flow limiting dissection, distal embolisation, and local haematoma at the retrograde access site were infrequent and observed in 2.1%, 0.6%, 0.1%, and 1.3% of the patients, respectively. The six month primary patency rate was 78% (five studies; 95% CI 46%-99%), the six month limb salvage rate was 77% (four studies; 95% CI 70%-84%). CONCLUSION The results indicated that the retrograde or bidirectional antegrade/retrograde approach is safe and effective and facilitates angioplasty when antegrade treatment fails. However, prospective studies with standardised wound care and surveillance protocols are needed to investigate retrograde techniques in patients with CLI who failed antegrade revascularisation, to improve long term limb salvage and survival.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Centre, University of Colorado, Denver, CO, USA
| | - Luis M Palena
- Endovascular Surgery Unit, Endovascular Interventions & Research, Foot & Ankle Clinic, Maria Cecilia Hospital, Cotignola, Italy
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Centre, University of Colorado, Denver, CO, USA.
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Rockley M, Jetty P, Wells G. Physiologic perfusion monitoring methods during endovascular revascularization for atherosclerotic peripheral arterial disease: protocol for a systematic review. Syst Rev 2020; 9:107. [PMID: 32384916 PMCID: PMC7210685 DOI: 10.1186/s13643-020-01357-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 04/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endovascular therapy is a fundamental treatment for peripheral arterial disease. However, the success rate of endovascular therapy remains poor, as a third of patients with critical limb ischemia ultimately require a major amputation for gangrene despite endovascular treatment. This failure rate has prompted investigation into methods of determining physiologic procedural success before and after treatment, before clinically apparent outcomes occur such as gangrene. The aim of this systematic review is to evaluate if in patients undergoing endovascular surgery for lower extremity atherosclerotic peripheral arterial disease, do changes in physiologic measures of perfusion during surgery correlate with clinical outcomes. METHODS We registered and designed a study protocol for a systematic review. Literature searches will be conducted in MEDLINE, EMBASE, and CENTRAL (from January 1977 onwards). Grey literature will be identified through OpenGrey and clinical trial registries, and supplemented by citation searches. We will include randomized controlled trials, quasi-experimental trials, and observational (cohort, case-control) studies conducted in human adults (age 18 or older) who received elective arterial angioplasty for atherosclerotic peripheral vascular disease. The primary outcome of interest will be major adverse limb events. Two investigators will independently screen all citation, full-text articles, and abstract data. The study quality (risk of bias) will be appraised appropriate tools. Data analysis and synthesis will be qualitative; no meta-analysis is planned, as the anticipated homogeneity of measurement and outcome reporting standardization is low. DISCUSSION The treatment of peripheral arterial disease is unique in that the tissue of the ischemic leg is easily accessible for direct monitoring during procedures. This is contrasted with cardiac and neurologic monitoring during cardiac and cerebral procedures, where indirect or invasive measures are required to monitor organ perfusion. Currently synthesized evidence describing limb perfusion focuses on static states of ischemia, and does not evaluate the value of change in perfusion measurement as an indicator of endovascular treatment success. These methods could potentially be applied to optimize procedural outcomes by guiding perfusion-based decision-making during surgery. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019138192.
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Affiliation(s)
- Mark Rockley
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital-Civic Campus, K1Y4E9, Ottawa, Canada.
| | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital-Civic Campus, K1Y4E9, Ottawa, Canada
| | - George Wells
- School of Epidemiology and Public Health, Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, K1Y4W7, Ottawa, Canada
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Spiliopoulos S, Brountzos E, Lazaris A. Commentary: Wound-Directed Revascularization for the Treatment of Diabetic Foot Ulcers: Comments on a Newly Proposed Algorithm. J Endovasc Ther 2020; 27:31-33. [PMID: 31774010 DOI: 10.1177/1526602819890313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Stavros Spiliopoulos
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Elias Brountzos
- 2nd Department of Radiology, Interventional Radiology Unit, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Andreas Lazaris
- Department of Vascular Surgery, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
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Rockley M, Jetty P, Wells GA. Protocol for a prospective observational diagnostic study: intraoperative simultaneous limb pressure monitoring (INSTANT) study. BMJ Open 2019; 9:e030456. [PMID: 31444190 PMCID: PMC6707646 DOI: 10.1136/bmjopen-2019-030456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/16/2019] [Accepted: 07/23/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Peripheral vascular disease (PVD) is a condition caused by arterial blockages causing inadequate blood flow, resulting in pain and gangrene of the legs. Endovascular therapy, such as angioplasty, can be used to treat PVD, however, the operator feedback during surgery is primarily anatomic based on the angiogram. Because physiologic blood perfusion can be difficult to determine based on anatomic images, we propose introducing physiological measurements into the operating room. This study will investigate whether the change in intraoperative monitoring of haemodynamic measurements such as the Toe-Brachial Index during endovascular surgery for lower extremity atherosclerotic PVD is associated with clinical outcomes such as major adverse limb events (MALEs). METHODS AND ANALYSIS This study will be a prospective, operator-blinded and blinded endpoint adjudicated observational diagnostic cohort study. A total of 80 legs will be enrolled in the study. Ankle and toe blood pressures will be measured non-invasively at predetermined time points before, during and after surgery, and we will assess associations between changes in intraoperative pressure measurements and postoperative clinical and haemodynamic outcomes. The primary outcome will be MALE within 1 year, and secondary outcomes include follow-up pressure measurements, vessel patency, reintervention, clinical staging improvement, amputation and death. ETHICS AND DISSEMINATION Regional hospital ethics approval has been granted (Ottawa Hospital Research Institute - Research Ethics Board, Protocol 20180656-01H). On completion of data analysis, the study will submitted for presentation at international vascular surgical society meetings, in addition to submission for publication in publicly accessible medical journals. TRIAL REGISTRATION NUMBER NCT03875846.
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Affiliation(s)
- Mark Rockley
- Division of Vascular Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Prasad Jetty
- Division of Vascular Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - George A Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Rockley M, Jetty P, Radonjic A, Rockley K, Wells G, Fergusson D. Prolonged versus brief balloon inflation during arterial angioplasty for de novo atherosclerotic disease: a systematic review and meta-analysis. CVIR Endovasc 2019; 2:29. [PMID: 32026993 PMCID: PMC6966366 DOI: 10.1186/s42155-019-0072-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 08/06/2019] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Angioplasty is a fundamental treatment for atherosclerotic disease and may be performed as the sole therapy in small vessel disease. However, the ideal duration of balloon inflation has not yet been identified. Our study investigated whether prolonged inflation of at least 1-min duration, when compared with brief inflation, affects residual stenosis after arterial angioplasty. DATA SOURCES AND METHODS Two independent reviewers conducted a systematic review of EMBASE, MEDLINE, CENTRAL, trial registries and grey literature, using pre-specified search syntax. Data abstraction and quantitative analysis was performed independently, according to pre-specified criteria. The primary outcome was residual stenosis after initial angioplasty, in addition to other pre-specific clinical and radiographic outcomes. All analyses were stratified by coronary, cerebrovascular, and peripheral territory. The study protocol is published and registered on PROSPERO (CRD42018092702). RESULTS Six relevant articles were identified, of which one investigated peripheral vascular angioplasty and five investigated coronary artery angioplasty, encompassing 1496 procedures. The studies were at moderate risk of bias. Minimal heterogeneity within coronary studies allowed for subgroup meta-analysis. Prolonged inflation was significantly associated with lower risk of residual stenosis post-inflation in the pooled coronary trials (RR 1.76 [95% CI 1.46-2.12], I2 = 0%, p < 0.001) in addition to approaching significance in the peripheral vascular trial (RR 2.40 [95% CI 0.94-6.13], p = 0.07). Prolonged inflation was associated with less risk of arterial dissection and need for adjunctive procedures such as stenting. Following adjunctive procedures, less residual stenosis was still observed in the prolonged angioplasty group in the reported coronary studies. Follow-up data did not reveal a significant difference in the presence of restenosis, however there was a long-term benefit of prolonged inflation in reducing overall severity of stenosis. DISCUSSION This is the first review investigating outcomes related to duration of balloon inflation. Both coronary and peripheral vascular evidence are in agreement that prolonged angioplasty balloon inflation greater than 60 s appears to be associated with improved immediate post-inflation results. However, long-term data is heterogeneous and inconsistently reported. We propose further investigation to address outstanding long-term outcomes, particularly in small vessel territories such as tibial vessels where angioplasty is often used as the only endovascular therapy. TRIAL REGISTRATION This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42018092702 ) prior to conduct of the review.
