Early Surgical Outcome After Failed Primary Stenting for Lower Limb Occlusive Disease

A systematic review and meta-analysis of primary bypass surgery compared with bypass surgery after endovascular treatment in peripheral artery disease patients

OBJECTIVE

Both bypass surgery and endovascular treatment are well-recognized interventions for the treatment of peripheral artery disease; however, the effect of failed endovascular treatment on subsequent surgeries remains controversial. A systematic review was conducted to compare the outcomes of primary bypass and bypass surgery after endovascular treatment.

METHODS

Three academic databases (Embase, PubMed, and Scopus) were searched from their inception to August 2022. Two independent investigators searched for studies that reported the outcomes of primary bypass surgery and bypass surgery after endovascular treatment in patients with peripheral artery disease. Abstracts and full-text studies were screened independently using duplicate data abstraction. Dichotomous outcome measures were reported using a random-effects model to generate a summary odds ratio (OR) and 95% confidence interval (CI). The risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

Seventeen retrospective observational studies were selected from 3911 articles and included 8064 patients, 6252 of whom underwent primary bypass surgery and 1812 underwent bypass surgery after endovascular treatment. The mean age was 69.0 years and 61.2% (n = 4938) were male. For perioperative outcomes, the 30-day results showed no difference in mortality (OR, 0.76; 95% CI, 0.53-1.10), or amputation (OR, 0.89; 95% CI, 0.67-1.20). For short- to mid-term outcomes, primary patency did not differ at 6 months (OR, 0.98; 95% CI, 0.81-1.19), 1 year (OR, 1.12; 95% CI, 0.97-1.30), or 2 years (OR, 1.17; 95% CI, 0.85-1.61) follow-up. Amputation-free survival did not differ at 6 months (OR, 1.03; 95% CI, 0.82-1.30), 1 year (OR, 1.09; 95% CI, 0.89-1.32), 2 years (OR, 1.18; 95% CI, 0.93-1.50), or 3 years (OR, 1.09; 95% CI, 0.84-1.40) of follow-up. No significant difference was found in overall survival or second patency.

CONCLUSIONS

This meta-analysis of retrospective, nonrandomized, observational studies suggests that prior endovascular treatment of lower extremity arterial disease does not result in worse perioperative, short-term, or mid-term clinical outcomes of subsequent infrainguinal bypass surgery compared with patients without prior endovascular treatment.

Outcomes and Fate of the Distal Landing Zone Compared Between Prosthetic and Autologous Grafts After Infra-Inguinal Graft Occlusions

Background

Due to an increasing life expectancy, more and more patients experience the failure of peripheral arterial revascularization. This study aims to investigate patients treated for the failure of infra-inguinal bypass grafts, and to investigate the interaction of different bypass materials [great saphenous vein (GSV) and polytetrafluoroethylene (PTFE)] and the further outcome.

Methods

Retrospective single-center analysis of consecutive patients treated for acute or chronic occlusion of infra-inguinal bypasses at a university hospital was conducted. Hospitalizations from 1st January 2010 through 31st December 2019 were included. Perioperative parameters from the index operation including graft material (prosthetic vs. autologous) were assessed. After bypass occlusion, the grade of ischemia, as well as the distal landing zone of the redo bypass compared with the primary bypass was investigated.

Results

In this study, 158 (65% men and 35% women with a m mean age of 70.5 years) eligible patients were included (57% vein and 42% prosthetic bypass grafts). After graft occlusion, 47% of the patients presented with symptoms of acute limb-threatening ischemia, 53% with symptoms of chronic leg ischemia. The rate of acute limb-threatening ischemia was significantly higher when prosthetic graft material was used during the index operation (p =0.016). Additionally, in case of reoperation, the landing zone of the redo bypass was significantly more distally located after occlusion of prosthetic bypass graft (p = 0.014)

Conclusion

Occlusions of prosthetic bypass grafts were associated with significantly higher rates of acute symptoms compared with vein grafts. Additionally, a shift to a more distal landing zone was recognized after the failure of a prosthetic bypass graft during the redo bypass operation.

Impact of prior endovascular interventions on outcomes of lower limb bypass surgery: A systematic review and meta-analysis

The aim of this meta-analysis was to evaluate the mortality, amputation and complication rates in patients with peripheral lower limb arterial disease undergoing bypass surgery with or without a prior history of endovascular operation. A systematic literature screen was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines on four academic databases, Medline, Scopus, Embase and Cochrane Central Register of Controlled Trials. Out of 1,072 records, six articles involving 11,420 patients (mean age, 68.1±2.0 years) met the inclusion criteria. The findings presented a 2b level of evidence (i.e. overall evidence represents data from individual cohort study or low quality randomized controlled trials) and suggested lower mortality, amputation and complication rates for patients undergoing bypass surgery without any history of endovascular operation, compared with those with a history of prior endovascular operation. Moreover, a random-effect meta-analysis suggested a small, positive reduction in mortality (Hedge's g=0.08), amputation (Hedge's g=0.18) and complication rates (Hedge's g=0.05) for patients undergoing bypass surgery without any history of endovascular operation. Nevertheless, owing to the scarcity of high-quality data, further studies and randomized clinical trials are needed to confirm these effects.

