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Ormaechevarria A, Vega de Céniga M, Blanco J, Yáñez L, Fernández J, Estallo L. Critical Limb Ischaemia in Octogenarians: Treatment Outcomes Compared With Younger Patients. EJVES Vasc Forum 2024; 61:36-42. [PMID: 38312331 PMCID: PMC10837062 DOI: 10.1016/j.ejvsvf.2023.12.003] [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: 04/27/2023] [Revised: 09/29/2023] [Accepted: 12/28/2023] [Indexed: 02/06/2024] Open
Abstract
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.
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Affiliation(s)
- Amaia Ormaechevarria
- Department of Angiology and Vascular Surgery, Galdakao-Usansolo University Hospital, Bizkaia, Spain
| | - Melina Vega de Céniga
- Department of Angiology and Vascular Surgery, Galdakao-Usansolo University Hospital, Bizkaia, Spain
| | - June Blanco
- Department of Angiology and Vascular Surgery, Galdakao-Usansolo University Hospital, Bizkaia, Spain
| | - Laura Yáñez
- Department of Angiology and Vascular Surgery, Galdakao-Usansolo University Hospital, Bizkaia, Spain
| | - June Fernández
- Department of Angiology and Vascular Surgery, Galdakao-Usansolo University Hospital, Bizkaia, Spain
| | - Luis Estallo
- Department of Angiology and Vascular Surgery, Galdakao-Usansolo University Hospital, Bizkaia, Spain
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Wang G, Li H, Chen B, Guo P, Zhang H. Amputation and limb salvage following endovascular and open surgery for the treatment of peripheral artery illnesses: A meta-analysis. Int Wound J 2023; 20:3558-3566. [PMID: 37328950 PMCID: PMC10588360 DOI: 10.1111/iwj.14229] [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: 04/15/2023] [Revised: 04/24/2023] [Accepted: 04/28/2023] [Indexed: 06/18/2023] Open
Abstract
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.
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Affiliation(s)
- Guohua Wang
- Department of General Surgery IIXinxiang Central HospitalXinxiangChina
| | - Huipeng Li
- Department of General Surgery IIXinxiang Central HospitalXinxiangChina
| | - Baoxing Chen
- Department of General Surgery IIXinxiang Central HospitalXinxiangChina
| | - Pengwei Guo
- Department of General Surgery IIXinxiang Central HospitalXinxiangChina
| | - Hua Zhang
- Department of General Surgery IIXinxiang Central HospitalXinxiangChina
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Li RD, Chia MC, Eskandari MK. Comprehensive Evaluation of Common Open and Endovascular Procedures and Their Relationship with Postdischarge Complications. Ann Vasc Surg 2023; 88:127-138. [PMID: 35803464 PMCID: PMC9969701 DOI: 10.1016/j.avsg.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Ruojia Debbie Li
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL
| | - Matthew C Chia
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern Medicine, Chicago, IL
| | - Mark K Eskandari
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
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Thai DQ, Lee DH, Lee WB, Hahn HM, Lee IJ. What is the impact of infrapopliteal endovascular intervention on free flap survival in diabetic foot reconstruction? J Orthop Surg Res 2021; 16:42. [PMID: 33430921 PMCID: PMC7802144 DOI: 10.1186/s13018-020-02173-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/25/2020] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Duy Quang Thai
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Dong Hwan Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Woo Beom Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Hyung Min Hahn
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Il Jae Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea.
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Wübbeke LF, Naves CCLM, Daemen JWHC, Jacobs MJ, Mees BME. 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. Eur J Vasc Endovasc Surg 2020; 60:231-241. [PMID: 32709468 DOI: 10.1016/j.ejvs.2020.04.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 03/19/2020] [Accepted: 04/21/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Lina F Wübbeke
- Department of Vascular Surgery, Maastricht University Medical Centre, the Netherlands
| | - Caroline C L M Naves
- Department of Vascular Surgery, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Jan-Willem H C Daemen
- Department of Vascular Surgery, Maastricht University Medical Centre, the Netherlands
| | - Michael J Jacobs
- Department of Vascular Surgery, Maastricht University Medical Centre, the Netherlands; European Vascular Centre, Aachen-Maastricht, Germany; European Vascular Centre, Maastricht, the Netherlands
| | - Barend M E Mees
- Department of Vascular Surgery, Maastricht University Medical Centre, the Netherlands; European Vascular Centre, Aachen-Maastricht, Germany; European Vascular Centre, Maastricht, the Netherlands.