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Affiliation(s)
- Mark Rockley
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital - Civic Campus, Ottawa, K1Y4E9, Canada.
| | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital - Civic Campus, Ottawa, K1Y4E9, Canada
| | - Aleksandar Radonjic
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital - Civic Campus, Ottawa, K1Y4E9, Canada
| | - Kathleen Rockley
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital - Civic Campus, Ottawa, K1Y4E9, Canada
| | - George Wells
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, K1Y4W7, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, K1H8L6, Canada
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Rockley M, Jetty P, Wells G, Rockley K, Fergusson D. Prolonged versus brief balloon inflation during arterial angioplasty for de novo atherosclerotic disease: protocol for a systematic review. Syst Rev 2019; 8:45. [PMID: 30722783 PMCID: PMC6362580 DOI: 10.1186/s13643-019-0955-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 01/18/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Angioplasty is a fundamental treatment for atherosclerotic disease in the cardiac, cerebrovascular, and peripheral vascular beds. However, the optimal duration of balloon inflation has not been identified. Our study will investigate whether prolonged angioplasty balloon inflation of at least 1 min duration, when compared with brief inflation, affects residual stenosis after arterial angioplasty. METHODS In compliance with PRISMA, two independent reviewers will conduct a systematic review of EMBASE, MEDLINE, CENTRAL, trial registries, grey literature, and ancestry and citation search. Data abstraction, quantitative, and quantitative meta-analysis will be performed according to pre-specified criteria. The primary outcome is residual stenosis immediately after initial angioplasty; however, secondary outcomes will include multiple short and long term pre-specific clinical and radiographic outcomes. Risk of bias, subgroup analyses, and sensitivity analyses are planned. DISCUSSION Despite the ubiquitous use of angioplasty in atherosclerotic disease and multiple trials investigating the ideal balloon inflation duration, there are no systematic reviews evaluating prolonged angioplasty balloon inflation. Currently synthesized evidence is insufficient to confidently direct clinical decision-making, and the current variation in operator preference of balloon angioplasty duration suggests ongoing clinical equipoise. Given the known availability of current primary evidence, our study intends to synthesize the evidence and guide future clinical decision making and investigation. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018092702.
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Affiliation(s)
- Mark Rockley
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital - Civic Campus, Ottawa, K1Y4E9, Canada.
| | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital - Civic Campus, Ottawa, K1Y4E9, Canada
| | - George Wells
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, K1Y4W7, Canada
| | - Kathleen Rockley
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital - Civic Campus, Ottawa, K1Y4E9, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, K1H8L6, Canada
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Lowry D, Saeed M, Narendran P, Tiwari A. A Review of Distribution of Atherosclerosis in the Lower Limb Arteries of Patients With Diabetes Mellitus and Peripheral Vascular Disease. Vasc Endovascular Surg 2018; 52:535-542. [PMID: 30068238 DOI: 10.1177/1538574418791622] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE There is a generally accepted hypothesis that patients with diabetes mellitus (DM) have a higher burden of atherosclerotic disease below the knee compared to patients without DM (NDM). The aim of this review was to summarize the evidence regarding this hypothesis. METHODS The literature was searched for papers that compared the anatomical distribution of atherosclerotic disease in patients with DM and those without using radiological imaging. Search terms used included "diabetes mellitus," "peripheral vascular disease," "distribution of disease," "angiography," "computed tomography angiography," and "magnetic resonance angiography." Where possible, the number of patients with disease in each arterial segment was extracted and included in a forest plot. A descriptive approach was taken when this was not possible or a scoring system was used. RESULTS Fourteen studies were included in the review and it was possible to summarize data from 9 of these in a forest plot. Fifteen different arterial segments were described; however, the most commonly used segments that differentiated between proximal and distal disease were aortoiliac (A-I; DM = 466 patients, NDM = 458), femoropopliteal (F-P; DM = 568, NDM = 585), tibial (DM = 306, NDM = 417). The resulting forest plot showed that those with DM were significantly less likely to have disease in the A-I segment (odds ratio [OR]: 0.25 [0.15-0.42]) and significantly more likely to have disease in the tibial segment (OR 1.94 [1.27-2.96]). In the DM group, there was a trend toward relative sparing in the F-P segment, but this does not reach significance (0.66 [0.33-1.31]). CONCLUSIONS These results support the hypothesis that patients with DM are more likely to have atherosclerotic disease in the tibial vessels than NDM. There is however limited information on how individual vessels are affected. Further information on this and a greater understanding of why the distal vessels are more affected are avenues for future research.
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Affiliation(s)
- Danielle Lowry
- 1 Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Mujahid Saeed
- 2 Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Parth Narendran
- 2 Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom.,3 Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Alok Tiwari
- 1 Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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The use of crossing catheters in the recanalization of below-the-knee chronic total occlusions in patients with critical limb ischemia. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 26:402-406. [PMID: 32082770 DOI: 10.5606/tgkdc.dergisi.2018.16129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/10/2018] [Indexed: 11/21/2022]
Abstract
Background This study investigates the procedural success of the use of a hydrophilic crossing catheter in the recanalization of below-the-knee artery chronic total occlusions in patients with critical limb ischemia. Methods We retrospectively identified below-the knee chronic total occlusion interventions in 30 patients performed between March 2013 and July 2017 in our institute. The inclusion criteria were critical limb ischemia (Rutherford Class 4 or greater) and occlusion of at least one tibial vessel with revascularization performed with the use of a crossing catheter. Primary technical success was defined as placement of a guide wire in the true lumen, past the distal chronic total occlusions cap. Results Thirty patients underwent 34 procedures, in which 41 lesions were treated with the use of crossing catheters. Nineteen anterior tibial arteries, 18 posterior tibial arteries, and four peroneal arteries were treated. Mean length was 110.2±36 mm and 20 lesions (48.8%) were severely calcified. The primary technical success rate was 80.5%. Recanalization was achieved with a guide wire and crossing catheter in 25 lesions (76%) and with the crossing catheter alone in eight cases (24%). Conclusion The use of a crossing catheter showed a high rate of technical and procedural success in infrapopliteal chronic total occlusions without significant complications.
