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Kleiss SF, van Mierlo-van den Broek PAH, Vos CG, Fioole B, Bloemsma GC, de Vries-Werson DAB, Bokkers RPH, de Vries JPPM. Outcomes and Patency of Endovascular Infrapopliteal Reinterventions in Patients With Chronic Limb-Threatening Ischemia. J Endovasc Ther 2024; 31:831-839. [PMID: 36609175 PMCID: PMC11401340 DOI: 10.1177/15266028221147457] [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: 01/09/2023]
Abstract
PURPOSE Endovascular revascularization is the preferred treatment to improve perfusion of the lower extremity in patients with chronic limb-threatening ischemia (CLTI). Patients with CLTI often present with stenotic-occlusive lesions involving the infrapopliteal arteries. Although the frequency of treating infrapopliteal lesions is increasing, the reintervention rates remain high. This study aimed to determine the outcomes and patency of infrapopliteal endovascular reinterventions. METHODS This retrospective, multicenter cohort study of 3 Dutch hospitals included patients who underwent an endovascular infrapopliteal reintervention in 2015 up to 2021 after a primary infrapopliteal intervention for CLTI. The outcome measures after the reintervention procedures included technical success rate, the mortality rate and complication rate (any deviation from the normal postinterventional course) at 30 days, overall survival, amputation-free survival (AFS), freedom from major amputation, major adverse limb event (MALE), and recurrent reinterventions (a reintervention following the infrapopliteal reintervention). Cox proportional hazard models were used to determine risk factors for AFS and freedom from major amputation or recurrent reintervention. RESULTS Eighty-one patients with CLTI were included. A total of 87 limbs underwent an infrapopliteal reintervention in which 122 lesions were treated. Technical success was achieved in 99 lesions (81%). The 30-day mortality rate was 1%, and the complication rate was 13%. Overall survival and AFS at 1 year were 69% (95% confidence interval [CI], 55%-79%) and 54% (95% CI, 37%-67%), respectively, and those at 2.5 years were 45% (95% CI, 33%-56%) and 21% (95% CI, 11%-33%), respectively. Freedom from major amputation, MALE, and recurrent reinterventions at 1 year and 2.5 years were 59% (95% CI, 46%-70%) and 41% (95% CI, 25%-56%); 54% (95% CI, 41%-65%) and 36% (95% CI, 21%-51%); and 68% (95% CI, 55%-78%) and 51% (95% CI, 33%-66%), respectively. A Global Limb Anatomic Staging System score of III showed an increased hazard ratio of 2.559 (95% CI, 1.078-6.072; p=0.033) for freedom of major amputation or recurrent reintervention. CONCLUSIONS The results of this study indicate that endovascular infrapopliteal reinterventions can be performed with acceptable 30-day mortality and complication rates. However, outcomes and patency were moderate to poor, with low AFS, high rates of major amputations, and recurrent reinterventions. CLINICAL IMPACT This multicenter retrospective study evaluating outcome and patency of endovascular infrapopliteal reinterventions for CLTI, shows that endovascular infrapopliteal reinterventions can be performed with acceptable 30-day mortality and complication rates. However, the short- and mid-term outcomes of the infrapopliteal reinterventions were moderate to poor, with low rates of AFS and a high need for recurrent reinterventions. While the frequency of performing infrapopliteal reinterventions is increasing with additional growing complexity of the disease, alternative treatment options such as venous bypass grafting or deep venous arterialization may be considered and should be studied in randomized controlled trials.
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Affiliation(s)
- Simone F Kleiss
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Cornelis G Vos
- Department of Surgery, Martini Hospital, Groningen, The Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Gijs C Bloemsma
- Medical Imaging Center, Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Debbie A B de Vries-Werson
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Reinoud P H Bokkers
- Medical Imaging Center, Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jean-Paul P M de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Tange FP, van den Hoven P, van Schaik J, Schepers A, van der Bogt KEA, van Rijswijk CSP, Putter H, Vahrmeijer AL, Hamming JF, van der Vorst JR. Near-Infrared Fluorescence Imaging With Indocyanine Green to Predict Clinical Outcome After Revascularization in Lower Extremity Arterial Disease. Angiology 2024; 75:884-892. [PMID: 37358400 PMCID: PMC11375904 DOI: 10.1177/00033197231186096] [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: 06/27/2023]
Abstract
Contemporary quality control methods are often insufficient in predicting clinical outcomes after revascularization in lower extremity arterial disease (LEAD) patients. This study evaluates the potential of near-infrared fluorescence imaging with indocyanine green to predict the clinical outcome following revascularization. Near-infrared fluorescence imaging was performed before and within 5 days following the revascularization procedure. Clinical improvement was defined as substantial improvement of pain free walking distance, reduction of rest- and/or nocturnal pain, or tendency toward wound healing. Time-intensity curves and 8 perfusion parameters were extracted from the dorsum of the treated foot. The quantified postinterventional perfusion improvement was compared within the clinical outcome groups. Successful near-infrared fluorescence imaging was performed in 72 patients (76 limbs, 52.6% claudication, 47.4% chronic limb-threatening ischemia) including 40 endovascular- and 36 surgical/hybrid revascularizations. Clinical improvement was observed in 61 patients. All perfusion parameters showed a significant postinterventional difference in the clinical improvement group (P-values <.001), while no significant differences were seen in the group without clinical improvement (P-values .168-.929). Four parameters demonstrated significant differences in percentage improvement comparing the outcome groups (P-values within .002-.006). Near-infrared fluorescence imaging has promising additional value besides clinical parameters for predicting the clinical outcome of revascularized LEAD patients.
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Affiliation(s)
- Floris P Tange
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Pim van den Hoven
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Jan van Schaik
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Abbey Schepers
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | | | | | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, The Netherlands
| | | | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Center, The Netherlands
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Popplewell MA, Bradbury AW. Responses to the Main Critiques of the Bypass Versus Angioplasty in Severe Ischemia of the Leg (BASIL)-2 Trial. Ann Vasc Surg 2024; 107:43-47. [PMID: 38582217 DOI: 10.1016/j.avsg.2023.11.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 11/22/2023] [Indexed: 04/08/2024]
Affiliation(s)
| | - Andrew W Bradbury
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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4
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Farber A, Menard MT, Conte MS, Rosenfield K, Schermerhorn M, Schanzer A, Powell RJ, Chaar CIO, Hicks CW, Doros G, Strong MB, Leers SA, Motaganahalli R, Stangenberg L, Siracuse JJ. Prosthetic Conduits have Worse Outcomes compared to Great Saphenous Vein Conduits in Femoropopliteal and Infrapopliteal Bypass in Patients with Chronic Limb Threatening Ischemia. J Vasc Surg 2024:S0741-5214(24)01897-4. [PMID: 39321895 DOI: 10.1016/j.jvs.2024.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Revised: 09/12/2024] [Accepted: 09/15/2024] [Indexed: 09/27/2024]
Abstract
OBJECTIVES Single segment great saphenous vein (SSGSV) has traditionally been considered the gold standard conduit for infrainguinal bypass. There are data supporting similar outcomes with prosthetic femoral-popliteal bypass. Moreover, some have advocated for prosthetic conduit for femoral tibial bypass when GSV is inadequate or unavailable. We sought to evaluate long-term outcomes of infrainguinal bypass based on conduit type for treating chronic limb threatening ischemia (CLTI). METHODS Data from the Best Endovascular versus Best Surgical Therapy of Patients with CLTI (BEST-CLI) multicenter, prospective, randomized controlled trial, comparing infrainguinal bypass with endovascular therapy in patients with CLTI, were evaluated. In this as-treated analysis, we compared outcomes of infrainguinal bypass using prosthetic, alternative autogenous vein (AAV), and cryopreserved vein (Cryo) with SSGSV bypass. Kaplan-Meier and multivariable analyses were performed to examine the associations of conduit type with major adverse limb event (MALE) events, reinterventions, above-ankle amputations, and all-cause death. RESULTS In total, 784 bypasses were analyzed (120 prosthetic, 33 AAV, 21 Cryo, 610 SSGSV). For prosthetic and SSGSV, the distribution was 357 femoropopliteal (93 prosthetic and 264 GSV) and 373 infrapopliteal (27 prosthetic and 346 GSV). Mean age for the overall cohort was 67.1 years; 27.4% were female gender, 29.9% were non-White, and 11.5% were of Hispanic ethnicity. Patients undergoing prosthetic bypass were older (69.2 vs. 66.7 years), more likely to have chronic obstructive pulmonary disease (22.5% vs. 14%), prior coronary artery bypass grafting (88.9% vs. 66.5%), prior stroke (23.3% vs. 14%), but less often were of Hispanic ethnicity (5.8% vs. 12.6%) and had diabetes (59.2% vs. 71.3%) (P<.05 for all). For femoropopliteal bypass, use of prosthetic conduit was associated with increased major reinterventions at 3 years overall (19% vs. 11.5%, P=.06) and on risk adjusted analysis (HR 2.13, 95% CI 1.09 - 4.2, P=.028). No significant differences in MALE or death, above-ankle amputation, or death were observed. Outcomes were similar for bypasses to above knee popliteal targets and below knee popliteal targets. For infrapopliteal bypass, use of prosthetic conduit was associated with increased major reintervention (25.3% vs. 10.3%, P=.005), death (68.6% vs. 34.8%, P<.001), MALE or death (90% vs. 48.1%, P<.001) at 3 years. After risk adjustment, infrapopliteal bypass with prosthetic conduit was associated with higher major reintervention (HR 4.14, 95% CI 1.36 - 12.6, P=.012), above-ankle amputation (HR 4.64, 95% CI 1.59 - 13.5, P=.005), death (HR 2.96, 95% CI 1.4 - 6.2, P=.004), and MALE or death (HR 3.59, 95% CI 1.64 - 7.86, P=.001) compared to bypass with SSGSV. Overall, AAV had similar outcomes at 3 years to SSGSV, however Cryo had significantly higher above ankle amputation (50% vs 12.8%) (HR 4.2, 95% CI 1.68 - 10.5, P=.002), major reintervention (41.9% vs. 10.7%) (HR 3.12, 95% CI 1.18 - 8.22, P=.02), and MALE/death (88.8% vs. 37.8%) (HR 2.96, 95% CI 1.43-6.14, P=.004). CONCLUSIONS Use of prosthetic conduit in infrainguinal bypass is associated with inferior outcomes compared to bypass using SSGSV, particularly for bypass to infrapopliteal targets. Cryo grafts were infrequent and also demonstrated inferior outcomes. SSGSV remains the preferred conduit of choice for infrainguinal bypass.
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Affiliation(s)
- Alik Farber
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA.
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA
| | - Kenneth Rosenfield
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, UMass Chan Medical School, Worcester, MA
| | - Richard J Powell
- Division of Vascular and Endovascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | | | - Caitlin W Hicks
- Division of Vascular and Endovascular Surgery, Johns Hopkins, Baltimore, MD
| | - Gheorghe Doros
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Michael B Strong
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA
| | - Steven A Leers
- Division of Vascular and Endovascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Raghu Motaganahalli
- Division of Vascular and Endovascular Surgery, Indiana University, Bloomington, IN
| | - Lars Stangenberg
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
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Saratzis A, Torsello GB, Cardona-Gloria Y, Van Herzeele I, Messeder SJ, Zayed H, Torsello GF, Chisci E, Isernia G, D'Oria M, Stavroulakis K. Cost Analysis of Target Lesion Revascularisation in Patients With Femoropopliteal In Stent Re-Stenosis or Occlusion: The COSTLY-TLR Study. Eur J Vasc Endovasc Surg 2024; 68:100-107. [PMID: 38331163 DOI: 10.1016/j.ejvs.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/10/2024] [Accepted: 02/01/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVE To report the cost of target lesion revascularisation procedures (TLR) for femoropopliteal peripheral artery disease (PAD) following stenting, from a healthcare payer's perspective. METHODS European multicentre study involving consecutive patients requiring femoropopliteal TLR (January 2017 - December 2021). The primary outcome was overall cost (euros) associated with a TLR procedure from presentation to discharge. Exact costs per constituent, clinical characteristics, and early outcomes were reported. RESULTS This study included 482 TLR procedures (retrospectively, 13 hospitals, six countries): 56% were female, mean age was 75 ± 2 years, 61% were Rutherford class 5 or 6, 67% had Tosaka class 3 disease, and 16% had common femoral or iliac involvement. A total of 52% were hybrid procedures and 6% involved open surgery only. Technical success was 70%, 30 day mortality rate was 1%, and the 30 day major amputation rate was 4%. Most costs were for operating time during the TLR (healthcare professionals' salaries, indirect and estate costs), with a mean of: €21 917 ± €2 110 for all procedures; €23 337 ± €8 920 for open procedures; €12 903 ± €3 108 for endovascular procedures; and €22 806 ± €3 977 for hybrid procedures. In a regression analysis, procedure duration was the main parameter associated with higher overall TLR costs (coefficient, 2.77; standard error, 0.88; p < .001). The mean cost per operating minute of TLR (indirect, estate costs, all salaried staff present included) was €177 and the mean cost per night stay in hospital (outside intensive care unit) was €356. The mean cost per overnight intensive care unit stay (minimum of 8 hours per night) was €1 193. CONCLUSION The main driver of the considerable peri-procedure costs associated with femoropopliteal TLR was procedure time.
