Infrainguinal percutaneous transluminal angioplasty or bypass surgery in patients aged 80 years and older with critical leg ischaemia

Critical Limb Ischaemia in Octogenarians: Treatment Outcomes Compared With Younger Patients

Objective

A growing proportion of patients with chronic limb threatening ischaemia (CLTI) are elderly, the most challenging for management decisions. The aim was to study the patient profile and outcome of CLTI in octogenarian patients, comparing them with younger patients.

Methods

Retrospective cohort of consecutive patients hospitalised for CLTI with infrainguinal disease in a Spanish centre (2013-2020). Data on age, comorbidity, anatomical characteristics, and treatment were gathered. Patients were stratified according to age (<80 and ≥80 years). The primary outcomes were overall survival and limb salvage (LS), analysed using Kaplan-Meier and Cox regression.

Results

: A total of 512 patients were enrolled: 305 were <80 years old with mean age 69.7 ± standard deviation (SD) 8.2 years, and 207 were ≥80 years old with mean age 85.3 ± SD 3.6 years. Smoking and diabetes mellitus were more frequent in younger patients (78.0% vs. 45.4%, p < .001; 68.5% vs. 59.5%, p = .037 respectively). Older patients had a higher prevalence of heart and kidney disease (70.5% vs. 57.0%, p = .002; 39.6% vs. 24.3%, p < .001, respectively). The arterial disease was femoropopliteal or tibial in 68.9% and 31.1% in patients <80 years and 58.9% and 41.1% in patients ≥80 years (p = .021). In younger patients, conservative treatment was indicated in 18.0%, endovascular treatment (ET) in 41.6%, and open or hybrid surgery (OS) in 40.3%; in patients ≥80 years these were 36.9%, 37.4%, and 25.7%, respectively (p <. 001). Mean follow up was 23.3 ± SD 17.4 months. One and two year overall survival was 85.4% and 73.0% in younger patients and 64.1% and 51.3% in patients ≥80 years (p < .001). LS was 83.7% and 79% at the same times in younger patients and 75.3% and 72.1% in older ones (p = .045). In younger patients ET led to worse LS than OS (p = .005) but not in older patients (p = .29).

Conclusion

Patients ≥80 years with CLTI have higher comorbidity and lower life expectancy and receive conservative treatment more frequently than younger patients. ET and OS are associated with similar survival and LS in these older patients.

Amputation and limb salvage following endovascular and open surgery for the treatment of peripheral artery illnesses: A meta-analysis

A meta-analysis investigation was executed to measure the outcome of endovascular surgery (ES) and open surgery (OS) for the management of peripheral artery diseases (PADs) on amputation and limb salvage (LS). A comprehensive literature inspection till February 2023 was applied and 3451 interrelated investigations were reviewed. The 31 chosen investigations enclosed 19 948 individuals with PADs were in the chosen investigations' starting point, 8861 of them were utilising ES, and 11 087 were utilising OS. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were utilised to compute the value of the effect of ES and OS for the management of PADs on amputation and LS by the dichotomous approaches and a fixed or random model. ES had significantly lower amputation (OR, 0.80; 95% CI, 0.68-0.93, P = 0.005) compared with those with OS in individuals with PADs. No significant difference was found between ES and OS in 30-day LS (OR, 0.95; 95% CI, 0.64-1.42, P = 0.81), 1-year LS (OR, 1.06; 95% CI, 0.81-1.39, P = 0.68), and 3-year LS (OR, 0.86; 95% CI, 0.61-1.19, P = 0.36) in individuals with PADs. ES had significantly lower amputation, 30-day LS, 1-year LS, and 3-year LS compared with those with OS in individuals with PADs. However, care must be exercised when dealing with its values because of the low sample size of some of the nominated investigations for the meta-analysis.

Comprehensive Evaluation of Common Open and Endovascular Procedures and Their Relationship with Postdischarge Complications

BACKGROUND

Percutaneous endovascular treatment for arterial vascular diseases has revolutionized vascular care. While these procedures offer improved morbidity, mortality, and length of stay (LOS), their effect on postdischarge complications is unknown. The objectives of the study were to evaluate trends in LOS and postdischarge complications over time and to assess factors associated with postdischarge complications.

METHODS

Patients who underwent surgery for common vascular pathologies (abdominal aortic aneurysm, aortoiliac occlusive disease, lower extremity disease, and carotid stenosis) were identified from the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted database (2014-2019). Outcomes included LOS, 30-day complications, and proportions of postdischarge complications. Predictors of postdischarge complications were assessed using a multivariable logistic regression.

RESULTS

Of 80,311 patients evaluated, median LOS did not change from 2014 to 2019 (2, interquartile range 1-5). Overall, 15.7% of patients experienced any 30-day complication, with 31.3% occurring after discharge. The proportion of postdischarge complications increased from 29.1% (2014) to 35.9% (2019), P < 0.001. With exception of carotid procedures, endovascular procedures had lower overall complication rates than open procedures; however, there was an increased proportion of postdischarge complications for endovascular procedures (all P < 0.001). Factors associated with an increased odds of postdischarge complications included female, Black or other race, dependent functional status, underweight or obesity, increased LOS, and procedural time, all P < 0.05.