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Tang QH, Chen J, Hu CF, Zhang XL. Comparison Between Endovascular and Open Surgery for the Treatment of Peripheral Artery Diseases: A Meta-Analysis. Ann Vasc Surg 2020; 62:484-495. [DOI: 10.1016/j.avsg.2019.06.039] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 06/18/2019] [Accepted: 06/30/2019] [Indexed: 11/17/2022]
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Nikulainen V, Helmiö P, Hakovirta H. 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. Int J Surg 2019; 72:118-125. [PMID: 31704419 DOI: 10.1016/j.ijsu.2019.10.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/27/2019] [Accepted: 10/30/2019] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Veikko Nikulainen
- Department of Vascular Surgery, Turku University Hospital, Hämeentie 11, 20521, Turku, Finland; University of Turku, Kiinanmyllynkatu 4-8, 20521, Turku, Finland.
| | - Päivi Helmiö
- Department of Vascular Surgery, Turku University Hospital, Hämeentie 11, 20521, Turku, Finland; University of Turku, Kiinanmyllynkatu 4-8, 20521, Turku, Finland
| | - Harri Hakovirta
- Department of Vascular Surgery, Turku University Hospital, Hämeentie 11, 20521, Turku, Finland; University of Turku, Kiinanmyllynkatu 4-8, 20521, Turku, Finland
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Ochoa Chaar CI, Fereydooni A, Lawrence PF, Dardik A. Raising the bar for appropriateness in the care of patients with peripheral artery disease. J Vasc Surg Cases Innov Tech 2019; 5:345-349. [PMID: 31334415 PMCID: PMC6614600 DOI: 10.1016/j.jvscit.2019.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/14/2019] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Cassius Iyad Ochoa Chaar
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | | | - Peter F. Lawrence
- Section of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Calif
| | - Alan Dardik
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
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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: 0.8] [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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Klaphake S, de Leur K, Thijsse W, Ho GH, de Groot HG, Veen EJ, Haans DH, van der Laan L. Reinterventions after Endovascular Revascularization in Elderly Patients with Critical Limb Ischemia: An Observational Study. Ann Vasc Surg 2018; 53:171-176. [DOI: 10.1016/j.avsg.2018.04.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/01/2018] [Accepted: 04/11/2018] [Indexed: 11/16/2022]
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Venermo M. Nonagenarians will be the Future Challenge for Vascular Specialists. Eur J Vasc Endovasc Surg 2018; 56:689. [PMID: 30287209 DOI: 10.1016/j.ejvs.2018.08.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 08/31/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Maarit Venermo
- Helsinki University Hospital and University of Helsinki, Finland.
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Liang P, Li C, O'Donnell TFX, Lo RC, Soden PA, Swerdlow NJ, Schermerhorn ML. In-hospital versus postdischarge major adverse events within 30 days following lower extremity revascularization. J Vasc Surg 2018; 69:482-489. [PMID: 30301689 DOI: 10.1016/j.jvs.2018.06.207] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/16/2018] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Chun Li
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Ruby C Lo
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Wang J, Shu C, Wu Z, Zhao J, Ma Y, Huang B, Yuan D, Yang Y, Bian H, He Y, Wang Z. Percutaneous Vascular Interventions Versus Bypass Surgeries in Patients With Critical Limb Ischemia: A Comprehensive Meta-analysis. Ann Surg 2018; 267:846-857. [PMID: 28654542 DOI: 10.1097/sla.0000000000002344] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Jiarong Wang
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Chi Shu
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Zhoupeng Wu
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yukui Ma
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Bin Huang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yi Yang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - He Bian
- Department of Statistics, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Yazhou He
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
- Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Evaluation of paramalleolar and inframalleolar bypasses in dialysis- and nondialysis-dependent patients with critical limb ischemia. J Vasc Surg 2018; 67:826-837. [DOI: 10.1016/j.jvs.2017.07.116] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/14/2017] [Indexed: 11/21/2022]
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15
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Gatti C, Cecchini S, Fabbietti P, Romagnoli F, Ricci S. Endovascular treatment of diabetic peripheral arterial disease in older and oldest old patients: a retrospective study. Aging Clin Exp Res 2018; 30:205-207. [PMID: 28584901 DOI: 10.1007/s40520-017-0760-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 04/10/2017] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Cristina Gatti
- Diabetic Foot Clinics, National Institute of Health and Science on Aging (INRCA), Ancona, Italy.