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Affiliation(s)
- Athanasios Saratzis
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK. http://www.twitter.com/a_saratzis
| | | | | | | | - Sarah J Messeder
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Hany Zayed
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Giovanni F Torsello
- Department of Interventional Radiology, Charité Universitätsmedizin, Berlin, Germany
| | - Emiliano Chisci
- Department of Vascular Surgery, San Giovanni di Dio Hospital, Florence, Italy
| | - Giacomo Isernia
- Department of Vascular Surgery, Azienda Ospedaliera di Perugia, Perugia, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, ASUGI, Trieste, Italy
| | - Konstantinos Stavroulakis
- Department of Vascular Surgery and Endovascular Surgery Ludwig-Maximilians University Hospital Munich, Munich, Germany.
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6
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Giles KA, Farber A, Menard MT, Conte MS, Nolan BW, Siracuse JJ, Strong MB, Doros G, Venermo M, Azene E, Rosenfield K, Powell RJ. Surgery or endovascular therapy for patients with chronic limb-threatening ischemia requiring infrapopliteal interventions. J Vasc Surg 2024:S0741-5214(24)01228-X. [PMID: 38908805 DOI: 10.1016/j.jvs.2024.05.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVE The recent publication of randomized trials comparing open bypass surgery to endovascular therapy in patients with chronic limb-threatening ischemia, namely, Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) and Bypass versus Angioplasty in Severe Ischaemia of the Leg-2 (BASIL-2), has resulted in potentially contradictory findings. The trials differed significantly with respect to anatomical disease patterns and primary end points. We performed an analysis of patients in BEST-CLI with significant infrapopliteal disease undergoing open tibial bypass or endovascular tibial interventions to formulate a relevant comparator with the outcomes reported from BASIL-2. METHODS The study population consisted of patients in BEST-CLI with adequate single segment saphenous vein conduit randomized to open bypass or endovascular intervention (cohort 1) who additionally had significant infrapopliteal disease and underwent tibial level intervention. The primary outcome was major adverse limb event (MALE) or all-cause death. MALE included any major limb amputation or major reintervention. Outcomes were evaluated using Cox proportional regression models. RESULTS The analyzed subgroup included a total of 665 patients with 326 in the open tibial bypass group and 339 in the tibial endovascular intervention group. The primary outcome of MALE or all-cause death at 3 years was significantly lower in the surgical group at 48.5% compared with 56.7% in the endovascular group (P = .0018). Mortality was similar between groups (35.5% open vs 35.8% endovascular; P = .94), whereas MALE events were lower in the surgical group (23.3% vs 35.0%; P<.0001). This difference included a lower rate of major reinterventions in the surgical group (10.9%) compared with the endovascular group (20.2%; P = .0006). Freedom from above ankle amputation or all-cause death was similar between treatment arms at 43.6% in the surgical group compared with 45.3% the endovascular group (P = .30); however, there were fewer above ankle amputations in the surgical group (13.5%) compared with the endovascular group (19.3%; P = .0205). Perioperative (30-day) death rates were similar between treatment groups (2.5% open vs 2.4% endovascular; P = .93), as was 30-day major adverse cardiovascular events (5.3% open vs 2.7% endovascular; P = .12). CONCLUSIONS Among patients with suitable single segment great saphenous vein who underwent infrapopliteal revascularization for chronic limb-threatening ischemia, open bypass surgery was associated with a lower incidence of MALE or death and fewer major amputation compared with endovascular intervention. Amputation-free survival was similar between the groups. Further investigations into differences in comorbidities, anatomical extent, and lesion complexity are needed to explain differences between the BEST-CLI and BASIL-2 reported outcomes.
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Affiliation(s)
- Kristina A Giles
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, ME.
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Woman's Hospital, Boston, MA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California San Francisco
| | - Brian W Nolan
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, ME
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | | | - Gheorghe Doros
- Department of Biostatistics, Boston University, School of Public Health, Boston, MA
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ezana Azene
- Department of Interventional Radiology, Gundersen Health System, La Crosse, WI
| | - Kenneth Rosenfield
- Vascular Medicine and Intervention, Massachusetts General Hospital, Boston, MA
| | - Richard J Powell
- Heart and Vascular Center, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
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7
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Popplewell MA, Meecham L, Davies HOB, Kelly L, Ellis T, Bate GR, Moakes CA, Bradbury AW. Editor's Choice - Bypass versus Angioplasty for Severe Ischaemia of the Leg (BASIL) Prospective Cohort Study and the Generalisability of the BASIL-2 Randomised Controlled Trial. Eur J Vasc Endovasc Surg 2024; 67:146-152. [PMID: 37778500 DOI: 10.1016/j.ejvs.2023.09.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/14/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE The Bypass versus Angioplasty in Severe Ischaemia of the Leg-2 (BASIL-2) randomised controlled trial has shown that, for patients with chronic limb threatening ischaemia (CLTI) who require an infrapopliteal (IP) revascularisation a vein bypass (VB) first revascularisation strategy led to a 35% increased risk of major amputation or death when compared with a best endovascular treatment (BET) first revascularisation strategy. The study aims are to place the BASIL-2 trial within the context of the CLTI patient population as a whole and to investigate the generalisability of the BASIL-2 outcome data. METHODS This was an observational, single centre prospective cohort study. Between 24 June 2014 and 31 July 2018, the BASIL Prospective Cohort Study (PCS) was performed which used BASIL-2 trial case record forms to document the characteristics, initial and subsequent management, and outcomes of 471 consecutive CLTI patients admitted to an academic vascular centre. Ethical approval was obtained, and all patients provided fully informed written consent. Follow up data were censored on 14 December 2022. RESULTS Of the 238 patients who required an infrainguinal revascularisation, 75 (32%) had either IP bypass (39 patients) or IP BET (36 patients) outside BASIL-2. Seventeen patients were initially randomised to BASIL-2. A further three patients who did not have an IP revascularisation as their initial management were later randomised in BASIL-2. Therefore, 95/471 (20%) of patients had IP revascularisation (16% outside, 4% inside BASIL-2). Differences in amputation free survival, overall survival, and limb salvage between IP bypass and IP BET performed outside BASIL-2 were not subject to hypothesis testing due to the small sample size. Reasons for non-randomisation into the trial were numerous, but often due to anatomical and technical considerations. CONCLUSION CLTI patients who required an IP revascularisation procedure and were subsequently randomised into BASIL-2 accounted for a small subset of the CLTI population as a whole. For a wide range of patient, limb, anatomical and operational reasons, most patients in this cohort were deemed unsuitable for randomisation in BASIL-2. The results of BASIL-2 should be interpreted in this context.
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Affiliation(s)
| | | | | | - Lisa Kelly
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tracy Ellis
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gareth R Bate
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Catherine A Moakes
- Birmingham Clinical Trial Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Andrew W Bradbury
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Koo MPM, Bookun HR. Post-operative transfusion is associated with infrainguinal bypass graft failure: contemporary Australian tertiary centre experience. ANZ J Surg 2023; 93:2382-2387. [PMID: 37698158 DOI: 10.1111/ans.18690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/31/2023] [Accepted: 08/18/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUNDS Peripheral arterial disease (PAD) is an increasingly prevalent and highly morbid pathology affecting the older population. Infra-inguinal bypass (IIB) surgery remains a robust revascularization option in these patients. This study aimed to identify modifiable predictors associated with graft patency and functional outcomes in contemporary Australian vascular surgical practice. METHODS A retrospective analysis of patients undergoing IIB between 2010 and 2020 at a tertiary vascular surgery centre in Australia was performed. Data regarding patient demographics, co-morbidities, pre-operative investigations, bypass characteristics, and discharge outcomes were collected. Surveillance ultrasound scans were reviewed to gain information on graft patency and compliance up to 2 years post-operatively. The primary outcome was graft failure. Secondary outcomes were mobility status and amputation-free survival at 1 year. RESULTS A total of 239 IIBs were performed on 207 patients during the 10-year period. Significant predictors for primary graft occlusion included regional referral (P < 0.01), low pre-operative haemoglobin level (P < 0.01), post-operative transfusion requirement (P = 0.02), use of prosthetic conduit (P < 0.01) and non-compliance to ultrasound surveillance (P < 0.01). Patients with a thrombosed graft were 2.4 times more likely to experience deterioration in mobility status (P < 0.01) and 8.6 times more likely to have major limb amputation or death at 1 year. The amputation-free survival was 88.3% at 1 year. CONCLUSION Optimization of pre-operative haemoglobin level for IIB should be advocated in clinical practice in order to reduce the risk of graft failure, deterioration in ambulatory function, major limb amputation and mortality.
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Affiliation(s)
- Mei Ping Melody Koo
- Department of Vascular Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Hansraj Riteesh Bookun
- Department of Vascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
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9
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Peters F, Behrendt CA. Limb Related Outcomes of Endovascular vs. Open Surgical Revascularisation in Patients with Peripheral Arterial Occlusive Disease: A Report from the Prospective GermanVasc Cohort Study. Eur J Vasc Endovasc Surg 2023; 66:85-93. [PMID: 36972814 DOI: 10.1016/j.ejvs.2023.03.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 03/01/2023] [Accepted: 03/23/2023] [Indexed: 03/28/2023]
Abstract
OBJECTIVE The goal of this study was to compare clinical outcomes in patients with peripheral arterial occlusive disease undergoing revascularisation by peripheral endovascular intervention (EVI), bypass surgery, endarterectomy (EA), and hybrid surgery in an unselected real world setting. METHODS This was a German, prospective, multicentre, comparative cohort study, enrolling patients at hospital admission for revascularisation at 35 vascular centres with 12 months of follow up. Primary composite endpoints were major amputation or death, major adverse limb events, and any minor or major amputation. Twelve month incidences and hazard ratios (HRs) for the four subgroups and 95% confidence intervals (CIs) were estimated using Kaplan-Meier functions and Cox proportional hazard models. Sociodemographic and clinical characteristics, pharmacological treatment, and comorbidities were used to adjust for patient differentials (unique identifier ClinicalTrials.gov: NCT03098290). RESULTS In total, 4 475 patients were analysed (mean age 69 years, 69.4% males, and 31.5% suffering from chronic limb threatening ischaemia). After 12 months of follow up, 5.3% (95% CI 3.6 - 6.9%) of the patients experienced either death or major amputation, 7.2% (95% CI 4.8 - 9.6%) major adverse limb event, and 6.6% (95% CI 5.0 - 8.2%) any minor or major amputation. Compared with EVI, bypass surgery was associated with an increased risk of amputation or death (HR 2.59, 95% CI 1.75 - 3.85), major adverse limb event (HR 1.93, 95% CI 1.11 - 3.36), and any minor or major amputation (HR 2.12, 95% CI 1.42 - 3.16), and hybrid surgery with an increased risk of amputation or death (HR 2.29, 95% CI 1.27 - 4.13) and major adverse limb event (HR 1.62, 95% CI 1.03 - 2.54). After adjusting for patient differentials, no significant differences among study groups remained. CONCLUSION More favourable outcomes after EVI were completely attributed to differentials in patient characteristics and not procedure type. The current study emphasised that all competing approaches performed similarly in a real world setting.
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Affiliation(s)
- Frederik Peters
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christian-Alexander Behrendt
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany; Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany; Brandenburg Medical School Theodor Fontane, Neuruppin, Germany.
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10
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Lyons OT, Behrendt CA, Björck M. Beyond Wires and Knives: What Can We Learn From BEST-CLI and BASIL-2? Eur J Vasc Endovasc Surg 2023; 66:1-3. [PMID: 37217073 DOI: 10.1016/j.ejvs.2023.05.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023]
Affiliation(s)
- Oliver T Lyons
- Vascular Endovascular & Transplant Surgery, Christchurch Hospital, New Zealand; Department of Surgery, University of Otago Christchurch, New Zealand.