CONCLUSIONS

Across 4 representative common vascular pathologies, endovascular treatments had a higher proportion of postdischarge complications compared to open procedures. Early identification and evaluation of postdischarge complications for endovascular patients may be warranted to avoid unplanned readmission.

What is the impact of infrapopliteal endovascular intervention on free flap survival in diabetic foot reconstruction?

Background

The combination of endovascular intervention and microvascular free flap transfer has been effectively used for chronic ischemic wounds of lower limb. The aim of this study was to determine the influence of angioplasty on free flap survival in diabetic foot ulcer reconstruction.

Methods

A retrospective research was conducted for 46 diabetic patients with chronic ulcer of the foot. All patients underwent free flap reconstruction because of their non-healing wound with tendon or bone exposure. Patient’s demography, clinical data related to vascular status, vascular intervention, and free flap transfer procedure were collected. Flap survival rate was compared between the group with severe arterial stenosis group and non-severe stenosis group. It was also compared among groups with different revascularization results.

Results

The average age of patients was 56.2 ± 10.8 years. There were 14 (30.4%) men and 32 (69.6%) women. Of 46 patients, 23 (50%) had severe infrapopliteal arterial stenosis. All 23 patients underwent endovascular intervention. Their final results of the pedal arch were type 1 in 13 patients, type 2A in 7 patients, type 2B in 2 patients, and type 3 in 1 patient. Total flap necrosis was found in 5 (10.9%) cases, marginal necrosis in 4 (8.7%) cases, and wound dehiscence in 4 (8.7%) cases. There was no significant difference in flap loss between severe arterial stenosis patients and non-severe arterial stenosis patients. In the severe arterial stenosis group, after endovascular intervention, patients with type 1 of pedal arch had a significantly lower rate of total flap necrosis than others. There was no association between the use of revascularized recipient artery and flap survival.

Conclusions

Our study revealed that the quality of pedal arch was crucial for free flap survival. Thus, PTA should aim to re-establish a complete pedal arch to increase wound healing rate and flap success.

Editor's Choice - Mortality and Major Amputation after Revascularisation in Octogenarians Versus Non-Octogenarians with Chronic Limb Threatening Ischaemia: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to assess the clinical outcomes after revascularisation in octogenarians with chronic limb threatening ischaemia (CLTI).

METHODS

This was a systematic review and meta-analysis, in which the Medline, Embase, and Cochrane Library databases were searched systematically by two independent researchers. Meta-analyses were performed to analyse one year mortality, one year major amputation, and one year amputation free survival (AFS) after revascularisation. Pooled outcome estimates were reported as percentages and odds ratio (OR) with 95% confidence intervals (CI). In addition, sensitivity and subgroup analyses were performed and the quality of evidence was determined according to the GRADE system.

RESULTS

The review includes 21 observational studies with patients who were treated for CLTI. Meta-analysis of 12 studies with a total of 17 118 patients was performed. A mortality rate of 32% was found in octogenarians (95% CI 27-37%), which was significantly higher than in the non-octogenarians (17%, 95% CI 11-22%/OR 2.52, 95% CI 1.93-3.29; GRADE: "low"). No significant difference in amputation rate was found (octogenarians 15%, 95% CI 11-18%; non-octogenarians 12%, 95% CI 7-14%; GRADE: "very low"). AFS was significantly lower in the octogenarian group (OR 1.55, 95% CI 1.03-2.43; GRADE: "very low"). In a subgroup analysis differentiating between endovascular and surgical revascularisation, amputation rates were comparable. For octogenarians, those treated conservatively had a mortality rate significantly higher than those treated by revascularisation (OR 1.76, 95% CI 1.19-2.60; GRADE: "very low"). No significant difference in mortality rate was found between primary amputation and revascularisation in octogenarians (OR 0.70, 95% CI 0.24-2.03; GRADE: "very low").

CONCLUSION

In octogenarians with CLTI, a substantial one year mortality rate of 32% was found after revascularisation. The amputation rates were comparable between both age groups. However, only low quality evidence could be obtained supporting the results of this meta-analysis because only observational studies were available for inclusion.

Changes in rates of vascular procedure types and lower extremity amputations in Finland for 2007-2017 inclusive, a population cohort study of 69,523 revascularizations

INTRODUCTION

Since 2000 the numbers of both open and endovascular revascularization procedures have increased. Despite these increases, the number of major lower extremity amputations (LEAs) has remained relatively constant. The aim of the present study was to assess the number of vascular procedures in relation to the frequency of major LEAs in Finland.

METHODS

The Finnish National Institute for Health and Welfare (THL) administers a national registry of all procedures conducted by official healthcare providers in Finland. Data regarding all revascularization procedures and major LEAs between 2007 and 2017 inclusive, were collected from the THL registry. The rates of both open and endovascular procedures were analyzed.

RESULTS

A total of 69,523 revascularization procedures were registered over the 11-year period. Of all revascularizations, 22.6% were endovascular in 2007, which rose to 60.5% in 2017. The annual rates of vascular procedures per 100,000 inhabitants increased from 66 in 2007 to 172 in 2017 (increase 10 procedures per year, 95% CI 8.6-12.3, P < 0.01) There was a significant increase (by 141 per year, 95% CI 110-174, P < 0.01) for open revascularizations (2705 operations in 2007, 3992 operations in 2017) and (by 491 per year, 95% CI 433-550, P < 0.01) for endovascular revascularizations (791 in 2007-5514 in 2017). Open aorto-iliac segment revascularization decreased, whereas the numbers of procedures increased for all other arterial segments. The overall frequency of amputations was 18-20 per 100,000. The frequency of amputations in the subpopulation over 65 years old decreased from 93 in 2007 to 72 in 2017 (P < 0.01).