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Radeleff B, Sumkauskaite M, Kortes N, Gnutzmann D, Mokry T, Kauczor HU, Stampfl U. [Subintimal recanalization. Indications, technique and results]. Radiologe 2016; 56:266-74. [PMID: 26885652 DOI: 10.1007/s00117-016-0078-x] [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] [Indexed: 11/26/2022]
Abstract
CLINICAL/METHODICAL ISSUE This article gives an overview of the current importance of so-called subintimal recanalization in the lower extremities. STANDARD RADIOLOGICAL METHODS The primary technical goal of endovascular interventions in the lower extremities is the endoluminal restoration of blood circulation from the iliac arteries into the feet. METHODICAL INNOVATIONS If endoluminal recanalization of e.g. high-grade flow-relevant stenoses or chronic total occlusion (CTO) is technically not possible, subintimal recanalization is a promising option and the only remaining minimally invasive alternative. During subintimal recanalization a channel is intentionally generated in the vessel wall (dissection) in order to bypass e. g. a chronic vascular occlusion over as short a distance as possible. PERFORMANCE The technical success rate for subintimal recanalization of CTO of the lower extremities is 65-100 %. Technical failure occurs in approximately 25 % using the catheter and wire technique and is caused in most cases by difficulties in reaching the true lumen after the subintimal passage (the so-called re-entry). ACHIEVEMENTS Compared to conventional subintimal recanalization, in recent years so-called re-entry devices have expanded the technical possibilities and depending on the medical experience and training level of the physician, provide an improvement in the technical success rate, a lower complication rate, a reduction of fluoroscopy time and the amount of necessary contrast medium but also result in higher costs. PRACTICAL RECOMMENDATIONS Subintimal recanalization, whether carried out conventionally with a catheter and wire or using re-entry devices, of high-grade stenoses or CTO in the lower extremities provides a high technical success rate but requires an experienced and trained physician who is capable of operating the elaborate materials and mastering any possible complications.
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Affiliation(s)
- B Radeleff
- Sektion für Interventionelle Radiologie, Diagnostische und Interventionelle Radiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
| | - M Sumkauskaite
- Sektion für Interventionelle Radiologie, Diagnostische und Interventionelle Radiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - N Kortes
- Sektion für Interventionelle Radiologie, Diagnostische und Interventionelle Radiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - D Gnutzmann
- Sektion für Interventionelle Radiologie, Diagnostische und Interventionelle Radiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - T Mokry
- Sektion für Interventionelle Radiologie, Diagnostische und Interventionelle Radiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - H U Kauczor
- Sektion für Interventionelle Radiologie, Diagnostische und Interventionelle Radiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - U Stampfl
- Sektion für Interventionelle Radiologie, Diagnostische und Interventionelle Radiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
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Lazaris AM, Kontopantelis E, Antonopoulos K, Mantas G, Kouvelos G, Moulakakis K, Matsagkas MI, Vasdekis SN, Geroulakos G. Effect of diabetes mellitus on the clinical outcome of lower limb arterial bypass surgery: A propensity score analysis. Vascular 2016; 25:364-371. [PMID: 27940896 DOI: 10.1177/1708538116682911] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Diabetic patients who undergo lower limb arterial bypass surgery are considered to have a worse clinical outcome compared to non-diabetics. The aim of the study was to test this hypothesis after applying propensity score matching analysis. Patients and methods A total of 113 consecutive lower limb bypass procedures (55 diabetic and 58 non-diabetic) were evaluated regarding their clinical outcome. Endpoints of the study included amputation-free survival, limb salvage, patency and patients' survival up to 36 months post-procedure. After propensity score matching analysis, two new groups, diabetic and non-diabetic, of 31 limbs in each one were created, both equivalent regarding all baseline characteristics. Results Between the propensity score matching groups, the amputation-free survival was 68.8% in the non-diabetic and 37.7% in the diabetic group at 36 months ( p = 0.004). Similarly, the survival was 88.6% and 57.6%, respectively, in the two groups at the same time point ( p = 0.01). On the contrary, no difference was found in patency (58.3% vs. 56%) and in limb salvage rate (74.1% vs. 60.8%). Conclusions Lower limbs arterial bypass surgery has similar results regarding patency and limb salvage rate in diabetic and non-diabetic patients. On the contrary, mortality is worse in diabetic patients, this affecting negatively their amputation-free survival.
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Affiliation(s)
- Andreas M Lazaris
- 1 Vascular Surgery Department, School of Medicine, National and Kapodistrian University of Athens, Attikon Teaching Hospital, Athens, Greece
| | | | - Konstantinos Antonopoulos
- 1 Vascular Surgery Department, School of Medicine, National and Kapodistrian University of Athens, Attikon Teaching Hospital, Athens, Greece
| | - Georgios Mantas
- 1 Vascular Surgery Department, School of Medicine, National and Kapodistrian University of Athens, Attikon Teaching Hospital, Athens, Greece
| | - Georgios Kouvelos
- 3 Department of Surgery, Vascular Surgery Unit, Medical School, University of Ioannina, Ioannina, Greece
| | - Konstantinos Moulakakis
- 1 Vascular Surgery Department, School of Medicine, National and Kapodistrian University of Athens, Attikon Teaching Hospital, Athens, Greece
| | - Miltiadis I Matsagkas
- 3 Department of Surgery, Vascular Surgery Unit, Medical School, University of Ioannina, Ioannina, Greece
| | - Spyros N Vasdekis
- 1 Vascular Surgery Department, School of Medicine, National and Kapodistrian University of Athens, Attikon Teaching Hospital, Athens, Greece
| | - George Geroulakos
- 1 Vascular Surgery Department, School of Medicine, National and Kapodistrian University of Athens, Attikon Teaching Hospital, Athens, Greece
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Hicks CW, Najafian A, Farber A, Menard MT, Malas MB, Black JH, Abularrage CJ. Below-knee endovascular interventions have better outcomes compared to open bypass for patients with critical limb ischemia. Vasc Med 2016; 22:28-34. [PMID: 27928034 DOI: 10.1177/1358863x16676901] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Both open surgery and endovascular peripheral interventions have been shown to effectively improve outcomes in patients with peripheral artery disease, but minimal data exist comparing outcomes performed at and below the knee. The purpose of this study was to compare outcomes following infrageniculate lower extremity open bypass (LEB) versus peripheral vascular intervention (PVI) in patients with critical limb ischemia. Using data from the 2008-2014 Vascular Quality Initiative, 1-year primary patency, major amputation, and mortality were compared among all patients undergoing LEB versus PVI at or below the knee for rest pain or tissue loss. Overall, 2566 patients were included (LEB=500, PVI=2066). One-year primary patency was significantly worse following LEB (73% vs 81%; p<0.001). One-year major amputation (14% vs 12%; p=0.18) and mortality (4% vs 6%; p=0.15) were similar regardless of revascularization approach. Multivariable analysis adjusting for baseline differences between groups confirmed inferior primary patency following LEB versus PVI (HR 0.74; 95% CI, 0.60-0.90; p=0.004), but no significant differences in 1-year major amputation (HR 1.06; 95% CI, 0.80-1.40; p=0.67) or mortality (HR 0.71; 95% CI, 0.44-1.14; p=0.16). Based on these data, we conclude that endovascular revascularization is a viable treatment approach for critical limb ischemia resulting from infrageniculate arterial occlusive disease.