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany. https://twitter.com/VASCevidence
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Institute of Clinical Medicine, Tartu University, Tartu, Estonia. https://twitter.com/mabjo425
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11
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Bradbury AW, Moakes CA, Popplewell M, Meecham L, Bate GR, Kelly L, Chetter I, Diamantopoulos A, Ganeshan A, Hall J, Hobbs S, Houlind K, Jarrett H, Lockyer S, Malmstedt J, Patel JV, Patel S, Rashid ST, Saratzis A, Slinn G, Scott DJA, Zayed H, Deeks JJ. A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial. Lancet 2023; 401:1798-1809. [PMID: 37116524 DOI: 10.1016/s0140-6736(23)00462-2] [Citation(s) in RCA: 119] [Impact Index Per Article: 119.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Chronic limb-threatening ischaemia is the severest manifestation of peripheral arterial disease and presents with ischaemic pain at rest or tissue loss (ulceration, gangrene, or both), or both. We compared the effectiveness of a vein bypass first with a best endovascular treatment first revascularisation strategy in terms of preventing major amputation and death in patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal, revascularisation procedure to restore limb perfusion. METHODS Bypass versus Angioplasty for Severe Ischaemia of the Leg (BASIL)-2 was an open-label, pragmatic, multicentre, phase 3, randomised trial done at 41 vascular surgery units in the UK (n=39), Sweden (n=1), and Denmark (n=1). Eligible patients were those who presented to hospital-based vascular surgery units with chronic limb-threatening ischaemia due to atherosclerotic disease and who required an infra-popliteal, with or without an additional more proximal infra-inguinal, revascularisation procedure to restore limb perfusion. Participants were randomly assigned (1:1) to receive either vein bypass (vein bypass group) or best endovascular treatment (best endovascular treatment group) as their first revascularisation procedure through a secure online randomisation system. Participants were excluded if they had ischaemic pain or tissue loss considered not to be primarily due to atherosclerotic peripheral artery disease. Most vein bypasses used the great saphenous vein and originated from the common or superficial femoral arteries. Most endovascular interventions comprised plain balloon angioplasty with selective use of plain or drug eluting stents. Participants were followed up for a minimum of 2 years. Data were collected locally at participating centres. In England, Wales, and Sweden, centralised databases were used to collect information on amputations and deaths. Data were analysed centrally at the Birmingham Clinical Trials Unit. The primary outcome was amputation-free survival defined as time to first major (above the ankle) amputation or death from any cause measured in the intention-to-treat population. Safety was assessed by monitoring serious adverse events up to 30-days after first revascularisation. The trial is registered with the ISRCTN registry, ISRCTN27728689. FINDINGS Between July 22, 2014, and Nov 30, 2020, 345 participants (65 [19%] women and 280 [81%] men; median age 72·5 years [62·7-79·3]) with chronic limb-threatening ischaemia were enrolled in the trial and randomly assigned: 172 (50%) to the vein bypass group and 173 (50%) to the best endovascular treatment group. Major amputation or death occurred in 108 (63%) of 172 patients in the vein bypass group and 92 (53%) of 173 patients in the best endovascular treatment group (adjusted hazard ratio [HR] 1·35 [95% CI 1·02-1·80]; p=0·037). 91 (53%) of 172 patients in the vein bypass group and 77 (45%) of 173 patients in the best endovascular treatment group died (adjusted HR 1·37 [95% CI 1·00-1·87]). In both groups the most common causes of morbidity and death, including that occurring within 30 days of their first revascularisation, were cardiovascular (61 deaths in the vein bypass group and 49 in the best endovascular treatment group) and respiratory events (25 deaths in the vein bypass group and 23 in the best endovascular treatment group; number of cardiovascular and respiratory deaths were not mutually exclusive). INTERPRETATION In the BASIL-2 trial, a best endovascular treatment first revascularisation strategy was associated with a better amputation-free survival, which was largely driven by fewer deaths in the best endovascular treatment group. These data suggest that more patients with chronic limb-threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal, revascularisation procedure to restore limb perfusion should be considered for a best endovascular treatment first revascularisation strategy. FUNDING UK National Institute of Health Research Health Technology Programme.
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Affiliation(s)
- Andrew W Bradbury
- University Department of Vascular Surgery, Solihull Hospital, University Hospitals Birmingham NHS Foundation Trust, Solihull, UK; Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Catherine A Moakes
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Matthew Popplewell
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Lewis Meecham
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Gareth R Bate
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Lisa Kelly
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Chetter
- Hull York Medical School, University of Hull and University of York, York, UK
| | - Athanasios Diamantopoulos
- Department of Interventional Radiology, Guy's and St Thoma's NHS Foundation Trust, London, UK; School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Arul Ganeshan
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jack Hall
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Simon Hobbs
- Department of Vascular Surgery, Dudley Group NHS Foundation Trust, Dudley, UK
| | - Kim Houlind
- Lillebaelt Hospital, University of Southern Denmark, Odense, Denmark
| | - Hugh Jarrett
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Suzanne Lockyer
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jonas Malmstedt
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden; Division of Vascular Surgery, Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Jai V Patel
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Smitaa Patel
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - S Tawqeer Rashid
- Department of Vascular Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Athanasios Saratzis
- National Institute for Health and Care Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Gemma Slinn
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - D Julian A Scott
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Hany Zayed
- Department of Vascular Surgery, Guy's and St Thoma's NHS Foundation Trust, London, UK
| | - Jonathan J Deeks
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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12
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Meecham L, Popplewell M, Bate G, Davies HOB, Kodama A, Conte MS, Bradbury AW. Evaluation of the Global Limb Anatomic Staging System in patients with chronic limb-threatening ischemia undergoing endovascular intervention for femoropopliteal disease. J Vasc Surg 2023; 77:474-479.e3. [PMID: 36108823 DOI: 10.1016/j.jvs.2022.07.188] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/12/2022] [Accepted: 07/24/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The Global Limb Anatomic Staging System (GLASS) is a new method of quantifying the anatomic severity of infrainguinal disease in patients with chronic limb-threatening ischemia. However, because GLASS has undergone limited validation, its value as an aid to shared decision-making regarding the choice of revascularization strategy remains incompletely defined. Here we report the relationship between GLASS and outcomes in a contemporary series comprising all 309 patients who underwent an attempt at femoropopliteal and/or infrapopiteal endovascular therapy for chronic limb-threatening ischemia in our unit between 2009 and 2014. METHODS Baseline patient characteristics and outcome data including immediate technical success (ITS), amputation-free survival (AFS), overall survival, limb salvage, freedom from reintervention (FF-R), and freedom from major adverse limb events (FF-MALE) were obtained from hospital databases. GLASS grades and stage were obtained from pre-endovascular therapy angiographic imaging. Outcome data were censored on May 31, 2017. RESULTS Baseline patient characteristics were similar across different GLASS femoropopliteal and IP grades and overall limb stages. Worsening GLASS stage was associated with a significant reduction in ITS (97.5% vs 91.5% vs 84.0%; P = .029). At 72 months FF-R (hazard ratio, 2.00; 95% confidence interval, 1.11-3.57; P = .020) and FF-MALE (hazard ratio, 1.76, 95% confidence interval, 1.10-2.81; P = .019) were significant worse in GLASS stage 3 than in stage 2 limbs. CONCLUSIONS In our study, there were significant differences in ITS, FF-R and FF-MALE between limbs with GLASS stage 2 and 3 disease. However, further GLASS refinement seems likely to be required if its usefulness in everyday clinical practice as an aid to shared decision-making regarding the choice of revascularization strategy is to be maximized.
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Affiliation(s)
- Lewis Meecham
- Department of Vascular Surgery, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Mathew Popplewell
- Department of Vascular Surgery, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gareth Bate
- Department of Vascular Surgery, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Huw O B Davies
- Department of Vascular Surgery, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Michael S Conte
- Department of Surgery, University of California at San Francisco, San Francisco, CA
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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13
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Zaid Al-Kaylani AHA, Schuurmann RCL, Maathuis WD, Slart RHJA, De Vries JPPM, Bokkers RPH. Clinical Applications of Quantitative Perfusion Imaging with a C-Arm Flat-Panel Detector-A Systematic Review. Diagnostics (Basel) 2022; 13:diagnostics13010128. [PMID: 36611421 PMCID: PMC9818280 DOI: 10.3390/diagnostics13010128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/20/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023] Open
Abstract
C-arm systems with digital flat-panel detectors are used in interventional radiology and hybrid operating rooms for visualizing and performing interventions on three-dimensional structures. Advances in C-arm technology have enabled intraoperative quantitative perfusion imaging with these scanners. This systematic review provides an overview of flat-panel detector C-arm techniques for quantifying perfusion, their clinical applications, and their validation. A systematic search was performed for articles published between January 2000 and October 2022 in which a flat-panel detector C-arm technique for quantifying perfusion was compared with a reference technique. Nine articles were retrieved describing two techniques: two-dimensional perfusion angiography (n = 5) and dual-phase cone beam computed tomography perfusion (n = 4). A quality assessment revealed no concerns about the applicability of the studies. The risk of bias was relatively high for the index and reference tests. Both techniques demonstrated potential for clinical application; however, weak-to-moderate correlations were reported between them and the reference techniques. In conclusion, both techniques could add new possibilities to treatment planning and follow-up; however, the available literature is relatively scarce and heterogeneous. Larger-scale randomized prospective studies focusing on clinical outcomes and standardization are required for the full understanding and clinical implementation of these techniques.
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Affiliation(s)
- Abdallah H. A. Zaid Al-Kaylani
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
| | - Richte C. L. Schuurmann
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
| | - Wouter D. Maathuis
- Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, 7522 NB Enschede, The Netherlands
| | - Riemer H. J. A. Slart
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
- Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, 7522 NB Enschede, The Netherlands
- Department of Nuclear Medicine & Molecular Imaging, Medical Imaging Center, University of Groningen, 9712 CP Groningen, The Netherlands
| | - Jean-Paul P. M. De Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
| | - Reinoud P. H. Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
- Correspondence: ; +31-50-3616161
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14
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Kalyanasundaram A, Choy M, Kotta A, Zielinski LP, Coughlin PA. Frailty predicts poor longer-term outcomes in patients following lower limb open surgical revascularization. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:716-723. [PMID: 36168946 DOI: 10.23736/s0021-9509.22.11895-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Frailty in vascular surgery patients is increasingly recognized as a marker of poor outcome. This provides particular challenges for patients with lower limb peripheral arterial disease who require surgical revascularization. This study aimed to assess the impact of frailty on short- and long-term outcome in this specific patient group using a specialty specific frailty score. METHODS Patients undergoing open surgical revascularization for chronic limb ischemia (January 2015-December 2016) were assessed. Demographics, mode of admission, diagnosis, and site of surgery were recorded alongside a variety of frailty-specific characteristics. We calculated the previously validated Addenbrookes Vascular Frailty Score (AVFS) and Long AVFS (LAVFS). Primary outcome was 3-year mortality. RESULTS Two hundred and sixty-one patients (75% men, median age 69 years) were studied. The median length of stay was 6 days with a 3-year mortality of 23%. The predictive power of vascular frailty scores showed that for 3-year mortality, area under the receiver operator curve values (AUROC) were specific for both the AVFS score (AUROC: 0.724, 95% CI: 0.654-0.794) and LAVFS Score (AUROC: 0.741, 95%CI: 0.670-0.813). Furthermore, the cumulative AVFS and LAVFS scores both predicted mortality over the follow-up period (P=0.0001) with increased mortality among patients with higher scores. CONCLUSIONS Incremental worsening of frailty, determined using a specialty specific frailty score, predicts mortality risk in patients undergoing lower limb surgical revascularization.
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Affiliation(s)
| | - Matthew Choy
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Alekhya Kotta
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Lukasz P Zielinski
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Patrick A Coughlin
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK -
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15
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Shan LL, Wang J, Westcott MJ, Tew M, Davies AH, Choong PF. A Systematic Review of Cost-Utility Analyses in Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2022; 85:9-21. [PMID: 35561892 DOI: 10.1016/j.avsg.2022.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/11/2022] [Accepted: 04/20/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND To review and describe the available literature on cost-utility analysis of revascularization and non-revascularization treatment approaches in chronic limb-threatening ischemia. METHODS A systematic review was performed on cost-utility analysis studies evaluating revascularization (open surgery or endovascular), major lower extremity amputation, or conservative management in adult chronic limb-threatening ischemia patients. Six bibliographic databases and online registries were searched for English language articles up to August 2021. The outcome for cost-utility analysis was quality-adjusted in life years. Procedures were compared using incremental cost-effectiveness ratios which were converted to 2021 United States dollars. Study reporting quality was assessed using the 2022 Consolidated Health Economic Evaluation Reporting Standards statement. The study was registered in International Prospective Register of Systematic Reviews (CRD42021273602). RESULTS Three trial-based and five model-based studies were included for review. Studies met between 14/28 and 20/28 criteria of the Consolidated Health Economic Evaluation Reporting Standards CHEERS statement. Only one study was written according to standardized reporting guidelines. Most studies evaluated infrainguinal disease, and adopted a health care provider perspective. There was a large variation in the incremental cost-effectiveness ratios presented across studies. Open surgical revascularization (incremental cost-effectiveness ratios: $3,678, $58,828, and $72,937), endovascular revascularization (incremental cost-effectiveness ratios: $52,036, $125,329, and $149,123), and mixed open or endovascular revascularization (incremental cost-effectiveness ratio: $8,094) maybe more cost-effective than conservative management. CONCLUSIONS The application of cost-utility analyses in chronic limb-threatening ischemia is in its infancy. Revascularization in infrainguinal disease may be favored over major lower extremity amputation or conservative management. However, data is inadequate to support recommendations for a specific treatment. This review identifies short and long-term considerations to address the current state of evidence. Cost-utility analysis is an important tool in healthcare policy and should be encouraged amongst the vascular surgical community.
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Affiliation(s)
- Leonard L Shan
- Department of Surgery, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.
| | - Jennifer Wang
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Mark J Westcott
- Department of Surgery, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Michelle Tew
- Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Alun H Davies
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Peter F Choong
- Department of Surgery, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
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16
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Argyriou C, Papanas N, Georgiadis GS. Diabetic Foot Management: Education of Vascular Surgeons Remains a Priority. INT J LOW EXTR WOUND 2022:15347346221124239. [PMID: 36052408 DOI: 10.1177/15347346221124239] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diabetic foot ulcers remain difficult to heal, especially in the setting of peripheral arterial disease (PAD). Vascular surgeons are very important members of the multidisciplinary foot care team. To make the most of their potential, adequate education of vascular trainees on diabetic PAD remains a priority. This should include not only endovascular therapies but also open surgical approaches. Evaluation of trainees' skills, as well as of the educational program itself, is also desirable. Finally, simulation-based training may prove a useful educational tool.