CONCLUSION

The present study demonstrated increases in vascular surgery procedures over the 11-year study-period. The increase was greatest for endovascular procedures. During the same period, there was a significant decrease in the frequency of major LEAs in the >65-year-old subpopulation.

Raising the bar for appropriateness in the care of patients with peripheral artery disease

Advances in endovascular therapy have exponentially increased the number of procedures performed for peripheral artery disease, but public concerns of overuse have placed the vascular community under scrutiny. The appropriateness of care has thus become a focus of discussion within several professional societies, but literature on the topic is limited. This report presents two cases of patients with peripheral artery disease, one patient who did not need revascularization and underwent an intervention and the other who required additional intervention that was not recognized owing to an incomplete diagnostic workup.

Cost-effectiveness of the treatments for critical limb ischemia in the elderly population

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.

In-hospital versus postdischarge major adverse events within 30 days following lower extremity revascularization

OBJECTIVE

Studies using hospital discharge data likely underestimate postoperative morbidity and mortality after lower extremity revascularization because they fail to capture postdischarge events. However, the degree of underestimation and the timing of postdischarge complications are not well-characterized.

METHODS

We used the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted vascular databases from 2011 to 2015 to tabulate 30-day adverse events (in hospital and after discharge) for lower extremity bypass (LEB) and percutaneous vascular interventions (PVIs) performed for claudication and chronic limb-threatening ischemia (CLTI).

RESULTS

A total of 14,125 patients underwent lower extremity revascularization, 8909 patients (63%) with LEB and 5216 (37%) with PVI. For CLTI, total 30-day mortality was similar between PVI and LEB (2.3% vs 2.1%; P = .61), but in-hospital deaths only accounted for 43% of PVI mortality and only 65% of LEB mortality (P ≤ .001). Major adverse cardiac events occurred in 2.9% of PVI patients and 4.6% of LEB patients (P < .001), with postdischarge events accounting for 37% of PVI events and 18% of LEB (P ≤ .001). Although the 30-day reoperation rates were 14% for PVI and 18% for LEB (P < .001), almost one-half occurred after discharge (PVI 46% vs LEB 44%; P = .55). Any postoperative major adverse events (MAEs) occurred in 22% of patients after PVI and 31% after LEB, with more than one-half occurring after discharge (PVI 56% vs LEB 53%; P = .17). For claudicants, total 30-day mortality was 0.4% for PVI and 0.7% for LEB (P = .32), with the vast majority of events occurring after discharge (PVI 90% vs LEB 50%; P = .049). The 30-day reoperation rates were 5.2% for PVI and 8.0% for LEB (P < .001), with more than one-half occurring after discharge (PVI 63% vs LEB 53%; P = .09). Any MAEs occurred in 7.0% of patients after PVI and 17% after bypass, with the majority occurring after discharge (PVI 65% vs LEB 63%; P = .66).

CONCLUSIONS

Most MAEs occur less frequently after PVI than LEB. However, a significant number of major of adverse events after lower extremity revascularization occur after leaving the hospital, especially after PVI, which may overestimate its benefits compared with LEB if only in-hospital data are evaluated. These data demonstrate the importance of reporting 30-day rather than in-hospital outcomes when evaluating postoperative adverse events.

Percutaneous Vascular Interventions Versus Bypass Surgeries in Patients With Critical Limb Ischemia: A Comprehensive Meta-analysis

OBJECTIVE

The aim of our study was to compare percutaneous vascular interventions (PVI) versus bypass surgeries (BSX) in patients with critical limb ischemia (CLI).

BACKGROUND

Previous relevant reviews with limited numbers of included studies did not strictly confine the inclusion criteria to CLI, also involving patients with severe claudication, which may introduce bias in the decision-making of CLI revascularization. Current treatment strategies for CLI still remain controversial.

METHODS

We performed a meta-analysis of all available randomized controlled trials and observational clinical studies comparing PVI with BSX in CLI patients. Primary endpoints included overall survival, amputation-free survival, 30-day mortality, and major adverse cardiovascular and cerebrovascular events.

RESULTS

We identified 45 cohorts and 1 RCT in over 20,903 patients. In overall population, PVI reduced the risks of 30-day mortality [odds ratio (OR) 0.69, 95% confidence interval (CI) 0.51-0.95), major adverse cardiovascular and cerebrovascular events (OR 0.42, 95% CI 0.29-0.61), and surgical site infection (OR 0.31, 95% CI 0.19-0.51), but increased the risks of long-term all-cause mortality [hazard ratio (HR) 1.16, 95% CI 1.05-1.27) and primary patency failure (HR 1.31, 95% CI 1.08-1.58). When compared with autogenous BSX, PVI was also associated with additional increased risks of long-term death or amputation (HR 1.41, 95% CI 1.02-1.94) and secondary patency failure (HR 1.51, 95% CI 1.17-1.95). In patients with infrapopliteal lesions, we found PVI had inferior primary patency (HR 1.39, 95% CI 1.10-1.75) compared with BSX.