| | - Sara Cecchini
- Unit of Radiology, National Institute of Health and Science on Aging (INRCA), Ancona, Italy
| | - Paolo Fabbietti
- Laboratory of Studies and Research in Biostatistics, National Institute of Health and Science on Aging (INRCA), Ancona, Italy
| | - Fabio Romagnoli
- Diabetic Foot Clinics, National Institute of Health and Science on Aging (INRCA), Ancona, Italy
| | - Stefano Ricci
- Unit of Radiology, National Institute of Health and Science on Aging (INRCA), Ancona, Italy
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Schindewolf M, Fuss T, Fink H, Gemperli A, Haine A, Baumgartner I. Efficacy Outcomes of Endovascular Versus Surgical Revascularization in Critical Limb Ischemia: Results From a Prospective Cohort Study. Angiology 2018; 69:677-685. [PMID: 29355026 DOI: 10.1177/0003319717750486] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Marc Schindewolf
- 1 Department of Clinical and Interventional Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Torsten Fuss
- 1 Department of Clinical and Interventional Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hanspeter Fink
- 1 Department of Clinical and Interventional Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Armin Gemperli
- 2 Department of Clinical Research, Clinical Trials Unit Bern, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,3 Swiss Paraplegic Research, Nottwil, Switzerland.,4 Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland
| | - Axel Haine
- 1 Department of Clinical and Interventional Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Iris Baumgartner
- 1 Department of Clinical and Interventional Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Klaphake S, de Leur K, Mulder PG, Ho GH, de Groot HG, Veen EJ, van der Laan L. Life Expectancy and Outcome of Different Treatment Strategies for Critical Limb Ischemia in the Elderly Patients. Ann Vasc Surg 2018; 46:241-248. [DOI: 10.1016/j.avsg.2017.06.141] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/20/2017] [Accepted: 06/25/2017] [Indexed: 10/19/2022]
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18
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Dinga Madou I, Slade MD, Orion KC, Sarac T, Ochoa Chaar CI. The Impact of Functional Status on the Outcomes of Endovascular Lower Extremity Revascularization for Critical Limb Ischemia in the Elderly. Ann Vasc Surg 2017. [DOI: 10.1016/j.avsg.2017.06.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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19
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Schreuder SM, Hendrix YMGA, Reekers JA, Bipat S. Predictive Parameters for Clinical Outcome in Patients with Critical Limb Ischemia Who Underwent Percutaneous Transluminal Angioplasty (PTA): A Systematic Review. Cardiovasc Intervent Radiol 2017; 41:1-20. [PMID: 28924874 PMCID: PMC5735197 DOI: 10.1007/s00270-017-1796-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 09/06/2017] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Sanne M Schreuder
- Department of Radiology and Nuclear Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Yvette M G A Hendrix
- Department of Radiology and Nuclear Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jim A Reekers
- Department of Radiology and Nuclear Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Shandra Bipat
- Department of Radiology and Nuclear Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Siracuse JJ, Farber A. Is Open Vascular Surgery or Endovascular Surgery the Better Option for Lower Extremity Arterial Occlusive Disease? Adv Surg 2017; 51:207-217. [PMID: 28797341 DOI: 10.1016/j.yasu.2017.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, 88 East Newton Street, Boston, MA 02118, USA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, 88 East Newton Street, Boston, MA 02118, USA.