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Affiliation(s)
- Christos Argyriou
- Department of Vascular Surgery, 387479Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupoli, Greece
| | - Nikolaos Papanas
- Diabetic Foot Clinic, Diabetes Centre, 387479Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupoli, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, 387479Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupoli, Greece
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17
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Mathlouthi A, Zarrintan S, Khan MA, Malas MB. Contemporary outcomes of open femoropopliteal bypass by autogenous vein graft in infra-inguinal arterial occlusive disease. Ann Vasc Surg 2022; 86:184-189. [PMID: 35470046 DOI: 10.1016/j.avsg.2022.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 03/30/2022] [Accepted: 04/12/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Although the majority of patients presenting with symptomatic peripheral arterial disease (PAD) are treated with the endovascular first approach, a significant number of these patients still require open bypass because of the extent of atherosclerotic burden or failure of the endovascular therapy. However, data available on the outcomes of femoropoliteal bypass in the contemporary era of PAD management is scarce. In this study, we evaluate real-world mid-term outcomes of femoropopliteal bypass for PAD. METHODS We identified all patients who underwent open femoropopliteal revascularization with autogenous vein conduits for PAD at one institution between January 2012 and December 2017. Main endpoints included primary patency, amputation-free survival, overall survival and limb salvage at two years. Outcomes were defined per the Society for Vascular Surgery standards. Descriptive statistics were performed using univariable analyses including mean and standard deviation for continuous variables and frequency and percentage for categorical variables. Event-free survival rates were estimated using Kaplan-Meier (KM) methods. RESULTS There were 129 patients who received autogenous vein grafts. Median follow-up was 19 months (IQR 11-26). Patients were predominantly male (59.7%), white (72.9%) with a mean age of 65±11 years. The indications for surgery were disabling claudication in 36.4% of patients (N=47) and chronic limb threatening ischemia (CLTI) in 63.6% (N=82). Most patients had TASC C or D lesions (N=81, 62.8%). Seventeen cases (16.3%) were redo bypasses. Arm veins and spliced vein conduits were used in 12% and 7%, respectively. In 66% of procedures the distal anastomosis was below the knee. Primary patency estimates at 6 months, 1 year and 2 years were 81.3%, 68.6% and 59.2%, respectively. Amputation-free survival rates were 93.4%, 88% and 82.1% at 6 months, 1 year and 2 years, respectively. Limb salvage rates among patients with CLTI were 93.4%, 90.4% and 87.2% at 6 months, 1 year and 2 years, respectively. Overall survival was 97.5%, 92.1% and 87.8% at 6 months, 1 year and 2 years, respectively. CONCLUSIONS In this contemporary cohort of patients, femoropopliteal bypass showed lower patency than previously described. The fact that bypass surgery is performed on sicker patients with more extensive disease in the endovascular era might explain this discrepancy. However, our results demonstrated satisfactory patency and limb salvage rates and suggest that vein should always be used if available.
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Affiliation(s)
- Asma Mathlouthi
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, California, The United States of America
| | - Sina Zarrintan
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, California, The United States of America
| | - Maryam Ali Khan
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, California, The United States of America
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, California, The United States of America.
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18
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Janák D, Novotný K, Fiala R, Miler I, Vik K, Šlais M, Burkert J, Pádr R, Roček M, Rohn V. Fresh cold-stored vascular allografts in subgenicular location: Our experience with rescue endovascular techniques. Ann Vasc Surg 2022; 85:156-166. [PMID: 35304297 DOI: 10.1016/j.avsg.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Critical limb ischemia (CLI) is considered the most severe pattern of peripheral artery disease. CLI is associated with high rates of morbidity and mortality and a high risk of limb amputation. In the absence of appropriate autologous grafts, unsuitability of prosthetic bypasses and endovascular methods, fresh cold-stored venous allografts is an option. Endovascular interventional methods are essential methods for maintaining primary and secondary patency. METHODS A single-centre retrospective analysis of 82 surgical revascularizations using allogeneic vascular grafts and rescue endovascular techniques restoring and maintaining the patency of these allogeneic revascularizations in the period between 7/2005 and 7/2021. RESULT We have performed 82 allogeneic revascularizations in 75 patients (52 reconstructions in men /63.4%/, 30 reconstructions in women /36.6%/). The median age of patients was 68 years (49 min, 87 max). We subsequently had to intervene a total of 26 bypasses. We intervened in 30 acute occluded allogeneic bypass grafts and 9 failing stenotic bypass grafts. We performed 52 angiographies. The success rate of rescue endovascular procedures in primary allogeneic reconstruction with distal anastomosis to the popliteal artery is statistically significant (p <0.02) compared to procedures with distal anastomosis to the tibial and pedal bed. The cumulative patency (primary at time) of allogeneic reconstructions in our group was 89% after 1 month, 51.9% after 12 months, 24.2% after 3 years, 9.8% after 5 years. Limb salvage was 72.6% in 1 year, 53% in 3 years, 36.5% in 5 years, respectively. CONCLUSION Cold-stored venous allografts may be used for performing below-the-knee revascularization for CLI with acceptable results despite poor long-term patency. Rescue endovascular techniques are an essential method for restoring or maintaining the patency of these reconstructions. These techniques have a high success rate and no other alternative.
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Affiliation(s)
- David Janák
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic.
| | - Karel Novotný
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Radovan Fiala
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Ivo Miler
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Karel Vik
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Marek Šlais
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Jan Burkert
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Radek Pádr
- Department of Radiology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Miloslav Roček
- Department of Radiology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Vilém Rohn
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
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Kleiss SF, Ma KF, El Moumni M, Ünlü Ç, Nijboer TS, Schuurmann RCL, Bokkers RPH, de Vries JPPM. Detecting Changes in Tissue Perfusion With Hyperspectral Imaging and Thermal Imaging Following Endovascular Treatment for Peripheral Arterial Disease. J Endovasc Ther 2022; 30:382-392. [PMID: 35255764 DOI: 10.1177/15266028221082013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE Hyperspectral imaging (HSI) and thermal imaging allow contact-free tissue perfusion measurements and may help determine the effect of endovascular treatment (EVT) in patients with peripheral arterial disease. This study aimed to detect changes in perfusion with HSI and thermal imaging peri-procedurally and determine whether these changes can identify limbs that show clinical improvement after 6 weeks. METHODS Patients with Rutherford class 2-6 scheduled for EVT were included prospectively. Hyperspectral imaging and thermal imaging were performed directly before and after EVT. Images were taken from the lateral side of the calves and plantar side of the feet. Concentrations of (de)oxyhemoglobin, oxygen saturation, and skin temperature were recorded. Angiographic results were determined on completion angiogram. Clinical improvement 6 weeks after EVT was defined as a decrease ≥ one Rutherford class. Peri-procedural changes in perfusion parameters were compared between limbs with and without good angiographic results or clinical improvement. To identify limbs with clinical improvement, receiver operating characteristic (ROC) curves were used to determine cutoff values for change in HSI. RESULTS Included were 23 patients with 29 treated limbs. Change in HSI values and temperature was not significantly different between limbs with good and poor angiographic results. Change in peri-procedural deoxyhemoglobin, determined by HSI, at the calves and feet was significantly different between limbs with and without clinical improvement at 6 week follow-up (p=0.027 and p=0.017, respectively). The ROC curve for change in deoxyhemoglobin at the calves showed a cutoff value of ≤1.0, and ≤-0.5 at the feet, which were discriminative for clinical improvement (sensitivity 77%; specificity 75% and sensitivity 62%; specificity 88%, respectively). CONCLUSIONS HSI can detect changes in perfusion at the calves after EVT in patients with Rutherford class 2-6. Peri-procedural deoxyhemoglobin changes at the calves and feet are significantly different between limbs with and without clinical improvement. Decrease in deoxyhemoglobin directly after EVT may identify limbs that show clinical improvement 6 weeks after EVT.
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Affiliation(s)
- Simone F Kleiss
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Kirsten F Ma
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mostafa El Moumni
- Department of Surgery, Division of Trauma Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Çagdas Ünlü
- Department of Vascular Surgery, Noordwest Hospital Group, Alkmaar, The Netherlands
| | - Thomas S Nijboer
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Richte C L Schuurmann
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jean-Paul P M de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Makowski L, Köppe J, Engelbertz C, Kühnemund L, Fischer AJ, Lange SA, Dröge P, Ruhnke T, Günster C, Malyar N, Gerß J, Freisinger E, Reinecke H, Feld J. OUP accepted manuscript. Eur Heart J 2022; 43:1759-1770. [PMID: 35134893 PMCID: PMC9076397 DOI: 10.1093/eurheartj/ehac016] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/25/2021] [Accepted: 01/11/2022] [Indexed: 12/24/2022] Open
Abstract
Aims The prevalence of chronic limb-threatening ischaemia (CLTI) is increasing and available data often derive from cohorts with various selection criteria. In the present study, we included CLTI patients and studied sex-related differences in their risk profile, vascular procedures, and long-term outcome. Methods and results We analysed 199 953 unselected patients of the largest public health insurance in Germany (AOK: Local healthcare funds), hospitalized between 2010 and 2017 for a main diagnosis of CLTI. A baseline period of 2 years before index hospitalization to assess comorbidities and previous procedures, and a follow-up period until 2018 were included. Female CLTI patients were older (median 81.4 vs. 73.8 years in males; P < 0.001) and more often diagnosed with hypertension, atrial fibrillation, chronic heart failure, and chronic kidney disease. Male patients suffered more frequently from diabetes mellitus, dyslipidaemia, smoking, cerebrovascular disease, and chronic coronary syndrome (all P < 0.001). Within hospitalized CLTI patients, females represent the minority (43% vs. 57%; P < 0.001) and during index hospitalization, women underwent less frequently diagnostic angiographies (67 vs. 70%) and revascularization procedures (61 vs. 65%; both P < 0.001). Moreover, women received less frequently guideline-recommended drugs like statins (35 vs. 43%) and antithrombotic therapy (48 vs. 53%; both P < 0.001) at baseline. Interestingly, after including age and comorbidities in a Cox regression analysis, female sex was associated with increased overall-survival (OS) [hazard ratio (HR) 0.95; 95% confidence interval (CI) 0.94–0.96] and amputation-free survival (AFS) (HR 0.84; 95% CI 0.83–0.85; both P < 0.001). Conclusion Female patients with CLTI were older, underwent less often vascular procedures, and received less frequently guideline-recommended medication. Nevertheless, female sex was independently associated with better OS and AFS during follow-up.
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Affiliation(s)
- Lena Makowski
- Corresponding author. Tel: +49 251 83 45569, Fax: +49 251 83 45101,
| | - Jeanette Köppe
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Christiane Engelbertz
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Albert Schweitzer Campus 1, A1, 48149 Muenster, Germany
| | - Leonie Kühnemund
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Albert Schweitzer Campus 1, A1, 48149 Muenster, Germany
| | - Alicia J Fischer
- Department of Cardiology III—Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Cardiol, Albert Schweitzer Campus 1, A1, 48149 Muenster, Germany
| | - Stefan A Lange
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Albert Schweitzer Campus 1, A1, 48149 Muenster, Germany
| | | | | | | | - Nasser Malyar
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Albert Schweitzer Campus 1, A1, 48149 Muenster, Germany
| | - Joachim Gerß
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Eva Freisinger
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Albert Schweitzer Campus 1, A1, 48149 Muenster, Germany
| | - Holger Reinecke
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Cardiol, Albert Schweitzer Campus 1, A1, 48149 Muenster, Germany
| | - Jannik Feld
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
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ELSHERIF M, ELSHARKAWI M, TAWFICK W, GHONEIM B, HYNES N, SULTAN S. Two decades of peripheral arterial disease intervention in a tertiary vascular referral center. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.23736/s1824-4777.21.01476-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Chronic limb-threatening ischemia requires aggressive risk factor management and a thoughtful approach to the complex decision of best strategy for revascularization. Patients often have multilevel disease amenable to endovascular, open surgical, or hybrid approaches. Limited high-quality evidence is available to support a specific strategy; randomized trials are ongoing. Acute limb ischemia is associated with a high risk of limb loss and mortality. Catheter-directed thrombolysis is mainstay of therapy in patients with marginally threatened limbs, whereas those immediately threatened with motor deficits require more rapid restoration of flow with open or endovascular techniques that can establish flow in single setting.