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Affiliation(s)
- Caitlin W Hicks
- 1 Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alireza Najafian
- 2 Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alik Farber
- 3 Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA, USA
| | - Matthew T Menard
- 4 Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mahmoud B Malas
- 1 Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - James H Black
- 1 Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Christopher J Abularrage
- 1 Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
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Hicks CW, Najafian A, Farber A, Menard MT, Malas MB, Black JH, Abularrage CJ. Diabetes does not worsen outcomes following infrageniculate bypass or endovascular intervention for patients with critical limb ischemia. J Vasc Surg 2016; 64:1667-1674.e1. [DOI: 10.1016/j.jvs.2016.07.107] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 07/06/2016] [Indexed: 11/28/2022]
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16
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Routine Use of Surgical Retrograde Transtibial Endovascular Approach for Failed Attempts at Antegrade Recanalization of Chronic Peripheral Artery Total Occlusions. Cardiovasc Intervent Radiol 2016; 39:1692-1701. [DOI: 10.1007/s00270-016-1449-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 06/19/2016] [Indexed: 11/24/2022]
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17
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Muhs BE, Gagne PJ, Maldonado T, Sheehan P. Minimally Invasive Revascularization Strategies for Chronic Lower Limb Ischemia. INT J LOW EXTR WOUND 2016; 5:35-9. [PMID: 16543211 DOI: 10.1177/1534734606286473] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Lower extremity wounds resulting from ischemia are increasingly becoming a common indication for surgical revascularization. Techniques in minimally invasive vascular surgery for the treatment of lower extremity chronic ischemia have expanded rapidly in recent years. The current standard of care with which all new modalities should be compared is the restoration of arterial flow via direct arterial revascularization using the autogenous reversed saphenous vein that can yield limb salvage rates of approximately 95%. Percutaneous transluminal angioplasty and stenting (PTA/S), cryoplasty, catheter-directed atherectomy, laser-assisted PTA/S, drug-eluting stents, and subintimal angioplasty are emerging minimally invasive modalities used for the treatment of lower extremity ischemia. Early success rates using many of these techniques have been promising. The outcomes of randomized controlled trials with long-term follow-ups are needed to make confident remarks about the effectiveness of these techniques.
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Affiliation(s)
- Bart E Muhs
- Division of Vascular Surgery, New York University School of Medicine, New York, NY 10016, USA.
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18
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Chou HH, Huang HL, Hsieh CA, Jang SJ, Cheng ST, Tsai SC, Wu TY, Ko YL. Outcomes of Endovascular Therapy With the Controlled Antegrade Retrograde Subintimal Tracking (CART) or Reverse CART Technique for Long Infrainguinal Occlusions. J Endovasc Ther 2016; 23:330-8. [DOI: 10.1177/1526602816630533] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To compare the safety, efficacy, and clinical outcomes associated with the controlled antegrade retrograde subintimal tracking (CART) or reverse CART (r-CART) technique to the conventional retrograde approach in the treatment of patients with long infrainguinal occlusions. Methods: From May 2008 to April 2014, 121 patients failed antegrade recanalization and underwent a retrograde approach to recanalize long infrainguinal occlusions. Patients who underwent successful endovascular therapy (EVT) by the conventional retrograde approach (CRA group) were compared to patients who had successful EVT using the CART/r-CART technique (CART group) after failure of a bidirectional approach. The efficacy, safety, vessel patency, and other clinical outcomes were compared between the groups. Results: Fifty-eight patients (mean age 71.6±12.2 years; 32 men) underwent successful EVT (47.9%, 58/121) using the conventional retrograde approach (CRA group), while 44 patients (mean age 70.8±11.1 years; 31 men) among the 50 patients who underwent the CART/r-CART technique were successfully treated (88.0%, 44/50). Both groups had similar average occlusion lengths and gained 100% immediate hemodynamic success after EVT. There was no significant difference between the groups regarding procedure-related complications. During follow-up, 28 patients died (p=0.380), but there were no differences in the rates of major (p=0.279) or minor amputation (p=0.417) between the groups. There was no difference in the 2-year primary patency (31% vs 24%, p=0.686), assisted primary patency (66% vs 76%, p=0.251), target vessel revascularization (65% vs 54%, p=0.845), or sustained clinical success (52% vs 46%, p=0.995) rates between the CRA and CART groups, respectively. Conclusion: Based on acceptable safety, efficacy, and follow-up results in this study, the CART/r-CART technique can salvage patients with long peripheral occlusions after failure of the conventional antegrade or retrograde approach.
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Affiliation(s)
- Hsin-Hua Chou
- Section of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Hsuan-Li Huang
- Section of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Chien-An Hsieh
- Section of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Shih-Jung Jang
- Section of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Shih-Tsung Cheng
- Section of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Sou-Chan Tsai
- Section of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Tien-Yu Wu
- Section of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Yu-Lin Ko
- Section of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
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Torres-Blanco Á, Edo-Fleta G, Gómez-Palonés F, Molina-Nácher V, Ortiz-Monzón E. Mid-Term Outcomes of Endovascular Treatment for TASC-II D Femoropopliteal Occlusive Disease with Critical Limb Ischemia. Cardiovasc Intervent Radiol 2015. [DOI: 10.1007/s00270-015-1175-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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20
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Takama T, Hirano K, Nakano M, Iida O, Suzuki K, Miyashita Y, Ishimori H, Ito Y, Tsukahara R, Muramatsu T. Intravascular ultrasound findings after knuckle wire technique for superficial femoral artery occlusion. Interv Cardiol 2014. [DOI: 10.2217/ica.14.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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21
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Liang GZ, Zhang FX. Novel devices and specialized techniques in recanalization of peripheral artery chronic total occlusions (CTOs) — A literature review. Int J Cardiol 2013; 165:423-9. [DOI: 10.1016/j.ijcard.2012.03.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2011] [Revised: 11/16/2011] [Accepted: 03/03/2012] [Indexed: 10/28/2022]
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Georgakarakos E, Papanas N, Papadaki E, Georgiadis GS, Maltezos E, Lazarides MK. Endovascular treatment of critical ischemia in the diabetic foot: new thresholds, new anatomies. Angiology 2012; 64:583-91. [PMID: 23129734 DOI: 10.1177/0003319712465172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This review discusses the role of endovascular treatment in diabetic patients with critical limb ischemia (CLI). Angioplasty of the femoropopliteal region achieves similar technical success and limb salvage rates in diabetic and nondiabetic patients. Angioplasty in as many as possible tibial vessels is accompanied by more complete and faster ulcer healing as well as better limb salvage rates compared to isolated tibial angioplasty. Targeted revascularization of a specific vessel responsible for the perfusion of a specific ulcerated area is a promising new approach: it replaces revascularization of the angiographically easiest-to-access tibial vessel, even if this is not directly responsible for the perfusion of the ulcerated area, by revascularization of area-specific vascular territories. In conclusion, the endovascular approach shows very high efficacy in ulcer healing for diabetic patients with CLI. Larger prospective studies are now needed to estimate the long-term results of this approach.