CONCLUSION

For patients in good physical condition with long life-expectancy, BSX may represent a better choice compared with PVI, particularly when autogenous bypass is available. While enhanced perioperative care for cardiovascular events and surgical site should be considered in patients underwent BSX to achieve comparable short-term outcomes provided by PVI.

Endovascular treatment of diabetic peripheral arterial disease in older and oldest old patients: a retrospective study

BACKGROUND

Peripheral arterial disease (PAD) is frequent among older diabetic patients, but the evidence about endovascular revascularization is very limited.

METHOD

We retrospectively analyzed data collected from 120 diabetic patients consecutively admitted to a Diabetic Foot Clinic, including 64 patients aged 65-79 years and 56 patients aged 80 or more.

RESULTS

Percutaneous transluminal angioplasty (PTA) was followed by technical success in 82.5% of older patients and 62.5% of oldest old ones (p = 0.05). No significant difference was observed in regards to complete re-epithelization (76.6 vs 76.8%, p = 0.820), recurrent stenosis (26.6 vs 19.6%, p = 0.371), intra- or post-procedure complications (21.9 vs 10.7%, p = 0.102), and amputations (12.5 vs 5.4%, p = 0.176).

DISCUSSION

Our findings suggest that older and oldest old patients with diabetic foot and critical ischemia could be effectively and safely treated with PTA.

Efficacy Outcomes of Endovascular Versus Surgical Revascularization in Critical Limb Ischemia: Results From a Prospective Cohort Study

Data on efficacy outcomes of endovascular versus surgical revascularization in patients with critical limb ischemia (CLI) in contemporary practice are limited. In this prospective cohort study, 353 consecutive patients with CLI were enrolled and allocated to endovascular (PTA [percutaneous transluminal angioplasty]), surgical (SURG), or no revascularization (No REVASC) after interdisciplinary consensus. Outcome measures were sustained primary clinical success (sPCS; survival without major amputation, repeated target extremity revascularization, and freedom from CLI), limb salvage, and amputation-free survival. Propensity-matched Kaplan-Meier analyses and stratified log-rank tests were performed. The PTA, SURG, and No REVASC groups consisted of 264, 62, and 27 patients, respectively. Compared to SURG patients, PTA patients were significantly older, had more risk factors, and more often had ischemic lesions. Propensity score-adjusted analyses showed no significant differences: sPCS was 51.3%/52.2%, limb salvage rate 91.5%/93.7%, and major amputation-free survival 90.5%/87.2% at 12 months for PTA and SURG, respectively. Amputation-free survival for the No REVASC group was 69% at 12 months. In conclusion, endovascular and surgical revascularization in CLI has comparable efficacy outcomes after 12 months. Contemporary overall outcome of patients with CLI is considerably better compared to earlier studies.

Predictive Parameters for Clinical Outcome in Patients with Critical Limb Ischemia Who Underwent Percutaneous Transluminal Angioplasty (PTA): A Systematic Review

Purpose

To identify possible risk factors in predicting clinical outcome in critical limb ischemia (CLI) patients undergoing percutaneous transluminal angioplasty (PTA).

Materials and Methods

PubMed and EMBASE were searched for studies analyzing CLI and clinical outcome after PTA from January 2006 to April 2017. Outcome measures were ulcer healing, amputation free survival (AFS)/limb salvage and overall survival. Data on predictive factors for ulcer healing, AFS/limb salvage and survival were extracted.

Results

Ten articles with a total of 2448 patients were included, all cohorts and based on prospective-designed databases. For ulcers, it seems that complete healing can be achieved in most of the patients within 1 year. No significant predictive factors were found. AFS/limb salvage: AFS rates for 1, 2 and 3 years ranged from 49.5 to 75.2%, 37 to 58% and 22 to 59%, respectively. Limb salvage rates for 1, 2 and 3 years ranged from 71 to 95%, 54 to 93.3% and 32 to 92.7%, respectively. All studies had different univariate and multivariate outcomes for predictive factors; however, age and diabetes were significant predictors in at least three studies. Survival: Survival rates for 1, 2 and 3 years ranged from 65.4 to 91.5%, 45.7 to 76% and 37.3 to 83.1%, respectively. Different predictive factors were found; however, age was found in 2 out of 5 studies reporting on predictive factors.

Conclusions

In several studies two factors, age and diabetes, were found as predictive factors for AFS/limb salvage and survival in patients with CLI undergoing PTA. Therefore, we believe that these factors should be taken into account in future research.

Level of Evidence

Level 2a.

Patient selection and perioperative outcomes of bypass and endovascular intervention as first revascularization strategy for infrainguinal arterial disease

OBJECTIVE

The optimal initial revascularization strategy remains uncertain for patients with peripheral arterial disease. The purpose of this study was to evaluate current nationwide selection and perioperative outcomes of patients undergoing bypass or endovascular intervention for infrainguinal disease in those with no prior ipsilateral revascularization.

METHODS

Patients undergoing nonemergent first-time infrainguinal revascularization were identified in the Targeted Vascular module of the National Surgical Quality Improvement Program (NSQIP) for 2011 to 2014 and stratified by symptom status (chronic limb-threatening ischemia [CLTI] or claudication). Patients treated with endovascular intervention were compared with those who underwent bypass. Multivariable logistic regression was used to evaluate current selection of patients and to establish independent associations between first-time procedures and postoperative outcomes.