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Affiliation(s)
- Jocelyn M Beach
- Section of Vascular Surgery, Heart and Vascular Institute, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
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Wei R, Zhang H, Guo W. Viabahn-Assisted Extra-Arterial Bypass Combined With Surgical Arterial Endarterectomy as a Salvage Technique to Treat Critical Limb Ischemia. Ann Vasc Surg 2021; 79:440.e1-440.e7. [PMID: 34653638 DOI: 10.1016/j.avsg.2021.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 06/23/2021] [Accepted: 07/11/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Revascularization of patients with critical limb ischemia (CLI) is always challenging because of long occlusive arterial lesions with severe calcification and poor general condition. Here we describe a novel hybrid technique to treat a CLI patient. METHODS The patient was a 60-year-old male with left foot ulcer. Preoperative scan showed long calcific and occlusive lesions running from the left proximal common femoral artery to P1 of the popliteal artery (PA). Surgical endarterectomy was performed on the proximal femoral artery. Then, retrograde PA access was achieved to protect the vital collateral artery at the proximal PA. When the retrograde V18 guidewire failed to advance because of severe occlusion in the middle one-third of the SFA, we punctured the artery with the V18 guidewire, and manually introduced it into the lumen of the proximal SFA. Three Viabahn stent grafts were successively implanted, parts of which were situated outside the SFA. RESULTS Computed tomography 1 week after surgery showed patent blood flow to the left toes. Good recovery was observed during a 1-year follow up, the toe wound healed after amputation, and no rest pain recurred. Ultrasound showed 60% stenosis in the PA stent, while the other stents were patent. The anklebrachial index of the left limb was 0.48. CONCLUSIONS This case illustrates successful use of Viabahn-assisted extra-arterial bypass combined with surgical arterial endarterectomy to salvage the limb after CLI. This novel technique might be an alternative in carefully selected patients.
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Affiliation(s)
- Ren Wei
- Department of Vascular and Endovascular Surgery, First Medical Center of General Hospital of People's Liberation Army, Beijing, People's Republic of China
| | - Hongpeng Zhang
- Department of Vascular and Endovascular Surgery, First Medical Center of General Hospital of People's Liberation Army, Beijing, People's Republic of China
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, First Medical Center of General Hospital of People's Liberation Army, Beijing, People's Republic of China.
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Popplewell MA, Andronis L, Davies HOB, Meecham L, Kelly L, Bate G, Bradbury AW. Procedural and 12-month in-hospital costs of primary infra-popliteal bypass surgery, infra-popliteal best endovascular treatment, and major lower limb amputation for chronic limb threatening ischemia. J Vasc Surg 2021; 75:195-204. [PMID: 34481898 DOI: 10.1016/j.jvs.2021.07.232] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 07/23/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Chronic limb-threatening ischemia (CLTI) is a growing global problem due to the widespread use of tobacco and increasing prevalence of diabetes. Although the financial consequences are considerable, few studies have compared the relative cost-effectiveness of different CLTI management strategies. The Bypass vs Angioplasty in Severe Ischaemia of the Leg (BASIL)-2 trial is randomizing patients with CLTI to primary infra-popliteal (IP) vein bypass surgery (BS) or best endovascular treatment (BET) and includes a comprehensive within-trial cost-utility analysis. The aim of this study is to compare over a 12-month time horizon, the costs of primary IP BS, IP best endovascular treatment (BET), and major limb major amputation (MLLA) to inform the BASIL-2 cost-utility analysis. METHODS We compared procedural human resource (HR) costs and total in-hospital costs for the index admission, and over the following 12-months, in 60 consecutive patients undergoing primary IP BS (n = 20), IP BET (n = 20), or MLLA (10 transfemoral and 10 transtibial) for CLTI within the BASIL prospective cohort study. RESULTS Procedural HR costs were greatest for BS (BS £2551; 95% confidence interval [CI], £1934-£2807 vs MLLA £1130; 95% CI, £1046-£1297 vs BET £329; 95% CI, £242-£390; P < .001, Kruskal-Wallis) due to longer procedure duration and greater staff requirement. With regard to the index admission, MLLA was the most expensive due to longer hospital stay (MLLA £13,320; 95% CI, £8986-£18,616 vs BS £8714; 95% CI, £6097-£11,973 vs BET £4813; 95% CI, £3529-£6097; P < .001, Kruskal-Wallis). The total cost of the index admission and in-hospital care over the following 12 months remained least for BET (MLLA £26,327; 95% CI, £17,653-£30,458 vs BS £20,401; 95% CI, £12,071-£23,926 vs BET £12,298; 95% CI, £6961-£15,439; P < .001, Kruskal-Wallis). CONCLUSIONS Over a 12-month time horizon, MLLA and IP BS are more expensive than IP BET in terms of procedural HR costs and total in-hospital costs. These economic data, together with quality of life data from BASIL-2, will inform the calculation of incremental cost-effectiveness ratios for different CLTI management strategies within the BASIL-2 cost-utility analysis.
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Affiliation(s)
- Matthew A Popplewell
- University of Birmingham Department of Vascular Surgery, Netherwood House, Solihull Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.
| | - Lazaros Andronis
- Population Evidence and Technologies, Warwick Medical School, University of Warwick, Warwick, United Kingdom
| | - Huw O B Davies
- University of Birmingham Department of Vascular Surgery, Netherwood House, Solihull Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Lewis Meecham
- University of Birmingham Department of Vascular Surgery, Netherwood House, Solihull Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Lisa Kelly
- University of Birmingham Department of Vascular Surgery, Netherwood House, Solihull Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Gareth Bate
- University of Birmingham Department of Vascular Surgery, Netherwood House, Solihull Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Andrew W Bradbury
- University of Birmingham Department of Vascular Surgery, Netherwood House, Solihull Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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Long-term results of the Japanese multicenter Viabahn trial of heparin bonded endovascular stent grafts for long and complex lesions in the superficial femoral artery. J Vasc Surg 2021; 74:1958-1967.e2. [PMID: 34182032 DOI: 10.1016/j.jvs.2021.05.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 05/21/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the long-term safety and efficacy of endovascular stent grafting to treat long, complex lesions in the superficial femoral artery (SFA). METHODS This prospective, multicenter study at 15 Japanese hospitals assessed heparin bonded stent grafts for treating long SFA lesions in patients with symptomatic peripheral arterial disease. Inclusion criteria were Rutherford category 2-5 symptoms (grade 5 without active infection), ankle-brachial index (ABI) ≤ 0.9, and SFA lesions ≥ 10 cm with ≥ 50% stenosis. The key efficacy and safety outcomes were primary-assisted patency (PAP) and adverse events through 24 months, respectively. Secondary outcomes included primary patency (PP), secondary patency, freedom from target lesion revascularization (fTLR), and VascuQOL scoring. RESULTS Of 103 subjects (mean age 74.2 ± 7.0 years; 82.5% male), 100 (97.1%) had intermittent claudication. Average lesion length was 21.8 ± 5.8 cm; 87 lesions (84.5%) were TASC C/D classification (65.7% chronic total occlusions). Ninety-two subjects and 61 subjects were evaluable through 24 months and 60 months, respectively. At 24 months, the Kaplan-Meier-estimated PAP rate was 85.7% (95% CI: 76.3‒91.5%), PP rate was 78.8% (95% CI: 68.8‒85.9%), and secondary patency rate was 92.0% (95% CI: 82.4-96.5%). Mean ABI was 0.64 ± 0.12 at baseline and 0.94 ± 0.19 at 24 months (P<.0001). At 24 months, fTLR was 87.2% (95% CI: 78.9-92.3%), and at 60 months, fTLR was 79.1% (95% CI: 67.9-86.8%). No device or procedure-related life- or limb-threatening critical events or acute limb ischemia cases were observed through 5 years. No stent fractures were detected in annually scheduled follow-up x-rays. Scores from the VascuQOL and Walking Impairment Questionnaire were significantly increased at 1 month through 24 months versus baseline values (P<.0001 for both). One subject was converted to open bypass through 5 years. CONCLUSIONS Stent grafting of long and complex SFA lesions in claudicant patients is safe and effective through long-term follow-up, with 79.1% fTLR and no study leg amputation, acute limb ischemia, or stent fractures through 5 years.
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Meecham L, Popplewell MA, Bate GR, Patel S, Bradbury AW. A Comparison of Contemporary Clinical Outcomes Following Femoro-Popliteal Plain Balloon Angioplasty and Bypass Surgery for Chronic Limb Threatening Ischemia. Vasc Endovascular Surg 2021; 55:544-550. [PMID: 33882737 DOI: 10.1177/15385744211004656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Despite the BASIL-1 trial concluding that bypass surgery (BS) was superior to plain balloon angioplasty (PBA) in terms of longer-term amputation free (AFS) and overall survival (OS), CLTI patients are increasingly offered an endovascular-first revascularization strategy. This study investigates whether the results of BASIL-1 are still relevant to current practice by comparing femoro-popliteal (FP) BS with PBA in a series of CLTI patients treated in our unit 10 years after BASIL-1 (1999-2004). METHODS We retrospectively analyzed prospectively gathered hospital data pertaining to 279 patients undergoing primary FP BS or PBA for CLTI in the period 2009 to 2014. We report baseline characteristics, 30-day morbidity and mortality, major adverse cardiovascular events (MACE) and long-term AFS, limb salvage (LS), OS, major adverse limb events (MALE), and freedom from re-intervention (FFR). RESULTS 234 (84%) and 45 (16%) patients underwent PBA and BS respectively. PBA patients were significantly older (77 vs 71 years, P = 0.001) and more likely to be female (45% vs 28%, P = 0.026). Bollinger and GLASS anatomic scores were significantly more severe in the BS group. Technical success was better for BS (100% vs 87%, P = 0.007). Index hospital stay was shorter for PBA (9.1 vs 15.6 days, P = 0.035) but there was no difference in hospital days or admissions over the next 12 months. AFS (HR 1.00), LS (HR 1.44), OS (HR 0.81), MALE (HR 1.25) and FFR (HR = 1.00) were not significantly different between PBA and BS. CONCLUSION Important clinical outcomes following FP BS and PBA for CLTI have not changed significantly in our unit in the 10 years following the BASIL-1 trial. BASIL-1 therefore remains relevant to our current practice and should inform our approach to the management of CLTI going forward.
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Affiliation(s)
- Lewis Meecham
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Birmingham, England
| | - Mathew A Popplewell
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Birmingham, England
| | - Gareth R Bate
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Birmingham, England
| | - Smitaa Patel
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Andrew W Bradbury
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Birmingham, England
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Arakelian VS. [Amputation as an anticipated consequence of peripheral artery disease and ways to improve the prognosis of limb salvage]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:182-190. [PMID: 33825747 DOI: 10.33529/angio2021101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Peripheral artery disease is a common and acute social burden worldwide. The main method of treatment of PAD consists in open surgical or endovascular revascularization. However, despite steady growth of the number and quality of interventions, the incidence of lower-limb amputation still remains at a high level. Lower-limb amputation is a severe psychological blow for the patient and leads to significant deterioration of his or her quality of life, as well as has an extremely negative prognosis concerning the frequency of subsequent complications and survival. Consequences of amputations include not only severe disability but also an unfavourable prognosis of life, thus determining the necessity of adequate prevention of such events. Reconstructive and endovascular operations, as well as amputations are associated with a significant increase of the probability of the development of major adverse cardiovascular events, the frequency of repeat hospitalizations and, finally, the cost of treatment. Prescribing pathogenetically substantiated antithrombotic therapy is considered to be one of the methods to improve the results of surgical treatment and prognosis for the patient. Presented in the article is a literature review making it possible to assess the risks and consequences of amputations in patients with PAD, as well as to determine therapy capable of improving the prognosis.
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Affiliation(s)
- V S Arakelian
- Department of Surgery for Arterial Pathology, National Medical Research Centre named after A.N. Bakulev under the RF Ministry of Public Health, Moscow, Russia
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Mahé G, Boge G, Bura-Rivière A, Chakfé N, Constans J, Goueffic Y, Lacroix P, Le Hello C, Pernod G, Perez-Martin A, Picquet J, Sprynger M, Behar T, Bérard X, Breteau C, Brisot D, Chleir F, Choquenet C, Coscas R, Detriché G, Elias M, Ezzaki K, Fiori S, Gaertner S, Gaillard C, Gaudout C, Gauthier CE, Georg Y, Hertault A, Jean-Baptiste E, Joly M, Kaladji A, Laffont J, Laneelle D, Laroche JP, Lejay A, Long A, Loric T, Madika AL, Magnou B, Maillard JP, Malloizel J, Miserey G, Moukarzel A, Mounier-Vehier C, Nasr B, Nelzy ML, Nicolini P, Phelipot JY, Sabatier J, Schaumann G, Soudet S, Tissot A, Tribout L, Wautrecht JC, Zarca C, Zuber A. Disparities Between International Guidelines (AHA/ESC/ESVS/ESVM/SVS) Concerning Lower Extremity Arterial Disease: Consensus of the French Society of Vascular Medicine (SFMV) and the French Society for Vascular and Endovascular Surgery (SCVE). Ann Vasc Surg 2021; 72:1-56. [DOI: 10.1016/j.avsg.2020.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 11/05/2020] [Indexed: 12/24/2022]
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Chen YC, Sheu JJ, Chiang JY, Shao PL, Wu SC, Sung PH, Li YC, Chen YL, Huang TH, Chen KH, Yip HK. Circulatory Rejuvenated EPCs Derived from PAOD Patients Treated by CD34 + Cells and Hyperbaric Oxygen Therapy Salvaged the Nude Mouse Limb against Critical Ischemia. Int J Mol Sci 2020; 21:ijms21217887. [PMID: 33114267 PMCID: PMC7660611 DOI: 10.3390/ijms21217887] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/09/2020] [Accepted: 10/13/2020] [Indexed: 11/17/2022] Open
Abstract
This study tested whether circulatory endothelial progenitor cells (EPCs) derived from peripheral arterial occlusive disease (PAOD) patients after receiving combined autologous CD34+ cell and hyperbaric oxygen (HBO) therapy (defined as rejuvenated EPCs) would salvage nude mouse limbs against critical limb ischemia (CLI). Adult-male nude mice (n = 40) were equally categorized into group 1 (sham-operated control), group 2 (CLI), group 3 (CLI-EPCs (6 × 105) derived from PAOD patient’s circulatory blood prior to CD34+ cell and HBO treatment (EPCPr-T) by intramuscular injection at 3 h after CLI induction) and group 4 (CLI-EPCs (6 × 105) derived from PAOD patient’s circulatory blood after CD34+ cell and HBO treatment (EPCAf-T) by the identical injection method). By 2, 7 and 14 days after the CLI procedure, the ischemic to normal blood flow (INBF) ratio was highest in group 1, lowest in group 2 and significantly lower in group 4 than in group 3 (p < 0.0001). The protein levels of endothelial functional integrity (CD31/von Willebrand factor (vWF)/endothelial nitric-oxide synthase (eNOS)) expressed a similar pattern to that of INBF. In contrast, apoptotic/mitochondrial-damaged (mitochondrial-Bax/caspase-3/PARP/cytosolic-cytochrome-C) biomarkers and fibrosis (Smad3/TGF-ß) exhibited an opposite pattern, whereas the protein expressions of anti-fibrosis (Smad1/5 and BMP-2) and mitochondrial integrity (mitochondrial-cytochrome-C) showed an identical pattern of INBF (all p < 0.0001). The protein expressions of angiogenesis biomarkers (VEGF/SDF-1α/HIF-1α) were progressively increased from groups 1 to 3 (all p < 0.0010). The number of small vessels and endothelial cell surface markers (CD31+/vWF+) in the CLI area displayed an identical pattern of INBF (all p < 0.0001). CLI automatic amputation was higher in group 2 than in other groups (all p < 0.001). In conclusion, EPCs from HBO-C34+ cell therapy significantly restored the blood flow and salvaged the CLI in nude mice.