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Venkatachalam S, Shishehbor MH, Gray BH. Basic Data Related to Endovascular Management of Peripheral Arterial Disease in Critical Limb Ischemia. Ann Vasc Surg 2012; 26:1039-51. [DOI: 10.1016/j.avsg.2012.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 04/13/2012] [Indexed: 10/28/2022]
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Rigatelli G, Cardaioli P, Dell'avvocata F, Giordan M, Lisato G, Mollo F. Endovascular management of patients with coronary artery disease and diabetic foot syndrome: A long-term follow-up. J Geriatr Cardiol 2012; 8:78-81. [PMID: 22783289 PMCID: PMC3390080 DOI: 10.3724/sp.j.1263.2011.00078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 06/08/2011] [Accepted: 06/15/2011] [Indexed: 12/05/2022] Open
Abstract
Background To investigate the long-term results of global coronary and peripheral interventional treatment of diabetic foot patients. Methods We retrospectively included 220 diabetic patients (78.5 ± 15.8 years, 107 females, all with Fontaine III or IV class) who were referred to our centre for diabetic foot syndrome and severe limb ischemia from January 2006 to December 2010. Patients were evaluated by a team of interventional cardiologists and diabetologists in order to assess presence of concomitant coronary artery disease (CAD) and eventual need for coronary revascularization. Stress-echo was performed in all patients before diagnostic peripheral angiography. Patients with indications for coronary angiography were submitted to combined diagnostic angiography and then to eventual staged peripheral and coronary interventions. Doppler ultrasonography and foot transcutaneous oximetry of transcutaneous oxygen pressure (TcPO2) before and after the procedure were performed as well as stress-echocardiography and combined cardiologic and diabetic examination at 1 and 6 month and yearly. Results Stress-echocardiography was performed in 94/220 patients and resulted positive in 56 patients who underwent combined coronary and peripheral angiography. In the rest of 126 patients, combined coronary and peripheral angiography was performed directly for concomitant signs and symptoms of coronary heart disease in 35 patients. Coronary revascularization was judged necessary in 85/129 patients and was performed percutaneously after peripheral interventions in 72 patients and surgically in 13 patients. For Diabetic foot interventions the preferred approach was ipsilateral femoral antegrade in 170/220 patients (77.7%) and contralateral cross-over in 40/220 patients (18.8%) and popliteal retrograde + femoral antegrade in 10/220 patients (4.5%). Balloon angioplasty was performed in 252 legs (32 patients had bilateral disease): the procedure was successful in 239/252 legs with an immediate success rate of 94.8% and a significant improvement in TcPO2 and ABI with ulcer healing in 233/252 legs (92.4%). Freedom from major amputation was 82.8% at a mean follow-up of 3.1 ± 1.8 years (range 1 to 5 years) whereas survival was 88%. Conclusions Global coronary and peripheral endovascular management of diabetic foot syndrome patients seems to lead to an high immediate success and limb salvage rates and increasing survival compared to historical series.
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Affiliation(s)
- Gianluca Rigatelli
- Cardiovascular Diagnosis and Endoluminal Intervention Unit, Rovigo General Hospital, Rovigo 45100, Italy
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25
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Comparison of initial hemodynamic response after endovascular therapy and open surgical bypass in patients with diabetes mellitus and critical limb ischemia. J Vasc Surg 2012; 56:380-6; discussion 386. [DOI: 10.1016/j.jvs.2012.01.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 01/17/2012] [Accepted: 01/18/2012] [Indexed: 11/19/2022]
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26
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Lee HJ, Park SW, Chang IS, Jeon HJ, Park JH. Strategies for successful percutaneous revascularization of chronic total occlusion of the femoropopliteal arteries when the antegrade passage of a guide wire fails. Korean J Radiol 2012; 13:467-75. [PMID: 22778569 PMCID: PMC3384829 DOI: 10.3348/kjr.2012.13.4.467] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 10/13/2011] [Indexed: 11/15/2022] Open
Abstract
Objective To evaluate the efficacy of various strategies for revascularization of chronic total occlusion of femoropopliteal arteries when the guide wire does not pass in an anterograde direction. Materials and Methods Twenty-four patients with totally occluded femoropopliteal arteries (mean occlusion length 13.75 cm; range, 6-22 cm) were treated by using a retrograde approach and two novel catheters. After successful recanalization or reentry, balloon angioplasty followed by stent placement was performed to complete the revascularization. Results In 16 cases in which to cross the occlusion via intraluminal or subintimal route was failed, we used Frontrunner catheters in five cases and Outback catheters in 11 cases. In eight cases in which to reenter after subintimal passage of the guide wire was failed, we used Outback catheters. Successful recanalization was achieved intraluminally or subintimally in all cases. One perforation occurred during subintimal passage of the guide wire that was controlled by recanalization of another subintimal tract. There were no cases of distal thromboembolism or other complications. Conclusion A retrograde approach and using the Frontrunner and Outback catheters are safe and effective for successful revascularization of chronic total occlusion of femoropopliteal arteries. In particular, they are useful when the initial antegrade attempts at recanalization have failed.
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Affiliation(s)
- Hui Jin Lee
- Department of Radiology, Konkuk University Hospital, Konkuk University School of Medicine, Seoul 143-729, Korea
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CARDAIOLI PAOLO, RIGATELLI GIANLUCA, DELL’AVVOCATA FABIO, GIORDAN MASSIMO, LISATO GIOVANNA, MOLLO FRANCESCO, VASSILEV DOBRIN, NANJUNDAPPA ARAVINDA. Endovascular Treatment of Diabetic Foot Syndrome: Results from a Single Center Prospective Registry Using Mixed Coronary and Peripheral Techniques and Equipment. J Interv Cardiol 2011; 24:562-8. [DOI: 10.1111/j.1540-8183.2011.00676.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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28
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Alexandrescu V, Vincent G, Azdad K, Hubermont G, Ledent G, Ngongang C, Filimon AM. A Reliable Approach to Diabetic Neuroischemic Foot Wounds: Below-the-Knee Angiosome-Oriented Angioplasty. J Endovasc Ther 2011; 18:376-87. [DOI: 10.1583/10-3260.1] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
Rest pain, tissue loss, and gangrene are manifestations of critical limb ischemia caused by peripheral arterial disease and define a patient subgroup at highest risk for major limb amputation. Patients with nonhealing lower extremity wounds should be screened for the risk factors for peripheral arterial disease and offered noninvasive vascular testing. The diagnosis of critical limb ischemia mandates prompt institution of medical and surgical management to achieve the best chance of limb salvage. Surgical intervention has evolved from primary amputation to open bypass to the present era of endovascular therapy. The goals of surgical bypass and endovascular therapy are to improve perfusion sufficiently to permit healing. Despite poorer patency rates and the more frequent need for reintervention, endovascular therapy has been shown in multiple retrospective studies to achieve limb salvage similar to open bypass. Only one large, prospective, randomized controlled trial exists comparing open bypass with endovascular therapy: The Bypass versus Angioplasty in Severe Limb Ischemia of the Leg (BASIL) trial. Close clinical surveillance and serial monitoring of limb perfusion by means of noninvasive arterial studies are needed to determine the need for further vascular intervention. Limb salvage patients suffer from multiple comorbidities and benefit from a multidisciplinary, team approach to care.