RESULTS

Of 5998 first-time infrainguinal revascularizations performed, 3193 were bypass procedures (63% for CLTI) and 2805 were endovascular interventions (64% for CLTI). Current patient characteristics associated with an endovascular-first approach as opposed to bypass-first in CLTI patients were age ≥80 years, tissue loss, nonsmoking, functional dependence, diabetes, dialysis, and tibial lesions, whereas age ≥80 years, nonwhite race, nonsmoking, diabetes, and tibial lesions were associated with an endovascular approach for claudication. In comparing first-time endovascular intervention with bypass, there was no difference in 30-day mortality in CLTI patients (univariate: 2.1% vs 2.2%; adjusted: odds ratio [OR], 0.7; 95% confidence interval [CI], 0.4-1.1) or claudication patients (0.3% vs 0.6%). Among CLTI patients, endovascular-first intervention was associated with lower rates of major adverse cardiovascular event (3.6% vs 4.7%; OR, 0.6; 95% CI, 0.4-0.9), surgical site infection (0.9% vs 7.7%; OR, 0.1; 95% CI, 0.1-0.2), bleeding (8.5% vs 17%; OR, 0.4; 95% CI, 0.3-0.5), unplanned reoperation (13% vs 17%; OR, 0.7; 95% CI, 0.5-0.8), and unplanned readmission (17% vs 18%; OR, 0.8; 95% CI, 0.7-0.9). Patients with claudication undergoing endovascular-first intervention also had lower rates of major adverse cardiovascular event (0.8% vs 1.6%; OR, 0.4; 95% CI, 0.2-0.95), surgical site infection (0.7% vs 6.6%; OR, 0.1; 95% CI, 0.04-0.2), bleeding (2.3% vs 6.0%; OR, 0.3; 95% CI, 0.2-0.5), unplanned reoperation (4.3% vs 6.6%; OR, 0.6; 95% CI, 0.4-0.9), and unplanned readmission (5.9% vs 9.0%; OR, 0.6; 95% CI, 0.4-0.8). Conversely, endovascular-first intervention was associated with a higher rate of secondary revascularizations within 30 days for CLTI (4.3% vs 3.1%; OR, 1.6; 95% CI, 1.04-2.3) but not for claudication (2.6% vs 1.9%; OR, 1.7; 95% CI, 0.9-3.4).

CONCLUSIONS

An endovascular-first approach as a revascularization strategy for infrainguinal disease was associated with substantially lower early morbidity but not mortality, at the cost of higher rates of postoperative secondary revascularizations. As a national representation of first-time revascularizations, this study highlights the early endovascular perioperative benefit, although more robust long-term data are needed to adopt either one strategy or the other in select patients with peripheral arterial disease.

Life Expectancy in Nonagenarians Suffering from Critical Limb Ischemia

BACKGROUND

Peripheral arterial disease has become an increasing problem in the aging population of the western world with a prevalence of 10-14%. This will result in a growing group of nonagenarians being referred to vascular surgeons, with an estimated growth of 2.5 times the number of nonagenarians between 2015 and 2040. Outcome results of nonagenarians suffering from critical limb ischemia (CLI) are scarce, which can cause difficulties in choosing superior therapy options. We propose that the life expectancy of nonagenarians suffering CLI compared to the overall population of nonagenarians is valuable information required in clinical decision-making.

METHODS

Between January 2012 and October 2015, all patients suffering from CLI were retrospectively reviewed in the Amphia Hospital, Breda, The Netherlands. Patients aged ≥90 years at admission were exclusively included. The main outcome result of this study is the life expectancy of nonagenarians suffering from CLI. Closely related to life expectancy is the primary end point of mortality. Secondary end points were adverse events, reoperations, and limb salvage.

RESULTS

A total of 36 patients were included in this study of which 27 were women. The median age was 92 years. Conservative therapy was performed in 61% of the patients. Based on 24 deaths (of which 19 were women), the mortality rate ratio of the study group relative to the Dutch population was 3.13 (95% confidence interval [CI], 2.00-4.66; P < 0.000001), adjusted for age and gender. Life expectancy in years of the total Dutch population at age 90 years in 2013 was 3.83 for men and 4.54 for women in contrast to, respectively, 1.23 (95% CI, 0.50-5.69) and 2.70 (95% CI, 1.76-3.74) years in our patient group.

CONCLUSIONS

CLI is a severe disease in nonagenarians with a dreadful life expectancy of 1.23 and 2.7 years for men and women, respectively, corresponding with an age- and gender-adjusted mortality rate ratio of 3.13 relative to the Dutch population. Individual factors such as preoperative status, arterial occlusive lesion, and especially predicted postoperative quality of life are important parameters in clinical decision-making. Results of conservative therapy might be acceptable in selected patients, but more focus on quality of life is needed to be conclusive.

Below-The-Knee Angioplasty for Critical Limb Ischemia: Results of a Series of 157 Procedures and Impact of the Angiosome Concept

BACKGROUND

To evaluate the long-term clinical results of below-the-knee percutaneous transluminal angioplasty (BTK-PTA) with or without stenting, in patients with critical limb ischemia (CLI), and to determine factors affecting clinical results including the role of the angiosome concept.