Perioperative outcomes of infrainguinal bypass surgery in patients with and without prior revascularization

OBJECTIVE

Although an increasing number of patients with peripheral arterial disease undergo multiple revascularization procedures, the effect of prior interventions on outcomes remains unclear. The purpose of this study was to evaluate perioperative outcomes of bypass surgery in patients with and those without prior ipsilateral treatment.

METHODS

Patients undergoing nonemergent infrainguinal bypass between 2011 and 2014 were identified in the National Surgical Quality Improvement Program Targeted Vascular module. After stratification by symptom status (chronic limb-threatening ischemia [CLTI] and claudication), patients undergoing primary bypass were compared with those undergoing secondary bypass. Within the secondary bypass group, further analysis compared prior bypass with prior endovascular intervention. Multivariable logistic regression analysis was used to establish the independent association between prior ipsilateral procedure and perioperative outcomes.

RESULTS

A total of 7302 patients were identified, of which 4540 (62%) underwent primary bypass (68% for CLTI), 1536 (21%) underwent secondary bypass after a previous bypass (75% for CLTI), and 1226 (17%) underwent secondary bypass after a previous endovascular intervention (72% for CLTI). Prior revascularization on the same ipsilateral arteries was associated with increased 30-day major adverse limb event in patients with CLTI (9.8% vs 7.4%; odds ratio [OR], 1.4 [95% confidence interval (CI), 1.1-1.7]) and claudication (5.2% vs 2.5%; OR, 2.1 [95% CI, 1.3-3.5]). Similarly, secondary bypass was an independent risk factor for 30-day major reintervention (CLTI: OR, 1.4 [95% CI, 1.1-1.8]; claudication: OR, 2.1 [95% CI, 1.3-3.5]), bleeding (CLTI: OR, 1.4 [95% CI, 1.2-1.6]; claudication: OR, 1.7 [95% CI, 1.3-2.4]), and unplanned reoperation (CLTI: OR, 1.2 [95% CI, 1.0-1.4]; claudication: OR, 1.6 [95% CI, 1.1-2.1]), whereas major amputation was increased in CLTI patients only (OR, 1.3 [95% CI, 1.01-1.8]). Postoperative mortality was not significantly different in patients undergoing secondary compared with primary bypass (CLTI: 1.7% vs 2.2% [P = .22]; claudication: 0.4% vs 0.6% [P = .76]). Among secondary bypass patients with CLTI, those with prior bypass had higher 30-day reintervention rates (7.8% vs 4.9%; OR, 1.5 [95% CI, 1.0-2.2]) but fewer wound infections (7.3% vs 12%; OR, 0.6 [95% CI, 0.4-0.8]) compared with patients with prior endovascular intervention.

CONCLUSIONS

Prior revascularization, in both patients with CLTI and patients with claudication, is associated with worse perioperative outcomes compared with primary bypass. Furthermore, prior endovascular intervention is associated with increased wound infections, whereas those with prior bypass had higher reintervention rates. The increasing prevalence of patients undergoing multiple interventions stresses the importance of the selection of patients for initial treatment and should be factored into subsequent revascularization options in an effort to decrease adverse events.

Occluded Superficial Femoral and Popliteal Artery Stents Can Have a Negative Impact on Bypass Target

PURPOSE

To identify whether occluded femoropopliteal stents influence previously available lower extremity bypass (LEB) targets.

METHODS

Among 621 consecutive patients who had undergone stenting of a superficial femoral artery or popliteal artery lesion from January 2009 to December 2013, 30 patients (mean age 69.9±10.2 years; 16 women) were found to have occluded stents. Angiograms before stent placement were analyzed to determine what would have been the optimal distal bypass site, which was compared with the angiogram following stent occlusion.

RESULTS

Seven (22%) limbs lost the bypass target. In one limb, the target changed from above-knee to below-knee popliteal, in 2 limbs from above-knee popliteal to tibial, and in 4 limbs from below-knee popliteal to tibial artery. Eleven (34%) limbs required LEB during follow-up. Chronic obstructive pulmonary disease (p=0.007), chronic renal insufficiency (p=0.026), a popliteal artery stent (p=0.001), and the below-knee popliteal artery as an optimal bypass target (p=0.026) were associated with loss of bypass target following stent occlusion.