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Affiliation(s)
- Yin-Chia Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (Y.-C.C.); (J.-J.S.)
| | - Jiunn-Jye Sheu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (Y.-C.C.); (J.-J.S.)
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan; (P.-H.S.); (Y.-L.C.); (T.-H.H.)
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
| | - John Y. Chiang
- Department of Computer Science and Engineering, National Sun Yat-Sen University, Kaohsiung 80424, Taiwan;
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung 80756, Taiwan
| | - Pei-Lin Shao
- Department of Nursing, Asia University, Taichung 41354, Taiwan;
| | - Shun-Cheng Wu
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 80756, Taiwan;
- Orthopaedic Research Center, Kaohsiung Medical University, Kaohsiung 80756, Taiwan
- Post-Baccalaureate Program in Nursing, Asia University, Taichung 41354, Taiwan
| | - Pei-Hsun Sung
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan; (P.-H.S.); (Y.-L.C.); (T.-H.H.)
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
- Department of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
| | - Yi-Chen Li
- Department of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
| | - Yi-Ling Chen
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan; (P.-H.S.); (Y.-L.C.); (T.-H.H.)
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
- Department of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
| | - Tien-Hung Huang
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan; (P.-H.S.); (Y.-L.C.); (T.-H.H.)
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
- Department of Nursing, Asia University, Taichung 41354, Taiwan;
- Department of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
| | - Kuan-Hung Chen
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
| | - Hon-Kan Yip
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan; (P.-H.S.); (Y.-L.C.); (T.-H.H.)
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
- Department of Nursing, Asia University, Taichung 41354, Taiwan;
- Department of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung 40402, Taiwan
- Division of Cardiology, Department of Internal Medicine, Xiamen Chang Gung Hospital, Xiamen 361028, China
- Correspondence:
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Popplewell MA, Davies HOB, Meecham L, Bate G, Bradbury AW. Comparison of Clinical Outcomes in Patients Selected for Infra-Popliteal Bypass or Plain Balloon Angioplasty for Chronic Limb Threatening Ischemia Between 2009 and 2013. Vasc Endovascular Surg 2020; 55:1538574420953949. [PMID: 32909893 PMCID: PMC7708666 DOI: 10.1177/1538574420953949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION A published subgroup analysis of the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL)-1 trial suggests that, in patients with chronic limb threatening ischemia (CLTI) due to infra-popliteal (IP) disease, clinical outcomes are better following vein bypass surgery (BS) than after plain balloon angioplasty (PBA). The aim of the present study is to determine if clinical outcomes following IP revascularization in our unit are concordant with those found in BASIL-1. METHODS We analyzed prospectively gathered data pertaining to 137 consecutive CLTI patients undergoing IP PBA or BS between 2009 and 2013. We compared 30-day morbidity and mortality, days in hospital (index admission and out to 12-months), amputation free survival (AFS), overall survival (OS), limb salvage (LS), and freedom from arterial re-intervention (FFR). Patient outcomes were censored on 1 February 2017, providing a minimum 3 years follow-up. RESULTS Patients undergoing BS (73/137, 47%) tended to be younger, have less comorbidity, and were more likely to be on best medical therapy (BMT). BS patients spent more days in hospital during the index admission (median 9 vs 5, p = .003), but not out to 12 months (median 15 vs 13, NS). BS patients suffered more 30-day morbidity (36% vs 10%, p < .001), mainly due to infective complications, but not mortality (3.1% vs 6.8%, NS). AFS (p = .001) and OS (p < .001), but not LS or FFR, were better after BS. CONCLUSIONS CLTI patients selected for revascularization by means of IP BS had better long-term outcomes in terms of AFS and OS, but not FFR or LS. Although we await the results of the BASIL-2 trial, current data support the BASIL-1 sub-group analysis which suggests that patients requiring revascularization for IP disease should have BS where possible and that PBA should usually be reserved for patients who are not suitable for BS.
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Affiliation(s)
| | - Huw O. B. Davies
- Department of Vascular Surgery, University of Birmingham, United Kingdom
| | - Lewis Meecham
- Department of Vascular Surgery, University of Birmingham, United Kingdom
| | - Gareth Bate
- Department of Vascular Surgery, University of Birmingham, United Kingdom
| | - Andrew W. Bradbury
- Department of Vascular Surgery, University of Birmingham, United Kingdom
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Editor's Choice - Relationship Between Global Limb Anatomic Staging System (GLASS) and Clinical Outcomes Following Revascularisation for Chronic Limb Threatening Ischaemia in the Bypass Versus Angioplasty in Severe Ischaemia of the Leg (BASIL)-1 Trial. Eur J Vasc Endovasc Surg 2020; 60:687-695. [PMID: 32778491 DOI: 10.1016/j.ejvs.2020.06.042] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 05/29/2020] [Accepted: 06/26/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The Global Vascular Guideline on chronic limb threatening ischaemia (CLTI) has introduced the Global Limb Anatomic Staging System (GLASS) as a new angiographic scoring system. However, the relationship between GLASS and outcomes following revascularisation has not previously been studied. METHODS Using pre-intervention angiograms the relationship between GLASS and immediate technical failure (ITF), amputation free survival (AFS), limb salvage (LS), overall survival (OS), and freedom from major adverse limb events (FF-MALE) was examined in 377 patients undergoing endovascular therapy (EVT, n = 213) or bypass surgery (BS, n = 164) in the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL)-1 trial (randomised 1999-2004). RESULTS There was no significant difference in GLASS between cohorts. There was a significant relationship between ITF and GLASS in EVT (I 14%, II 15%, III 28%, p = .049). GLASS was significantly related to AFS (hazard ratio [HR], 1.37; 95% CI 1.01-1.85; p = .042), LS (HR 1.96; 95 % CI 1.12-3.43; p = .018), and FF-MALE (HR 1.49; 95% CI 1.04-1.87; p = .028) in the EVT cohort. In BS patients, there was no relationship between GLASS and these outcomes. FF-MALE was significantly worse after EVT than BS in GLASS II (p = .038) and III (p = .001). Among the subgroup of patients with femoropopliteal (FP) disease (BS, n = 109 or EVT, n = 159), FF-MALE was significantly higher after BS than EVT (p < .001). The superiority of BS over EVT with increasing GLASS FP grade was greater in the analysis of patients using vein grafts. CONCLUSION In the BASIL-1 cohort, GLASS is associated with outcomes following EVT but not BS. Although further validation in contemporary CLTI cohorts is required, GLASS seems likely be useful in shared decision making and for stratifying patients in future trials.
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Carroll C, Tattersall A. Research and Policy Impact of Trials Published by the UK National Institute of Health Research (2006-2015). VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:727-733. [PMID: 32540230 DOI: 10.1016/j.jval.2020.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/17/2020] [Accepted: 01/25/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Health technology assessment aims to inform and support healthcare decision making, and trials are part of that process. The purpose of this study was to measure the impact of a sample of trials in a meaningful but robust fashion. METHODS All randomized controlled trials funded and published by the UK National Institute of Health Research in the Health Technology Assessment journal series and other peer-reviewed journals were identified for 2006 to 2015. Citation analysis was performed for all trials, and quantitative content analysis was undertaken on a purposive sample to determine whether impact could be categorized as "instrumental" (ie, having a clear influence on key research and policy publications). RESULTS The search identified 133 relevant trials. The citation rate per trial was 102.97. Of the 133 trials, 129 (98%) were cited in 1 or more systematic reviews or meta-analyses (mean per trial = 7.18, range = 0-44). Where they were cited, the trials were used in some form of synthesis 63% of the time. Ninety-one of the 133 (68%) trials were found to be cited in 1 or more guidance or policy document (mean per trial = 2.75, range = 0-26) and had an instrumental influence 41% of the time. The publication of these trials' results in journals other than the Health Technology Assessment journal appears to enhance the discoverability of the trial data. Altmetric.com proved to be very useful in identifying unique policy and guidance documents. CONCLUSION These trials have impressive citation rates, and a sizeable proportion are certainly being used in key publications in a genuinely instrumental manner.
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Affiliation(s)
- Christopher Carroll
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, England, UK.
| | - Andy Tattersall
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, England, UK
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Lamaina M, Childers CP, Liu C, Mak SS, Booth MS, Conte MS, Maggard-Gibbons M, Shekelle PG. Clinical Effectiveness and Resource Utilization of Surgery versus Endovascular Therapy for Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2020; 68:510-521. [PMID: 32439522 DOI: 10.1016/j.avsg.2020.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND The clinical effectiveness of surgical versus endovascular therapy for chronic limb-threatening ischemia (CLTI) continues to be debated, and the resources required for each therapy are unclear. METHODS Systematic review of randomized controlled trials (RCTs) and observational studies comparing surgery with endovascular therapy for CLTI, which reported clinical effectiveness and resource utilization. Short-term and long-term clinical outcomes were examined. RESULTS The search yielded 4,231 titles, of which 17 publications met our inclusion criteria. Five publications were all from 1 RCT, and 12 publications were observational studies. In the RCT, the surgical approach had greater resource use in the first year (total hospital days across all admissions for surgery versus angioplasty: 46.14 ± 53.87 vs. 36.35 ± 51.39; P < 0.001; also true for days in high-dependency and intensive therapy units), but differences were not statistically significant in subsequent years. All-cause mortality presented a nonsignificant difference favoring angioplasty in the first 2 years (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [95% CI], 0.75-2.15), but after 2 years, it favored surgical treatment (aHR, 0.34; 95% CI, 0.17-0.71). The observational studies reported short-term effectiveness and resource utilization favoring endovascular therapy, but most differences were not statistically significant. Long-term outcomes were more mixed; in particular, mortality outcomes generally favored surgery, although concluding that cause and effect is not possible as endovascularly treated patients tended to be older and may have had a shorter life expectancy regardless of therapy. CONCLUSIONS The clinical effectiveness and resource utilization of surgery compared with endovascular therapy for CLTI is not known with certainty and will not be known until ongoing trials report results. It is likely that findings will vary by the time horizon, where initial outcomes and utilization tend to favor endovascular interventions, but long-term outcomes favor surgical revascularization.