METHODS

All patients undergoing primary BTK-PTA from January 2007 to December 2011 were included. Primary patency, assisted patency, limb salvage, survival, and wound healing were assessed using the Kaplan-Meier method. Predictors of patency, limb salvage, survival, and wound healing, including the role of the angiosome theory, were determined using multivariate models.

RESULTS

A total of 157 procedures were performed in 139 patients with CLI (Rutherford IV 10.8%; Rutherford V-VI 89.2%). Mean age was 74.2 years and 68.3% were men; 60% had diabetes and 31% renal insufficiency. PTA was confined to the infrapopliteal segment alone in 53.5% of cases. Technical success was 87.9%. Stents were placed in 42.6% of cases. The mean follow-up was 14.7 months (range, 1-67 months). Four-year primary and secondary patency were 51% and 61%, respectively. Limb salvage at 4 years was 68.8%. Complete wound healing was 52% at 4 years. Positive predictors of survival were the absence of renal insufficiency (P < 0.0001) and technical success (P = 0.029). Target vessel occlusion of >50% was a negative predictor of limb salvage (P = 0.0072). Positive predictors of wound healing were technical success (P = 0.0067), the absence of renal insufficiency (P < 0.0001) and continuity between a leg artery and a foot artery (P = 0.02).

CONCLUSIONS

BTK-PTA can be performed with favorable long-term results in patients with limited longevity. Secondary interventions may be necessary to maintain target vessel patency. In our experience, the angiosome concept had no impact on clinical success.

Immediate results and long-term cardiovascular outcomes of endovascular therapy in octogenarians and nonoctogenarians with peripheral arterial diseases

Purpose

To investigate the clinical outcomes of endovascular therapy (EVT) in octogenarians and nonoctogenarians with peripheral arterial disease.

Methods

A retrospective analysis of 511 patients (654 affected legs) who underwent EVT between July 2005 and December 2013 was conducted in a prospectively maintained database. Immediate results and long-term vascular outcomes were analyzed and compared between octogenarians and nonoctogenarians.

Results

Octogenarians were more likely to be female and have atrial fibrillation (AF), whereas nonoctogenarians had higher rates of obesity, claudication, and medical comorbidities. There were no differences in the rates of EVT success, 30-day major adverse vascular events, and 6-month functional improvement between groups. Over the 10-year follow-up period, the rates of 3-year limb salvage, sustained clinical success, freedom from major cerebrovascular and cardiovascular events, and composite vascular events were similar between groups, but the survival rate was better in nonoctogenarians than in octogenarians (73% vs 63%, respectively, P=0.004). In Cox regression analysis, dependence on dialysis and AF were significant predictors of death (odds ratio [OR] 4.44 in dialyzed and 2.83 in AF patients), major cerebrovascular and cardiovascular events (OR 3.49 and 2.45), and composite vascular events (OR 3.14 and 2.25).

Conclusion

EVT in octogenarians was feasible, without an increased risk of periprocedural complications. The rates of limb salvage, sustained clinical success, and long-term vascular events were comparable between groups. Dialysis dependence and AF are independent predictors for poor prognosis in patients with peripheral arterial disease. However, these observations require further confirmation in larger scale studies.

[Endovascular versus conventional vascular surgery--old-fashioned thinking? Part 2: carotid artery stenosis and peripheral arterial occlusive disease]

Endovascular therapy has widely replaced conventional open vascular surgical reconstruction. For this reason, both techniques were widely considered to be competing approaches. Evidence-based data from randomized prospective trials, meta-analyses and clinical registries, however, demonstrated that both techniques should be used to complement each other. It became increasingly more evident that the use of either procedure depends on the underlying disease and the anatomical conditions, whereby a combination of both (hybrid approach) may be the preferred option in certain situations. This review focuses on the treatment of patients with carotid artery stenosis, intermittent claudication, critical limb ischemia and acute limb ischemia.

Comparison between superficial femoral artery stenting and bypass surgery in severe lower-limb ischaemia: a retrospective study

BACKGROUND

Symptomatic femoro-popliteal disease is treated by bypass surgery or angioplasty with or without stenting. The aim of this study was to compare the results of stenting and bypass surgery with regard to limb salvage in patients with severe leg ischaemia.

METHODS

A total of 213 patients with femoro-popliteal disease presenting with severe claudication or critical limb ischaemia between January 2009 and December 2013 were evaluated; 118 patients (139 limbs) had stents placed and 95 patients (104 limbs) had bypass surgery. Most (60%) presented with critical limb ischaemia (rest pain 40%, tissue necrosis 20%), and the remainder with severe claudication. The treatment groups had matching risk factors.

RESULTS

The average age was 66 years and 73% were male. Tissue necrosis was found in 26% of the stent group and 12% of the bypass group (p = 0.009). In the stent group 26% had adjunctive procedures, compared to 16% in the bypass group (p = 0.138). During the one-year follow up, there were 30 stent occlusions (22%) and 18 graft occlusions (17%) (p = 0.42). There were 14 major amputations (10%) in the stent group, and 13 (13%) in the bypass group (p = 0.68). Limb salvage rate was 90% in the stent group, and 88% in the bypass group (p = 0.68). There were no peri-operative deaths in the stent group, but one in the bypass group (1%). One-year mortality rate was equal (8%) in both groups (p = 1.00).

CONCLUSION

One-year outcome was comparable in both groups with regard to mortality, stent or graft patency and limb salvage rates.