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Ihnat DM, Mills JL. Current assessment of endovascular therapy for infrainguinal arterial occlusive disease in patients with diabetes. J Am Podiatr Med Assoc 2011; 100:424-8. [PMID: 20847357 DOI: 10.7547/1000424] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Endovascular therapy has increasingly become the initial clinical option for the treatment of lower-extremity peripheral arterial occlusive disease not only for patients with claudication but also for those with critical limb ischemia. Despite this major clinical practice paradigm shift, the outcomes of endovascular therapy for peripheral arterial disease are difficult to evaluate and compare with established surgical benchmarks because of the lack of prospective randomized trials, incomplete characterization of indications for intervention, mixing of arterial segments and extent of disease treated, the multiplicity of endovascular therapy techniques used, the exclusion of early treatment failures, crossover to open bypass during follow-up, and the frequent lack of intermediate and long-term patency and limb salvage rates in life-table format. These data limitations are especially problematic when one tries to assess the outcomes of endovascular therapy in patients with diabetes. The purpose of the present article is to succinctly review and objectively analyze available data regarding the results of endovascular therapy in patients with diabetes.
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Affiliation(s)
- Daniel M Ihnat
- Department of Vascular and Endovascular Surgery, University of Arizona Health Sciences Center, Tucson, AZ 85724, USA
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Boufi M, Dona B, Orsini B, Auquier P, Hartung O, Alimi YS. A comparison of the standard bolia technique versus subintimal recanalization plus Viabahn stent graft in the management of femoro-popliteal occlusions. J Vasc Surg 2010; 52:1211-7. [DOI: 10.1016/j.jvs.2010.05.107] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Revised: 05/21/2010] [Accepted: 05/27/2010] [Indexed: 10/19/2022]
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Ihnat DM, Mills JL. Current assessment of endovascular therapy for infrainguinal arterial occlusive disease in patients with diabetes. J Vasc Surg 2010; 52:92S-95S. [DOI: 10.1016/j.jvs.2010.06.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Combined Retrograde–Antegrade Arterial Recanalization Through Collateral Vessels: Redefinition of the Technique for Below-the-Knee Arteries. Cardiovasc Intervent Radiol 2010; 34 Suppl 2:S78-82. [DOI: 10.1007/s00270-010-9890-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 04/21/2010] [Indexed: 10/19/2022]
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Uccioli L, Gandini R, Giurato L, Fabiano S, Pampana E, Spallone V, Vainieri E, Simonetti G. Long-term outcomes of diabetic patients with critical limb ischemia followed in a tertiary referral diabetic foot clinic. Diabetes Care 2010; 33:977-82. [PMID: 20200304 PMCID: PMC2858201 DOI: 10.2337/dc09-0831] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We describe the long-term outcomes of 510 diabetic patients with critical limb ischemia (CLI) and an active foot ulcer or gangrene, seen at the University Hospital of Rome Tor Vergata, a tertiary care clinic. RESEARCH DESIGN AND METHODS These patients were seen between November 2002 and November 2007 (mean follow-up 20 +/- 13 months [range 1-66 months]). The Texas Wound Classification was used to grade these wounds that were either class C (ischemia) and D (ischemia+infection) and grade 2-3 (deep-very deep). This comprehensive treatment protocol includes rapid and extensive initial debridement, aggressive use of peripheral percutaneous angioplasty, empirical intravenous antibiotic therapy, and strict follow-up. RESULTS The protocol was totally applied (with percutaneous angioplasty [PA+]) in 456 (89.4%) patients and partially (without percutaneous angioplasty [PA-]) in 54 (10.6%) patients. Outcomes for the whole group and PA+ and PA- patients are, respectively: healing, n = 310 (60.8%), n = 284 (62.3%), and n = 26 (48.1%); major amputation, n = 80 (15.7%), n = 67 (14.7%), and n = 13 (24.1%); death, n = 83 (16.25%), n = 68 (14.9%), and n = 15 (27.8%); and nonhealing, n = 37 (7.25%), n = 37 (8.1%), and n = 0 (0%) (chi(2) <0.0009). Predicting variables at multivariate analysis were the following: for healing, ulcer dimension, infection, and ischemic heart disease; and for major amputation, ulcer dimension, number of minor amputations, and age. Additional predicting variables for PA+ patients were the following: for healing, transcutaneous oxygen tension [DeltaTcPo(2)]; and for major amputation, basal TcPo(2), basal A1C, DeltaTcPo(2), and percutaneous angioplasty technical failure. CONCLUSIONS Early diagnosis of CLI, aggressive treatment of infection, and extensive use of percutaneous angioplasty in ischemic affected ulcers offers improved outcome for many previously at-risk limbs. Ulcer size >5 cm(2) indicates a reduced chance of healing and increased risk of major amputation. It was thought that all ulcers warrant aggressive treatment including percutaneous angioplasty and that treatment should be considered even for small ischemic ulcers.
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Affiliation(s)
- Luigi Uccioli
- 1Department of Internal Medicine, University of Tor Vergata, Rome, Italy.
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Insulin use is associated with poor limb salvage and survival in diabetic patients with chronic limb ischemia. J Vasc Surg 2010; 51:1178-89; discussion 1188-9. [PMID: 20304581 DOI: 10.1016/j.jvs.2009.11.077] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Revised: 11/15/2009] [Accepted: 11/16/2009] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The goal was to compare the outcomes in patients with disabling claudication (DC) or critical limb ischemia (CLI) to determine if diabetics (DM) have poorer patency, limb salvage (LS), and survival rates than nondiabetic patients and if the diabetic regimen affects these outcomes. METHODS All patients who presented with DC or CLI between June 2001 and September 2008 were included. Non-DM patients were compared with those with DM who are currently managed by diet only or oral medications (D-OM), oral medications plus insulin (OM+INS), or insulin alone (INS). RESULTS Of the 746 patients (886 limbs), there were 406 patients (464 limbs) in non-DM, 96 patients (135 limbs) in D-OM, 98 patients (118 limbs) in OM+INS, and 146 patients (185 limbs) in INS groups. There were more patients with coronary artery disease, hypertension, and renal insufficiency in the DM group than non-DM, with the INS group having the highest incidence of renal insufficiency/dialysis (46%/20%). Gangrene and foot sepsis were significantly more frequent in patients in OM+INS (45%/3%) and INS (50%/6%) than non-DM (15%/0.2%) and D-OM groups (25%/1%; P < .001). More patients in the INS group (14%) and OM+INS (9%) had primary amputation than non-DM (4%) and D-OM (4%; P < .01). Mean follow-up was 26.3 +/- 20.7 months. Overall survival following revascularization was similar in D-OM and non-DM and OM+INS and INS, the latter being significantly worse (P < .001). The LS rate in D-OM and non-DM was also identical, whereas OM-INS and INS had significantly worse LS, with OM-INS marginally better than INS (P = .094). Primary patency (PP) was worse in endovascular-treated patients on insulin than non-DM and D-OM patients (P < .001), whereas PP was similar between groups in open-treated patients. Multivariate analysis showed that coronary artery disease, renal insufficiency, chronic obstructive pulmonary disease, indication for intervention, insulin use, nonambulatory status, and statin drug non-use were independently associated with decreased survival, whereas insulin use, presence of gangrene, need for infrapopliteal interventions, and nonambulatory status were independently associated with limb loss. TransAtlantic Inter-Society Consensus (TASC) classification of the treated lesions being C or D, infrapopliteal interventions, and indication of intervention (DC vs CLI) were independently associated with primary patency, whereas insulin use was not. CONCLUSIONS Diabetic patients who present with limb ischemia can be subdivided into three distinct subgroups based on their diabetic regimen. The survival and LS rates of those controlled with diet or OM are nearly identical to nondiabetics, both of which are significantly better than OM+INS or INS. The PP rate in endovascular-treated patients is worse in patients who are on insulin. Being on insulin is independently associated with decreased survival and limb loss but not PP.