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Affiliation(s)
- Margherita Lamaina
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Charles Liu
- Department of Surgery, Stanford University, Stanford, CA; David Geffen School of Medicine, National Clinician Scholars Program, University of California Los Angeles, Los Angeles, CA; Department of Surgery, Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Selene S Mak
- Department of Surgery, West Los Angeles Veterans Affairs Medical Center, Los Angeles, CA
| | | | - Michael S Conte
- Division of Vascular Surgery, Department of Surgery, University of California, San Francisco, CA
| | | | - Paul G Shekelle
- Department of Surgery, Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA
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Kobayashi T, Hamamoto M, Ozawa M, Harada T, Takahashi S. Long-Term Results and Risk Analysis of Redo Distal Bypass for Critical Limb Ischemia. Ann Vasc Surg 2020; 68:409-416. [PMID: 32335252 DOI: 10.1016/j.avsg.2020.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/20/2020] [Accepted: 04/14/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Distal bypass is the optimal treatment for patients with critical limb ischemia (CLI). However, effectiveness of redo distal bypass (rDB) after failed initial distal bypass (iDB) remains uncertain. This study aimed to analyze long-term results of rDB for CLI. METHODS Patients undergoing rDB for CLI from 2009 to 2018 at a single institute were retrospectively reviewed. Operative details, primary and secondary patency, survival rate, major amputation-free rate, and risk factors affecting patency were analyzed. The distal runoff was evaluated using the infrapopliteal Global Limb Anatomic Staging System (GLASS) grade (0 to 4: 0 represents good runoff and 4 represents the poorest runoff). RESULTS Of 310 iDB (251 patients), 46 rDB were performed in 44 patients: 27 men, mean age 75 ± 10 years, diabetes mellitus 77%, chronic renal failure with hemodialysis 45%. Only the autologous veins were used in distal bypasses: a great saphenous vein (GSV) in 28 (57%), a small saphenous vein in 13 (27%), an arm vein in 6 (12%), and a superficial femoral vein in 2 (4%). The GSV was used less frequently for rDB than for iDB (57% vs. 90%, P < 0.0001). The infrapopliteal GLASS grade 4 was recognized more in rDB than iDB (76% vs. 60%, P = 0.04). Primary and secondary patency of rDB was 25% and 44% at 1 year and 14% and 29% at 3 years, respectively, which were significantly lower than those of iDB (P < 0.0001). The survival rate after rDB was 68% at 1 year and 53% at 3 years. Freedom from major amputation rate in rDB was 83% at 1 year and 66% at 3 years. Multivariate analysis showed the risk factor influencing on secondary patency was patent duration of the iDB graft (P = 0.012). Secondary patency of rDB was higher in the group of late graft occlusion ≥6 months after iDB (late group) than in the group of early graft occlusion < 6 months after iDB (early group) (94% vs. 9% at 1 year and 75% vs. 5% at 3 years, P < 0.0001). However, freedom from major amputation rate at 3 years was comparable between both groups (71% in the late group vs. 61% in the early group). CONCLUSIONS Patency of rDB was significantly lower than that of iDB partly because of less use of the GSV and poorer runoff. Because survival and graft patency after rDB was low, rDB should be a suboptimal treatment especially in patients with early graft occlusion within 6 months after iDB.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan.
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Masamichi Ozawa
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Takumi Harada
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University, Hiroshima, Japan
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Ni Q, Yang S, Xue G, Zhou Z, Zhang L, Ye M. Viabahn Stent Graft for the Endovascular Treatment of Occlusive Lesions in the Femoropopliteal Artery: A Retrospective Cohort Study with 4-Year Follow-Up. Ann Vasc Surg 2019; 66:573-579. [PMID: 31743785 DOI: 10.1016/j.avsg.2019.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/30/2019] [Accepted: 11/10/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND The polytetrafluoroethylene-covered Viabahn stent may be effective for the endovascular treatment of patients with femoropopliteal artery occlusive lesions. However, the long-term efficacy of Viabahn stent remains unclear. The aim of the study is to evaluate the long-term patency of Viabahn stent grafts in patients with occlusive lesions in the femoropopliteal artery. METHODS Consecutive patients with occlusive lesions in the femoropopliteal artery who had been treated with Viabahn stent grafts during the period from June 2013 to December 2016 at our center were retrospectively included. Accumulative incidences of primary patency and secondary patency were estimated by Kaplan-Meier survival analysis, and the predictors of primary patency were evaluated by Cox regression analysis. RESULTS A total of 66 patients underwent successful endovascular treatment and were included in the study. Endovascular treatment with a Viabahn stent was associated with a complication rate of 9.1% and a 30-day mortality rate of 1.5%. Sixty-one patients were followed for a mean duration of 29.5 months. The 1-year, 2-year, 3-year, and 4-year primary patency rates were 81.7%, 74.7%, 67.6%, and 58.9%, respectively. The secondary patency rates were 94.9%, 92.9%, 90.1%, and 90.1%, respectively. The overall major amputation rate was 5.0%. The results of multivariate Cox regression analyses showed that stent location was the only independent predictor of primary patency (P = 0.001). Implantation of a Viabahn stent above the knee, compared with implantation below the knee, was associated with a higher rate of primary patency. CONCLUSIONS The Viabahn stent graft is associated with a satisfactory rate of long-term patency for the endovascular treatment of occlusive lesions in the femoropopliteal artery, especially for those located above the knee.
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Affiliation(s)
- Qihong Ni
- Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China
| | - Shuofei Yang
- Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China
| | - Guanhua Xue
- Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China
| | - Zhaoxiong Zhou
- Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China
| | - Lan Zhang
- Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China
| | - Meng Ye
- Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, P. R. China.
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Bolton L. Peripheral arterial disease: Scoping review of patient-centred outcomes. Int Wound J 2019; 16:1521-1532. [PMID: 31597226 DOI: 10.1111/iwj.13232] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 09/04/2019] [Accepted: 09/13/2019] [Indexed: 01/13/2023] Open
Abstract
Peripheral arterial disease (PAD) impairs patients' quality of life (QOL), walking and ulcer healing, increasing patient pain, costs, and risks of amputation or mortality. A literature appraisal described PAD treatment capacity to improve validated patient-centred outcomes in controlled clinical studies. The PUBMED database was searched from 1 January 1970 to 21 June 2018, for original and derivative controlled clinical trial references addressing MeSH terms for 'ischemia' AND 'leg ulcer'. Non-ischemic ulcer treatment references were excluded. Frequencies of improved (P < .05) outcomes were reported. Eighty-eight studies on 4153 patients were summarized. Walking, pain or QOL improved mainly for interventions administered before PAD became severe. Amputation incidence, pain and ulcer healing were more frequently reported in those with severe PAD. Independent of PAD severity, patients experienced more likely improved walking, QOL, or pain reduction in response to structured walking interventions or those increasing calf muscle activity. Those with more severe PAD were more likely to report amputation reduction, mainly in response to invasive interventions. Those with PAD experienced more consistently improved patient-centred outcomes if they received multidisciplinary PAD management with supervised walking or calf muscle activity, with more likely amputation risk reduced for those with more severe PAD.
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Affiliation(s)
- Laura Bolton
- Department of Surgery, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
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Lee J, Cheng N, Tai H, Jimmy Juang J, Wu C, Lin L, Hwang J, Lin J, Chiang F, Tsai C. CYP2C19 Polymorphism is Associated With Amputation Rates in Patients Taking Clopidogrel After Endovascular Intervention for Critical Limb Ischaemia. Eur J Vasc Endovasc Surg 2019; 58:373-382. [DOI: 10.1016/j.ejvs.2019.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 02/12/2019] [Indexed: 02/08/2023]
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Meecham L, Bate G, Patel S, Bradbury AW. A Comparison of Clinical Outcomes Following Femoropopliteal Bypass or Plain Balloon Angioplasty with Selective Bare Metal Stenting in the Bypass Versus Angioplasty in Severe Ischaemia of the Limb (BASIL) Trial. Eur J Vasc Endovasc Surg 2019; 58:52-59. [DOI: 10.1016/j.ejvs.2019.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 01/04/2019] [Indexed: 01/25/2023]
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 749] [Impact Index Per Article: 149.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GUIDELINE SUMMARY Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69:3S-125S.e40. [PMID: 31159978 PMCID: PMC8365864 DOI: 10.1016/j.jvs.2019.02.016] [Citation(s) in RCA: 719] [Impact Index Per Article: 143.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minn
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Suh HP, Hong JP. The role of reconstructive microsurgery in treating lower-extremity chronic wounds. Int Wound J 2019; 16:951-959. [PMID: 31148396 DOI: 10.1111/iwj.13127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 01/22/2023] Open
Abstract
Frequently considered chronic wounds for reconstruction are wounds lacking healing progress despite good wound care. And those needing microsurgical reconstruction are chronic wounds that are unable to close by local flap or skin grafts, wounds with exposed vital structure such as tendon and bones, and wounds that have prolonged infections such as osteomyelitis and skin necrosis. The reconstruction for soft tissue defects not only aims to provide coverage but to restore function and acceptable form as well. Wound preparation prior to microsurgical reconstruction consists of improving or restoring vascular supply, stabilising skeletal structures, and obtaining clinically clean wounds. Microsurgery is a surgical discipline that combines magnification with a advanced microscope, specialised precision tools, and various operating techniques. Thus microsurgery allows flap to be transferred far from the donor site restoring form and function to areas of the body that have lost skin, fat, muscle movement, and/or skeletal support. Microsurgery has expanded reconstructive surgery's elements and strategies and is still evolving. Along with the multidisciplinary approach and good principle of wound care, the repair and restoration strategies using microsurgery have widened the possibilities for limb salvage from complex chronic wounds.
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Affiliation(s)
- Hyunsuk Peter Suh
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joon Pio Hong
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FGR, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RAG, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019; 69:e71-e126. [PMID: 27851992 DOI: 10.1016/j.jacc.2016.11.007] [Citation(s) in RCA: 438] [Impact Index Per Article: 87.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Gao W, Chen D, Liu G, Ran X. Autologous stem cell therapy for peripheral arterial disease: a systematic review and meta-analysis of randomized controlled trials. Stem Cell Res Ther 2019; 10:140. [PMID: 31113463 PMCID: PMC6528204 DOI: 10.1186/s13287-019-1254-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 02/05/2023] Open
Abstract
Background Peripheral arterial disease (PAD) is a common cause of disability and mortality. The reconstruction of blood circulation presents to be the key to treatment, which can be achieved by surgery and interventional therapy. Since 40% patients have lost the chance for the therapy, a new method is needed to reduce the amputation and mortality rate for “no-option” patients. The objective of our systematic review and meta-analysis was to evaluate the efficacy and safety of autologous implantation of stem cells in patients with PAD critically, compared with active controls and placebo. Methods Randomized controlled trials (RCTs) of autologous implantation of stem cells compared with placebo and control for PAD were included. Electronic medical databases including MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the Chinese Biomedical Literature Database, China National Knowledge Infrastructure (CNKI), and ClinicalTrials.gov were searched from initial period to September 2018. Independently, two reviewers screened citations, extracted data, and assessed the risk of bias according to the criteria of the Cochrane handbook. The quality of evidence was evaluated by GRADE evidence profile. The primary outcomes consisted of amputation rate, major amputation rate, ulcer healing rate, and side effects. The second outcomes included ankle-brachial index (ABI), transcutaneous oxygen tension (TcO2), pain-free walking distance (PFWD), and rest pain score. Statistical analysis was conducted via RevMan 5.3 and Stata 12.0. Results According to the twenty-seven RCTs, 1186 patients and 1280 extremities were included and the majority of studies showed a high risk of bias. Meta-analysis indicated that autologous stem cell therapy was more effective than conventional therapy on the healing rate of ulcers [OR = 4.31 (2.94, 6.30)]. There was also significant improvement in ABI [MD = 0.13 (0.10, 0.17)], TcO2 [MD = 0.13 (0.10, 0.17)], and PFWD [MD = 178.25 (128.18, 228.31)] while significant reduction was showed in amputation rate [OR = 0.50 (0.36, 0.69)] and rest pain scores [MD = − 1.61 (− 2.01, − 1.21)]. But the result presented no significant improvement in major limb salvage [0.66 (0.42, 1.03)]. Besides, stem cell therapy could reduce the amputation rate [OR = 0.50 (0.06, 0.45] and improve the ulcer healing rate [OR = 4.34 (2.96, 6.38] in DM subgroup. Eight trials reported the side effects of autologous stem cell therapy, and no serious side effects related to stem cells were reported. GRADE evidence profile showed all the quality evidence of outcomes were low. Conclusions Based on the review, autologous stem cell therapy may have a positive effect on “no-option” patients with PAD, but presented no significant improvement in major limb salvage. However, the evidence is insufficient to prove the results due to high risk of bias and low-quality evidence of outcomes. Further researches of larger, randomized, double-blind, placebo-controlled, and multicenter trials are still in demand. Electronic supplementary material The online version of this article (10.1186/s13287-019-1254-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wei Gao
- Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.,Health Management Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Dawei Chen
- Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Guanjian Liu
- Chinese Cochrane Centre, Chinese EBM Centre, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Xingwu Ran
- Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
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Peters CML, de Vries J, Redeker S, Timman R, Eijck GJV, Steunenberg SL, Verbogt N, Ho GH, van Busschbach JJ, van der Laan L. Cost-effectiveness of the treatments for critical limb ischemia in the elderly population. J Vasc Surg 2019; 70:530-538.e1. [PMID: 30922757 DOI: 10.1016/j.jvs.2018.11.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/16/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The treatment of critical limb ischemia (CLI), with the intention to prevent limb loss, is often an intensive and expensive therapy. The aim of this study was to examine the cost-effectiveness of endovascular and conservative treatment of elderly CLI patients unsuitable for surgery. METHODS In this prospective observational cohort study, data were gathered in two Dutch peripheral hospitals. CLI patients aged 70 years or older were included in the outpatient clinic. Exclusion criteria were malignant disease, lack of language skills, and cognitive impairment; 195 patients were included and 192 patients were excluded. After a multidisciplinary vascular conference, patients were divided into three treatment groups (endovascular revascularization, surgical revascularization, or conservative therapy). Subanalyses based on age were made (70-79 years and ≥80 years). The follow-up period was 2 years. Cost-effectiveness of endovascular and conservative treatment was quantified using incremental cost-effectiveness ratios (ICERs) in euros per quality-adjusted life-years (QALYs). RESULTS At baseline, patients allocated to surgical revascularization had better health states, but the health states of endovascular revascularization and conservative therapy patients were comparable. With an ICER of €38,247.41/QALY (∼$50,869/QALY), endovascular revascularization was cost-effective compared with conservative therapy. This is favorable compared with the Dutch applicable threshold of €80,000/QALY (∼$106,400/QALY). The subanalyses also established that endovascular revascularization is a cost-effective alternative for conservative treatment both in patients aged 70 to 79 years (ICER €29,898.36/QALY; ∼$39,765/QALY) and in octogenarians (ICER €56,810.14/QALY; ∼$75,557/QALY). CONCLUSIONS Our study has shown that endovascular revascularization is cost-effective compared with conservative treatment of CLI patients older than 70 years and also in octogenarians. Given the small absolute differences in costs and effects, physicians should also consider individual circumstances that can alter the outcome of the intervention. Cost-effectiveness remains one of the aspects to take into consideration in making a clinical decision.