Safety and effectiveness of endovascular therapy for claudication in octogenarians

BACKGROUND

Advanced age (≥ 80 years) has been associated with adverse outcomes after lower extremity bypass for critical limb ischemia (CLI), but endovascular therapy (ET) is reported to have comparable safety across age groups. Here, we assess the safety and effectiveness of advanced age on outcomes after ET for lifestyle-limiting intermittent claudication (IC).

METHODS

A retrospective review of a prospectively maintained institutional database (2007-2012) identified all patients undergoing ET for IC. Demographics, procedural details, and outcomes were assessed via univariate analysis and multivariate Cox regression. Effectiveness was assessed across a panel of outcome metrics including the following: overall survival, freedom from major adverse limb event (MALE), and freedom from reintervention, amputation, or restenosis (RAS). Freedom from MALE + perioperative death (MALE + POD) was the primary safety end point.

RESULTS

Two hundred thirty-six patients underwent primary ET for 284 affected limbs. Of these, 46 interventions (16%) were performed in patients ≥ 80 years old. The average age of octogenarians treated was 84.4 years compared with 67.4 years among those aged <80 (P < 0.001). Compared with younger claudicants, octogenarians were less likely to have hypercholesterolemia (43.5% vs. 63.9%, P = 0.01) and more likely to deny a history of smoking (41.3% vs. 14.7%, P < 0.001). Octogenarians were also more likely to undergo interventions involving the popliteal artery (50% vs. 31.9%, P = 0.03). There were no other significant differences in demographics, comorbidities, TransAtlantic Inter-Society Consensus II classification, or treated arterial segment. Thirty-day freedom from MALE + POD was 100% in octogenarians and 99.6% in patients <80 years, with no difference between age groups. There were no differences in freedom from MALE, freedom from RAS, or overall survival at 1- and 3-year follow-up.

CONCLUSIONS

Although age >80 years has been identified as an independent risk factor for poor outcomes in the surgical treatment of CLI, our results suggest that ET for selected octogenarians with lifestyle-limiting claudication is as safe and effective as ET in younger patients. Advanced age alone should not prohibit consideration of ET for patients with IC.

Economic evaluations of guideline-based or strategic interventions for the prevention or treatment of chronic wounds

BACKGROUND

Costs of chronic wound care are significant, but systematic reviews of cost-effectiveness studies regarding guideline-based or strategic interventions are scarce.

OBJECTIVES

Our objectives were to assess/compare the cost effectiveness of new interventions/systems designed to improve the prevention/treatment of chronic wounds in adult populations against current care and provide decision makers with information on which to base future interventions for chronic wound management.

DATA SOURCES

Data sources included PubMed, Scopus, HTA, and NHS EED.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

We included comparative health economic evaluations of interventions published in English designed to prevent or treat adult chronic wounds that were guideline-based or strategic in nature and from which an incremental cost-effectiveness ratio or incremental net health benefit was reported or could be calculated.

STUDY APPRAISAL AND SYNTHESIS METHODS

Study and model characteristics and outcomes were extracted into pre-designed tables. Quality assessment of studies was based on literature-reported methods. Studies were assigned strength of evidence ratings and recommendation level for decision makers.

RESULTS

A total of 16 health economic evaluations were included, of which ten were trial based and six were wholly model based. Only three studies had high, and five studies moderate, strength of evidence and were recommended for decision makers. All studies had some shortcomings regarding time horizon, costs, effectiveness units, and methodological reporting. Two studies had major flaws.

LIMITATIONS

Limitations include missed studies published in non-English languages or not cited in searched databases; judgment bias in assessing studies.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Few well conducted cost-effectiveness studies exist to guide decision makers regarding guideline-based or strategic interventions for chronic wounds.

Therapeutic approach to CLI with tissue loss--a comparative prospective cohort study in Finland and Japan

BACKGROUND

To compare the demographics, chosen treatment options, and 1-year outcome of patients with severe critical limb ischemia (Fontaine IV) in 2 different patient cohorts.

METHODS

A total of 118 consecutive patients with an ischemic tissue lesion in a lower extremity referred for the first time to the vascular surgery outpatient clinic of Helsinki University Hospital and 96 patients referred to the Division of Vascular Surgery of the Tokyo Medical and Dental University Hospital were included in this comparative analysis. Kaplan-Meier estimates were used to assess survival, leg salvage, and amputation-free survival (AFS). Propensity score analysis was used to adjust for differences between the study groups.

RESULTS

The median age of the study cohorts was greater in Finland than in Japan (80 vs. 69 years, P < 0.001). The prevalence of coronary artery disease and hypertension were greater in the Finnish cohort (72% vs. 41%, P < 0.001 and 86% vs. 51%, P < 0.001, respectively). The prevalence of male gender (77% vs. 42%, P < 0.001), cerebrovascular disease (35% vs. 20%, P = 0.015), end-stage renal disease (35% vs. 5%, P < 0.001), and current smoking (64% vs. 21%, P < 0.001) was greater in the Japanese cohort. The prevalence of diabetes did not differ between the cohorts (52% vs. 47%, P = 0.286). The proportion of independently ambulant patients at referral was greater in Finland (80% vs. 54%, P < 0.001). In Helsinki and Tokyo, the initial treatment was bypass, an endovascular procedure, conservative treatment, and amputation in 42% vs. 41%, 24% vs. 14%, 24% vs. 41%, and 10% vs. 5% of the cases, respectively. One-year survival, leg salvage, and AFS were 65% vs. 71% (P = 0.326), 82% vs. 74% (P = 0.216), and 59% vs. 55% (P = 0.573) in the Finnish and Japanese cohorts, respectively. AFS was significantly better in ambulant than in nonambulant patients in the combined data (68% vs. 36%, P < 0.001). Adjusted propensity score analysis showed no statistical difference in survival between the study cohorts.