CONCLUSION

Superficial femoral artery and popliteal artery stent occlusion can affect target vessels in patients who may require subsequent LEB. This should be considered when performing stenting.

A review of surgically treated patients with obstruction after stenting in the femoropopliteal artery region

In this study, we retrospectively reviewed 36 cases that required surgical treatment in the femoropopliteal regions (46 regions) because of the development of obstructions after stent placement in these patients. Of the 46, stents were placed in 37 involved regions (80.4%) that included the common femoral and popliteal arteries; such as the common femoral, entire length of superficial femoral, or popliteal arteries, and the anastomosis site created during femoropopliteal (prosthetic graft) bypass surgeries (Group A). In contrast, 9 involved regions (19.6%) did not include the common femoral or popliteal arteries; the stents were primarily localized in the superficial femoral artery (Group B). Symptoms of stent occlusion were more severe in the former group of patients, who subsequently required peripheral artery bypass surgery. These results indicate that placement of stents in the common femoral artery and popliteal arteries should be avoided. (English translation of J Jpn Coll Angiol 2012; 52: 19-23).

Prior failed ipsilateral percutaneous endovascular intervention in patients with critical limb ischemia predicts poor outcome after lower extremity bypass

BACKGROUND

Although open surgical bypass remains the standard revascularization strategy for patients with critical limb ischemia (CLI), many centers now perform peripheral endovascular intervention (PVI) as the first-line treatment for these patients. We sought to determine the effect of a prior ipsilateral PVI (iPVI) on the outcome of subsequent lower extremity bypass (LEB) in patients with CLI.

METHODS

A retrospective cohort analysis of all patients undergoing infrainguinal LEB between 2003 and 2009 within hospitals comprising the Vascular Study Group of New England (VSGNE) was performed. Primary study endpoints were major amputation and graft occlusion at 1 year postoperatively. Secondary outcomes included in-hospital major adverse events (MAE), 1-year mortality, and composite 1-year major adverse limb events (MALE). Event rates were determined using life table analyses and comparisons were performed using the log-rank test. Multivariate predictors were determined using a Cox proportional hazards model with multilevel hierarchical adjustment.

RESULTS

Of 1880 LEBs performed, 32% (n = 603) had a prior infrainguinal revascularization procedure (iPVI, 7%; ipsilateral bypass, 15%; contralateral PVI, 3%; contralateral bypass, 17%). Patients with prior iPVI, compared with those without a prior iPVI, were more likely to be women (32 vs 41%; P = .04), less likely to have tissue loss (52% vs 63%; P = .02), more likely to require arm vein conduit (16% vs 5%; P = .001), and more likely to be on statin (71% vs 54%; P = .01) and beta blocker therapy (92% vs 81%; P = .01) at the time of their bypass procedure. Other demographic factors were similar between these groups. Prior PVI or bypass did not alter 30-day MAE and 1-year mortality after the index bypass. In contrast, 1-year major amputation and 1-year graft occlusion rates were significantly higher in patients who had prior iPVI than those without (31% vs 20%; P = .046 and 28% vs 18%; P = .009), similar to patients who had a prior ipsilateral bypass (1 year major amputation, 29% vs 20%; P = .022; 1 year graft occlusion, 33% vs 18%; P = .001). Independent multivariate predictors of higher 1-year amputation and graft occlusion rates were prior iPVI, prior ipsilateral bypass, dialysis dependence, prosthetic conduit and distal (tibial and pedal) bypass target.

CONCLUSIONS

Prior iPVI is highly predictive for poor outcome in patients undergoing LEB for CLI with higher 1-year amputation and graft occlusion rates than those without prior revascularization, similar to prior ipsilateral bypass These findings provide information, which may help with the complex decisions surrounding revascularization options in patients with CLI.

[Diagnostics and therapy of the diabetic foot syndrome from a vascular surgery perspective]

There are more than 6 million diabetic patients in Germany. Due to neuropathic and angiopathic long term damage the number of patients with diabetic foot syndrome has been increasing dramatically over the past years. Despite all efforts for prevention, early diagnosis and adequate therapy, more than 20,000 diabetics undergo major limb amputation in Germany every year. A major portion of these amputations could be avoided if an improvement of the arterial perfusion would be timely considered. By consequent therapy in interdisciplinary centres, and by applying all methods of arterial revascularization, the amputation rate in patients with diabetic foot problems could be reduced by 80%. This article describes the diagnostics and therapy of the diabetic foot syndrome from a vascular surgical point of view. The importance of endovascular, vascular surgical as well as combined (hybrid) procedures of revascularization is emphasized.