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Affiliation(s)
| | - Jolanda de Vries
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands; Department of Medical Psychology, Elisabeth Two Cities, Tilburg, The Netherlands
| | - Steef Redeker
- Section of Medical Psychology and Psychotherapy, Department of Psychiatry, Erasmus MC, Rotterdam, The Netherlands
| | - Reinier Timman
- Section of Medical Psychology and Psychotherapy, Department of Psychiatry, Erasmus MC, Rotterdam, The Netherlands
| | | | | | | | - Gwan H Ho
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Jan J van Busschbach
- Section of Medical Psychology and Psychotherapy, Department of Psychiatry, Erasmus MC, Rotterdam, The Netherlands
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Vossen RJ, Philipszoon PC, Vahl AC, Montauban van Swijndregt AD, Leijdekkers VJ, Balm R. A Comparative Cost-Effectiveness Analysis of Percutaneous Transluminal Angioplasty With Optional Stenting and Femoropopliteal Bypass Surgery for Medium-Length TASC II B and C Femoropopliteal Lesions. J Endovasc Ther 2019; 26:172-180. [DOI: 10.1177/1526602819833646] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Purpose: To evaluate the total midterm costs and cost-effectiveness of percutaneous transluminal angioplasty with optional stenting (PTA/S) as initial treatment compared with femoropopliteal bypass (FPB) surgery in patients with medium-length TransAtlantic Inter-Society Consensus II (TASC) B and C femoropopliteal lesions. Materials and Methods: Over a period of 3 years, all hospital health care costs for 226 consecutive patients were calculated: 170 patients with a TASC B lesion and 56 patients with a TASC C lesion. In the 135-patient PTA/S group (mean age 69.9±10.9 years; 83 men), 108 (63.5%) patients had TASC B lesions and 27 (48.2%) patients had TASC C lesions. Ninety-one patients (mean age 68.4±10.9 years; 60 men) were treated with FPB for 62 TASC B and 29 TASC C femoropopliteal lesions. The main outcome measure was the primary patency rate at 3-year follow-up. Multiple imputation and bootstrapping techniques were used to analyze the data. The adjusted incremental cost-effectiveness ratios (ICERs) were calculated by dividing the difference in total costs by the difference in 3-year primary patency rate. Costs were expressed in euros (€), and cost differences are presented with the 95% confidence interval (CI). Results: Mean total costs per patient were €29,058 in the PTA/S treatment group vs €42,437 in the FPB group (mean adjusted difference –€14,820, 95% CI –€29,044 to −€5976). Differences in 3-year primary patency between PTA/S and FPB were small and nonsignificant (68.9% and 70.3%, respectively). An ICER of 563,716 was found, indicating that FPB costs €563,716 more per one extra patient reaching 3-year primary patency in comparison with PTA/S treatment. Conclusion: FPB in medium-length femoropopliteal lesions involved higher total costs when evaluated over a 3-year follow-up period. An endovascular-first approach is recommended, as this will result in cost minimization for patients with medium-length femoropopliteal disease.
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Affiliation(s)
- Rianne J. Vossen
- Department of Vascular Surgery, Onze Lieve Vrouwe Gasthuis (OLVG) Amsterdam, the Netherlands
| | - Pilar C. Philipszoon
- Department of Health Sciences, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Anco C. Vahl
- Department of Vascular Surgery, Onze Lieve Vrouwe Gasthuis (OLVG) Amsterdam, the Netherlands
- Clinical Epidemiology, OLVG Amsterdam, the Netherlands
| | | | - Vanessa J. Leijdekkers
- Department of Vascular Surgery, Onze Lieve Vrouwe Gasthuis (OLVG) Amsterdam, the Netherlands
| | - Ron Balm
- Amsterdam Cardiovascular Sciences, Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
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Vossen RJ, Vahl AC, Fokkema TM, Leijdekkers VJ, van Swijndregt ADM, Balm R. Endovascular therapy versus femoropopliteal bypass surgery for medium-length TASC II B and C lesions of the superficial femoral artery: An observational propensity-matched analysis. Vascular 2019; 27:542-552. [DOI: 10.1177/1708538119837134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objectives This study was designed to compare clinical outcomes of percutaneous transluminal angioplasty with optional stenting (PTA/s) and femoropopliteal bypass (FPB) surgery as primary invasive treatment in patients with medium-length superficial femoral artery (SFA) lesions. Methods We performed a single-center retrospective, observational analysis in all consecutive patients who had undergone initial invasive treatment for medium-length, TASC II B and TASC II C, SFA lesions from 2004 to 2015. Primary endpoints were primary and secondary clinical patency. Secondary endpoints were complication rates and number of amputations. Kaplan–Meier curves were used to compare patency rates in the two treatment groups. Multivariate Cox regression analysis was performed to adjust for confounding variables and propensity score matching analysis was used to balance treatment groups. Results A total of 362 patients with a mean observation period of 4.0 years (SD ± 2.6) were analyzed. In this group, 231 patients (64%) underwent PTA/s and 131 patients (36%) FPB surgery. There was no difference in primary clinical patency at one-, three- and five-year follow-up between the PTA/s and FPB group, with rates of 79% vs. 63%, 53% vs. 78% and 71% vs. 66%, respectively ( P = 0.46). Secondary clinical patency estimates were comparable, resulting in one-, three- and five-year secondary clinical patency rates of 88%, 76% and 67% in the PTA/s group versus 88%, 80% and 79% in the bypass group ( P = 0.40). Multivariate analysis revealed no significant differences between the PTA/s and FPB groups in terms of primary clinical patency (HR 1.4; 95% CI 0.9–2.2) and secondary clinical patency (HR 1.7; 95% CI 0.9–2.9). This was confirmed in the propensity score analysis. Hospital stay (4.8 vs. 10.3 days) and complication rate (2.6% vs. 18.3%) were significantly lower in the PTA/s group ( P = 0.00). The number of amputations was comparable ( P = 0.75). Conclusions The clinical success of endovascular therapy and surgery for medium-length SFA lesions is comparable. Taking into account the lower morbidity rate, shorter length of hospital stay and the less invasive character of PTA/s compared with bypass surgery, patients with medium-length SFA lesions are ideally treated by an endovascular-first approach.
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Affiliation(s)
- RJ Vossen
- Department of Vascular Surgery, OLVG Amsterdam, Amsterdam, The Netherlands
| | - AC Vahl
- Department of Vascular Surgery, OLVG Amsterdam, Amsterdam, The Netherlands
- Clinical Epidemiology OLVG Amsterdam, Amsterdam, The Netherlands
| | - TM Fokkema
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - VJ Leijdekkers
- Department of Vascular Surgery, OLVG Amsterdam, Amsterdam, The Netherlands
| | | | - R Balm
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Vascular fellow and resident experience performing infrapopliteal revascularization with endovascular procedures and vein bypass during training. J Vasc Surg 2019; 68:1533-1537. [PMID: 30360842 DOI: 10.1016/j.jvs.2018.01.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 01/25/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Endovascular aneurysm repair has led to a significant reduction in vascular trainee experience in the surgical treatment of aortic aneurysms. We sought to evaluate whether the vascular training paradigm or the "endovascular first" approach to lower extremity vascular disease has had a similar effect on trainee experience with infrapopliteal endovascular therapy and vein bypass. METHODS Deidentified data were provided by the Vascular Surgery Board on the number of procedures performed by each 2014 fellowship and residency (0 + 5) graduate during training. Data were analyzed using parametric and nonparametric methods, where appropriate. RESULTS Of 125 trainees (109 fellows, 16 residents), 33 (27%) performed 10 or fewer infrapopliteal vein bypasses and 37 (29%) performed 10 or fewer infrapopliteal endovascular procedures during their training. Eleven trainees (9%) performed 10 or fewer of both procedures. There was a positive correlation between number of infrapopliteal vein bypass and endovascular procedures performed (r = 0.19; P = .03). There was no difference between fellows and residents in the mean number of bypass operations performed during training (17.3 vs 19.1; P = .50; range, 0-53). However, residents performed more infrapopliteal endovascular procedures than fellows did (median, 29 vs 16; P = .03; range, 0-128). CONCLUSIONS More than one in four graduates of both training paradigms finish with a low number of infrapopliteal bypasses and endovascular interventions. The number of these procedures needed for proficiency is not known. Vascular surgery training programs should critically evaluate the number of infrapopliteal procedures required to achieve proficiency.
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Bolíbar I, Gich I, Anglès A, Romero JM, Escudero JR. Variability of revascularization techniques among Catalan hospitals and impact on leg salvage in patients with peripheral arterial disease. INT ANGIOL 2019; 38:54-61. [DOI: 10.23736/s0392-9590.18.04041-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Viljoen A, Hoxer CS, Johansen P, Malkin S, Hunt B, Bain SC. Evaluation of the long-term cost-effectiveness of once-weekly semaglutide versus dulaglutide for treatment of type 2 diabetes mellitus in the UK. Diabetes Obes Metab 2019; 21:611-621. [PMID: 30362224 PMCID: PMC6587509 DOI: 10.1111/dom.13564] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/08/2018] [Accepted: 10/19/2018] [Indexed: 01/20/2023]
Abstract
AIMS Glucagon-like peptide-1 (GLP-1) receptor agonists are appealing as glucose-lowering therapy for individuals with type 2 diabetes mellitus (T2DM) as they also reduce body weight and are associated with low rates of hypoglycaemia. This analysis assessed the long-term cost-effectiveness of semaglutide 0.5 and 1 mg vs dulaglutide 1.5 mg (two once-weekly GLP-1 receptor agonists) from a UK healthcare payer perspective, based on the head-to-head SUSTAIN 7 trial, to inform healthcare decision making. MATERIALS AND METHODS Long-term outcomes were projected using the IQVIA CORE Diabetes Model (version 9.0). Baseline cohort characteristics, changes in physiological parameters and adverse event rates were derived from the 40-week SUSTAIN 7 trial. Costs to a healthcare payer were assessed, and these captured pharmacy costs and costs of complications. Utilities were taken from published sources. RESULTS Once-weekly semaglutide 0.5 and 1 mg were associated with improvements in quality-adjusted life expectancy of 0.04 and 0.10 quality-adjusted life years, respectively, compared with dulaglutide 1.5 mg. Clinical benefits were achieved at reduced costs, with lifetime cost savings of GBP 35 with once-weekly semaglutide 0.5 mg and GBP 106 with the once-weekly semaglutide 1 mg, resulting from fewer diabetes-related complications due to better glycaemic control. Therefore, both doses of once-weekly semaglutide were considered dominant vs dulaglutide 1.5 mg (improving outcomes and reducing costs). CONCLUSIONS Compared with treatment with dulaglutide, once-weekly semaglutide represents a cost-effective option for treating individuals in the UK with T2DM who are not achieving glycaemic control with metformin, projected to both improve clinical outcomes and reduce costs.
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Affiliation(s)
- Adie Viljoen
- Borthwick Diabetes Research Centre, Lister Hospital (East and North Hertfordshire NHS Trust)StevenageUK
| | | | | | - Samuel Malkin
- Ossian Health Economics and CommunicationsBaselSwitzerland
| | - Barnaby Hunt
- Ossian Health Economics and CommunicationsBaselSwitzerland
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Tummala S, Scherbel D. Clinical Assessment of Peripheral Arterial Disease in the Office: What Do the Guidelines Say? Semin Intervent Radiol 2019; 35:365-377. [PMID: 30728652 DOI: 10.1055/s-0038-1676453] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Lower extremity peripheral arterial disease (PAD) is the manifestation of atherosclerotic disease within the lower extremities. The presentation of PAD is diverse ranging from asymptomatic disease to claudication or to debilitating rest pain, nonhealing ulcers, and gangrene. PAD is associated with significant morbidity, mortality, and healthcare costs. Proper diagnosis and management of PAD is important so as to maintain quality of life and reduce the risk of cardiovascular disease and adverse limb events such as amputation. This document provides a comprehensive outpatient approach to the clinical assessment of PAD that includes risk factors, diagnosis, treatment, and follow-up options.
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Affiliation(s)
- Srini Tummala
- Limb Preservation Program, Department of Interventional Radiology, University of Miami, Miller School of Medicine, Miami, Florida
| | - Derek Scherbel
- University of Miami, Miller School of Medicine, Miami, Florida
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