CONCLUSIONS

The pattern of comorbid conditions in these 2 patient cohorts is significantly different, but the outcome did not differ significantly between cohorts.

Comparison of above-the-knee prosthetic femoro-popliteal bypass versus percutaneous transluminal angioplasty and stenting for treatment of occlusive superficial femoral artery disease

Background and Aims:

Treatment of occlusive femoro-popliteal artery disease has changed during the last decade because of intensive development of endovascular technology. The aim of this study was to evaluate patient treated endovascularly or surgically for femoro-popliteal atherosclerotic lesions and to assess perioperative and mid-term outcome.

Material and Methods:

This is a retrospective analysis of consecutive patients who had undergone prosthetic above-the-knee femoro-popliteal bypass or percutaneous transluminal angioplasty and stenting of superficial femoral artery stenosis or occlusion at Tampere University Hospital, Finland, between January 2007 and December 2009. Patients who were alive were re-evaluated in 2010. Primary and secondary patency and outcomes were assessed.

Results:

A total of 131 patients were treated; surgically 63 patients (69 procedures) and endovascularly 68 patients (74 procedures). The mean follow-up time was 17 months (SD ± 13 months). In the late follow-up visit, 8 (18%) patients in the bypass group suffered from claudication and 9 (20%) from critical limb ischemia. The corresponding figures for the endovascular group were 20 (36%) and 8 (20%), respectively. The primary patency was 60% at 2 years in the bypass group and 73% in the endovascular group (p = 0.092); the primary assisted patency was 62% versus 76%, respectively (p = 0.068). The secondary patency was 74% in the bypass group versus 79% in the endovascular group (p = 0.487).

Conclusions:

According to current results following TASC II guideline, satisfied overall mid-term results can be achieved in the treatment of superficial femoral artery atherosclerotic disease.

Meta-analysis of contemporary short- and long-term mortality rates in patients diagnosed with critical leg ischaemia

BACKGROUND

Critical leg ischaemia (CLI) has been associated with high mortality rates. There is a lack of contemporary data on both short- and long-term mortality rates in patients diagnosed with CLI.

METHODS

This was a systematic literature search for studies prospectively reporting mortality in patients diagnosed with CLI. Meta-analysis and meta-regression models were developed to determine overall mortality rates and specific patient-related factors that were associated with death.

RESULTS

A total of 50 studies were included in the analysis The estimated probability of all-cause mortality in patients with CLI was 3·7 per cent at 30 days, 17·5 per cent at 1 year, 35·1 per cent at 3 years and 46·2 per cent at 5 years. Men had a statistically significant survival benefit at 30 days and 3 years. The presence of ischaemic heart disease, tissue loss and older age resulted in a higher probability of death at 3 years.

CONCLUSION

Early mortality rates in patients diagnosed with CLI have improved slightly compared with previous historical data, but long-term mortality rates are still high.

Percutaneous transluminal angioplasty for critical limb ischemia in very elderly diabetic patients

In diabetic subjects, new less invasive therapies for critical limb ischemia (CLI) are available to obtain limb salvage. One of these is the percutaneous transluminal angioplasty (PTA), a minor surgical intervention which allows obtaining an effective revascularization, avoiding the traditional major surgery and its post-operative complications. Our case report regards a 94-year-old woman with CLI due to critical obstruction (stage IV according to Leriche's classification) of superficial femoral and popliteal arteries and infrapopliteal arteries that should have been treated by the left limb amputation considering her age, severe co-morbidities, and poor compliance. Instead of this quite common approach, our team treated the patient with PTA. This led to very good outcomes, above all in terms of pain control. PTA is able to avoid major surgery, lower intra and post-operative risks, reduce length of hospital stay, and preserve functional autonomy. Therefore, this procedure should be taken into account also for frail very elderly diabetic patients with peripheral artery disease (PAD).

The Role of Hybrid Procedures in the Management of Peripheral Vascular Disease

This paper provides a summary of up-to-date information and experience with the combined treatment of patients suffering from peripheral arterial disease (PAD) with endovascular and open surgery, performed simultaneously and in a single operating room. Hybrid intervention is reported to have good results in well-indicated groups of patients with acute and chronic limb ischemia, even with older, high-risk patients. The indications for the use of this technique remain unclear with inconsistent opinions among vascular surgeons. The indications for treatment were divided into three main groups: 1) Patients with chronic limb ischemia, 2) acute limb ischemia, and 3) occlusion of a previous vascular reconstruction. The operating techniques for the most commonly used combinations are described.

In conclusion, hybrid operating techniques are often useful when treating complex problems and multilevel disease in patients with chronic or acute lower limb ischemia. Modern vascular surgeons need to master both open and endovascular techniques, and to combine them in a creative fashion to the benefit of our patients.