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Vamos EP, Bottle A, Majeed A, Millett C. Trends in lower extremity amputations in people with and without diabetes in England, 1996-2005. Diabetes Res Clin Pract 2010; 87:275-82. [PMID: 20022126 DOI: 10.1016/j.diabres.2009.11.016] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Revised: 10/30/2009] [Accepted: 11/24/2009] [Indexed: 11/24/2022]
Abstract
AIMS To examine trends in non-traumatic lower extremity amputations over a 10-year-period in people with and without diabetes (DM) in England. METHODS All individuals admitted to NHS hospitals for non-traumatic amputations between 1996 and 2005 in England were identified using hospital activity data. Postoperative and 1-year mortality were examined between 2000 and 2004. RESULTS There was a reduction in minor and major amputations during the study period. The number of type 1 DM- and non-DM-related minor amputations decreased by 11.4% and 32.4%, respectively, while the number of type 2 DM-related minor amputations almost doubled. The incidence of type 1- and non-DM-related minor amputations decreased from 1.5 to 1.2 and from 8.1 to 5.1/100,000 population, respectively, while type 2 DM-related amputations increased from 2.4 to 4.1/100,000 population. The number of type 1- and non-DM-related major amputations declined by 41% and 22%, respectively, whereas type 2 DM-related amputations increased by 43%. The incidence of type 2 DM-related amputations increased from 2.0 to 2.7/100,000 population. Overall perioperative and 1-year mortality did not significantly change between 2000 and 2004. CONCLUSIONS While several factors may explain the increase in type 2 DM-related LEAs, these findings highlight the importance of diabetes prevention strategies and controlling risk factors for LEAs in people with diabetes.
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Affiliation(s)
- Eszter Panna Vamos
- Department of Primary Care and Public Health, Imperial College London, UK.
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Charalambous N, Schäfer PJ, Trentmann J, Hümme TH, Stöhring C, Müller-Hülsbeck S, Heller M, Jahnke T. Percutaneous Intraluminal Recanalization of Long, Chronic Superficial Femoral and Popliteal Occlusions Using the Frontrunner XP CTO Device: A Single-Center Experience. Cardiovasc Intervent Radiol 2009; 33:25-33. [PMID: 19777300 DOI: 10.1007/s00270-009-9700-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2009] [Accepted: 08/21/2009] [Indexed: 10/20/2022]
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Bown MJ, Bolia A, Sutton AJ. Subintimal angioplasty: meta-analytical evidence of clinical utility. Eur J Vasc Endovasc Surg 2009; 38:323-37. [PMID: 19570689 DOI: 10.1016/j.ejvs.2009.05.014] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Accepted: 05/22/2009] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to determine accurate estimates of the success rate of subintimal angioplasty in terms of ability to recanalise occluded vessels, patency over time and limb salvage rates. DESIGN A meta-analysis of published literature. MATERIALS All studies reporting unique patient data published in English language between 1989 and 2008. METHODS Separate meta-analyses were performed for immediate technical success, 12-month patency rates and 12-month limb salvage rates. Longer-term outcomes were analyzed in separate meta-analyses. Meta-regression was applied to determine whether any of these outcomes had improved over time. RESULTS Pooled estimates for technical success, primary patency at 12 months and limb salvage at 12 months were 85.7% (95% confidence interval: 83.3%-87.7%, 2810 limbs), 55.8% (95% confidence interval: 47.9%-63.4%, 1342 limbs), and 89.3% (95% confidence interval: 85.5%-92.2%, 2810 limbs), respectively. Regression analysis demonstrated no significant change in outcomes over time. There was some evidence of publication bias, however, after adjusting for this there was little change in the pooled outcome estimates. CONCLUSIONS This study demonstrates that the outcomes for subintimal angioplasty are good and that this method should be considered as an alternative to surgical bypass.
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Affiliation(s)
- M J Bown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
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Sultan S, Hynes N. Five-Year Irish Trial of CLI Patients With TASC II Type C/D Lesions Undergoing Subintimal Angioplasty or Bypass Surgery Based on Plaque Echolucency. J Endovasc Ther 2009; 16:270-83. [DOI: 10.1583/08-2581.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Setacci C, Chisci E, de Donato G, Setacci F, Iacoponi F, Galzerano G. Subintimal angioplasty with the aid of a re-entry device for TASC C and D lesions of the SFA. Eur J Vasc Endovasc Surg 2009; 38:76-87. [PMID: 19427245 DOI: 10.1016/j.ejvs.2009.03.020] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 03/27/2009] [Indexed: 10/20/2022]
Abstract
AIM The aim of this prospective study was to assess the clinical effectiveness and related midterm patency of subintimal angioplasty (SAP) in patients suffering from critical limb ischaemia (CLI) in a single tertiary care university centre. The secondary aim was to evaluate the safety and clinical effectiveness of using a re-entry device when re-canalisation by SAP was unsuccessful. METHODS From January 2005 to December 2007, consecutive patients suffering from CLI (Rutherford clinical categories: 4-6) were treated with SAP. All patients included in the study had occluded SFA (TASC C and D) and underwent clinical and ultrasound follow-up examinations at day 30 and at 3, 6, 9 and 12 months, and then yearly. A re-entry device (Outback, Cordis Corporation, Miami Lakes, Florida, USA in all cases) was only used when re-canalisation by simple SAP was unsuccessful, and stenting was used when residual stenosis was >30% or there was a flow-limiting dissection. Factors that could modify the outcome were analysed. RESULTS In this study, 145 patients were treated, with a technical success rate of 83.5% (121 of 145) for simple SAP. Stenting was performed in 43% (n=62) of successful SAP procedures. No death occurred in the perioperative period, while the 30-day mortality was 4.8% (7 of 145). The re-entry device (Outback) was used in 24 cases (16.5%). The technical success of the re-entry device was 79% (19 of 24), with a 90% success rate of stent placement at the site of re-entry. Complications occurred in 6.2% of all procedures (n=9) (three arterial perforations (2.1%), three distal embolisations (2.1%), two femoral artery pseudo-aneurysms (1.4%) and one arterio-venous fistula (0.7%)). Factors capable of independently affecting the patency were renal insufficiency (p=0.03), current smoking (p=0.01) and diabetes (p=0.04). The primary patency at 1 and 3 years was 70% and 34% and the secondary patency at 1 and 3 years was 77% and 43%, respectively. At the same time intervals, the limb-salvage rate was 88% and 49%. CONCLUSIONS SAP with the aid of a re-entry device for TASC C and D lesions of the SFA seems to be safe and clinically effective in patients suffering from CLI, according to the experience at our centre. Further follow-up and more data are necessary to confirm these findings.