Microdialysis assessment of peripheral metabolism in critical limb ischemia after endovascular revascularization

Background

Critical limb ischemia is a chronic pathologic condition defined by the lack of blood flow in peripheral circulation. Microdialysis is a well-known and sensitive method for the early detection of tissue ischemia. The aim of the present study was to use microdialysis in order to analyse cellular metabolism changes after peripheral endovascular revascularization.

Methods

Ten patients diagnosed with critical limb ischemia was enrolled. CMA 60 (CMA^® - Solna, Sweden) catheter with a 20 kDa cut-off was placed subcutaneously on the anterior aspect of the foot of both limbs. Samples were collected starting 12-hours before surgery and throughout the following 72-hours, using a CMA 600 (CMA^® - Solna, Sweden) microdialysis analyser.

Results

Technical revascularization was successful in all cases. The cannulation was well tolerated in all patients. The site of catheter insertion healed easily in few days without infective complications in any case. Two patients underwent major amputation. After revascularization, glucose showed a strong increase (mean, 5.86 ± 1.52 mMol/L, p = .008). No restoration of the circadian rhythm was noted in patients who underwent major amputation. Glycerol concentration curves were not deductibles in both the ischemic and the control limbs (mean, 148.43 ± 42.13 mMol/L vs 178.44 ± 75.93 mMol/L, p = .348). Within the first 24-hours after revascularization, lactate concentration raised strongly (6.58 ± 1.56 mMol/L, p = .002): thereafter, it immediately decreased to a concentration similar to the control level (1.71 ± 1.69 mMol/L). In both patients who underwent major amputation, lactate did not show the typical peak of the successful revascularization. The trend of the lactate/pyruvate ratio after a brief initial decrease of the ratio increased again in both the patients who finally underwent amputation.

Conclusions

Restoration of glucose and glycerol circadian rhythm, coupled with low lactate concentration and lactate/pyruvate ratio seemed to be linked to good surgical outcome.

Multislice computed tomographic angiography versus digital subtraction angiography in the follow-up of nitinol stents in the superficial femoral artery

PURPOSE

To compare quantitative and qualitative parameters obtained from digital subtraction angiography (DSA) with multislice computed tomographic angiography (MSCTA) in the follow-up of superficial femoral artery (SFA) stents.

METHODS

Thirteen patients who had SMART stents implanted in the SFA were examined systematically with DSA and MSCTA (16-row scanner) at 6 months. Quantitative analysis and morphological assessment were performed on DSA images by an independent core laboratory, while the MSCTA images were analyzed by 2 radiologists in consensus. DSA measurements included stent length, minimal lumen diameter and reference diameter at mid stent and 5 mm either side of the stent, and percentage of stenosis. For MSCTA images, lumen area and the minimum, maximum, and mean diameters were also recorded. The images were analyzed qualitatively for diameter stenosis (<50%, 50% to 70%, 71% to 99%, and occlusion), bends, fractures, and calcifications.

RESULTS

There were no statistical differences between lengths of stented segments, diameter measurements, or percentages of stenosis from DSA and MSCTA images. The Bland-Altman method showed good agreement between the 2 methods of measurement. MSCTA detected in-stent proliferation with a diameter stenosis <50% in all 13 cases diagnosed on DSA (there was no stenosis >50%). There were no bends or stent fractures on either set of images. The agreement between DSA and MSCTA for the presence and grading of calcifications was moderate (kappa=0.5).

CONCLUSION

MSCTA provided quantitative and qualitative data comparable with DSA in the analysis of SFA nitinol stents.

Treatment for diabetic foot ulcers

People with diabetes develop foot ulcers because of neuropathy (sensory, motor, and autonomic deficits), ischaemia, or both. The initiating injury may be from acute mechanical or thermal trauma or from repetitively or continuously applied mechanical stress. Patients with clinically significant limb ischaemia should be assessed by a vascular surgeon to determine the need for angioplasty, stenting, or femorodistal bypass. When infection complicates a foot ulcer, the combination can be limb or life-threatening. Infection is defined clinically, but wound cultures reveal the causative pathogens. Tissue specimens are strongly preferred to wound swabs for wound cultures. Antimicrobial therapy should be guided by culture results, and should aim to cure the infection, not to heal the wound. Alleviation of the mechanical load on ulcers (off-loading) should always be a part of treatment. Neuropathic ulcers typically heal in 6 weeks with total contact casting, because it effectively relieves pressure at the ulcer site and enforces patient compliance. The success of other approaches to off-loading similarly depends on the patients' adherence to the effectiveness of pressure relief. Surgery to heal ulcers and prevent recurrence can include tenotomy, tendon lengthening, reconstruction, or removal of bony prominences. However, these procedures may result in secondary ulceration and other complications. Ulcer recurrence rates are high, but appropriate education for patients, the provision of posthealing footwear, and regular foot care can reduce rates of re-ulceration.