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Affiliation(s)
- C Setacci
- Department of Surgery, University of Siena, Siena, Italy.
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Alexandrescu V, Hubermont G, Philips Y, Guillaumie B, Ngongang C, Coessens V, Vandenbossche P, Coulon M, Ledent G, Donnay JC. Combined Primary Subintimal and Endoluminal Angioplasty for Ischaemic Inferior-limb Ulcers in Diabetic Patients: 5-year Practice in a Multidisciplinary ‘Diabetic-Foot’ Service. Eur J Vasc Endovasc Surg 2009; 37:448-56. [DOI: 10.1016/j.ejvs.2008.12.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Accepted: 12/14/2008] [Indexed: 11/17/2022]
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Nair DG, Samson R. Which diabetics are at risk for lower-extremity problems and what preventive measures can be taken? Semin Vasc Surg 2009; 21:154-9. [PMID: 18774451 DOI: 10.1053/j.semvascsurg.2008.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Diabetes mellitus is a well-known risk factor for development and progression of peripheral arterial disease. Prospective cardiovascular clinical trials have also clearly demonstrated that diabetics fare worse than their nondiabetic counterparts. Diabetics also differ from nondiabetics in that multiple revascularization procedures may be required in order for the clinical outcome to be equivalent to that of a nondiabetic patient. However, by advocating an aggressive approach to peripheral arterial disease, good results in survival and limb salvage can be achieved in diabetic patients despite the presence of increased medical comorbidities. Key to the management of such patients will be identifying which diabetic patients will be at most risk so that preventive measures can be undertaken.
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Affiliation(s)
- Deepak G Nair
- Sarasota Vascular Specialists, 600 N. Cattlemen Road, Suite 220, Sarasota, FL 34232, USA.
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Schmieder GC, Panneton JM. Endovascular superficial femoral artery treatment: can it be as good as bypass? Semin Vasc Surg 2008; 21:186-94. [PMID: 19073308 DOI: 10.1053/j.semvascsurg.2008.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Care of the vascular patient has changed drastically during the last decade, with the introduction of endovascular therapies. Medical management and open surgical bypass have been the traditional options for superficial femoral artery (SFA) occlusive disease. Endovascular revascularization of the SFA, however, has been increasingly utilized during the past decade. Results of endovascular interventions for SFA stenoses and/or occlusions have been mixed. In addition, several different techniques have been developed to address similar lesions. This added complexity makes it difficult to compare endovascular therapies to surgical bypass. This review will discuss the difficulties in comparing open and endovascular therapies as well as outcomes of endovascular therapies. Finally, the role of endovascular interventions for SFA lesions in the future will be discussed.
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Affiliation(s)
- Gregory C Schmieder
- Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, VA 23507, USA
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Stenting vs above knee polytetrafluoroethylene bypass for TransAtlantic Inter-Society Consensus-II C and D superficial femoral artery disease. J Vasc Surg 2008; 48:1166-74. [DOI: 10.1016/j.jvs.2008.06.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Revised: 05/30/2008] [Accepted: 06/02/2008] [Indexed: 11/24/2022]
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Alexandrescu VA, Hubermont G, Philips Y, Guillaumie B, Ngongang C, Vandenbossche P, Azdad K, Ledent G, Horion J. Selective Primary Angioplasty Following an Angiosome Model of Reperfusion in the Treatment of Wagner 1–4 Diabetic Foot Lesions:Practice in a Multidisciplinary Diabetic Limb Service. J Endovasc Ther 2008; 15:580-93. [DOI: 10.1583/08-2460.1] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Edmonds M. A natural history and framework for managing diabetic foot ulcers. ACTA ACUST UNITED AC 2008; 17:S20, S22, S24-9. [PMID: 18773593 DOI: 10.12968/bjon.2008.17.sup5.29648] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
When treating diabetic foot ulcers it is important to be aware of the natural history of the diabetic foot, which can be divided into five stages: stage 1 - normal foot; stage 2 - high risk foot; stage 3 - ulcerated foot; stage 4 - infected foot; stage 5 - necrotic foot. This covers the entire spectrum of foot disease but emphasizes the development of the foot ulcer as a pivotal event in stage 3, demanding urgent and aggressive management. Diabetic foot wound care in all stages needs multidisciplinary management to control mechanical, wound, microbiological, vascular, metabolic and educational aspects. Achieving good metabolic control of blood glucose, lipids and blood pressure is important in each stage, as is educational control to teach proper foot care appropriate for each stage. Aggressive management of diabetic foot ulceration will reduce the number of feet proceeding to infection and necrosis and thus reduce the number of major amputations in diabetic foot patients.
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Affiliation(s)
- Michael Edmonds
- Diabetic Foot Clinic, King's College Hospital, Denmark Hill, London
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Abstract
Abstract Chronic critical limb ischemia (CLI) occurs when arterial perfusion is reduced below a threshold level that results in rest pain and/or tissue breakdown in the lower extremities. Importantly, it is associated with high cardiovascular morbidity and mortality. Without prompt revascularization, CLI may result in loss of a limb (i.e. amputation) and/or life. The goal of endovascular therapy is the re-establishment of pulsatile, straight-line flow to the distal extremity. Percutaneous transluminal angioplasty (PTA) has been shown to be effective and safe in the setting of CLI, with limb salvage rates that compare favorably with surgical procedures. Stents are indicated for failed PTA, while adjunctive therapies such as lasers, thermal angioplasty and atherectomy devices lack data demonstrating improved efficacy compared with conventional lower extremity interventions. In addition to successful revascularization, the institution of lifestyle changes, atherosclerotic risk factor modification, and pharmacologic therapies are indicated to reduce cardiovascular morbidity and mortality.
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Affiliation(s)
- Salman A Arain
- Department of Cardiology, Ochnser Clinic Foundation, New Orleans, LA, USA
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Antusevas A, Aleksynas N, Kaupas R, Inciura D, Kinduris S. Comparison of Results of Subintimal Angioplasty and Percutaneous Transluminal Angioplasty in Superficial Femoral Artery Occlusions. Eur J Vasc Endovasc Surg 2008; 36:101-6. [DOI: 10.1016/j.ejvs.2008.02.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Accepted: 02/12/2008] [Indexed: 12/01/2022]
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49
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Primary Infrainguinal Subintimal Angioplasty in Diabetic Patients. Cardiovasc Intervent Radiol 2008; 31:713-22. [DOI: 10.1007/s00270-008-9366-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 05/07/2008] [Accepted: 05/08/2008] [Indexed: 10/22/2022]
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Paraskevas KI, Baker DM, Pompella A, Mikhailidis DP. Does Diabetes Mellitus Play a Role in Restenosis and Patency Rates Following Lower Extremity Peripheral Arterial Revascularization? A Critical Overview. Ann Vasc Surg 2008; 22:481-91. [DOI: 10.1016/j.avsg.2007.12.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Accepted: 12/26/2007] [Indexed: 10/21/2022]
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