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21
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Patient selection and perioperative outcomes of bypass and endovascular intervention as first revascularization strategy for infrainguinal arterial disease. J Vasc Surg 2017; 67:206-216.e2. [PMID: 28844467 DOI: 10.1016/j.jvs.2017.05.132] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 05/31/2017] [Indexed: 12/15/2022]
Abstract
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.
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Uhl C, Steinbauer M, Torsello G, Bisdas T, Adili F, Balzer K, Billing A, Böckler D, Brixner D, Debus SE, Eckstein HH, Florek HJ, Gkremoutis A, Grundmann R, Hupp T, Hwang SW, Keck T, Wojciech K, Lang W, May B, Meyer A, Mühling B, Oberhuber A, Reinecke H, Reinhold C, Ritter RG, Schelzig H, Schlensack C, Schmitz-Rixen T, Schulte KL, Spohn M, Stavroulakis K, Storck M, Trede M, Weis-Müller B, Wenk H, Zeller T, Zhorzel S, Zimmermann A. Outcomes After Endovascular Revascularization in Octogenarians and Non-Octogenarians With Critical Limb Ischemia. J Endovasc Ther 2017; 24:471-477. [DOI: 10.1177/1526602817711424] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Christian Uhl
- Department of Vascular Surgery, Barmherzige Brueder Hospital, Regensburg, Germany
| | - Markus Steinbauer
- Department of Vascular Surgery, Barmherzige Brueder Hospital, Regensburg, Germany
| | - Giovanni Torsello
- Department of Vascular Surgery, University Clinic of Münster, Germany
- Department of Vascular Surgery, St Franziskus Hospital GmbH, Münster, Germany
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Noronen K, Saarinen E, Albäck A, Venermo M. Analysis of the Elective Treatment Process for Critical Limb Ischaemia with Tissue Loss: Diabetic Patients Require Rapid Revascularisation. Eur J Vasc Endovasc Surg 2017; 53:206-213. [DOI: 10.1016/j.ejvs.2016.10.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
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Long-term Results of Inframalleolar Bypass for Critical Limb Ischaemia. Eur J Vasc Endovasc Surg 2016; 52:815-822. [DOI: 10.1016/j.ejvs.2016.08.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 08/29/2016] [Indexed: 11/21/2022]
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25
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Meltzer AJ, Sedrakyan A, Isaacs A, Connolly PH, Schneider DB. Comparative effectiveness of peripheral vascular intervention versus surgical bypass for critical limb ischemia in the Vascular Study Group of Greater New York. J Vasc Surg 2016; 64:1320-1326.e2. [DOI: 10.1016/j.jvs.2016.02.069] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/14/2016] [Indexed: 11/16/2022]
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Gentile F, Lundberg G, Hultgren R. Outcome for Endovascular and Open Procedures in Infrapopliteal Lesions for Critical Limb Ischemia: Registry Based Single Center Study. Eur J Vasc Endovasc Surg 2016; 52:643-649. [DOI: 10.1016/j.ejvs.2016.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 07/11/2016] [Indexed: 10/21/2022]
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Steunenberg SL, Faber MJ, Raats JW, Mulder PGH, van der Laan L. Life Expectancy in Nonagenarians Suffering from Critical Limb Ischemia. Ann Vasc Surg 2016; 36:218-225. [PMID: 27427354 DOI: 10.1016/j.avsg.2016.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 03/29/2016] [Accepted: 04/05/2016] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
| | | | - Jelle W Raats
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Paul G H Mulder
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
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Pavé M, Benadiba L, Berger L, Gouicem D, Hendricks M, Plissonnier D. Below-The-Knee Angioplasty for Critical Limb Ischemia: Results of a Series of 157 Procedures and Impact of the Angiosome Concept. Ann Vasc Surg 2016; 36:199-207. [PMID: 27427347 DOI: 10.1016/j.avsg.2016.03.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/10/2016] [Accepted: 03/23/2016] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Marie Pavé
- Department of Vascular Surgery, Charles Nicolle University Hospital, Rouen, France.
| | - Laurent Benadiba
- Department of Vascular Surgery, Charles Nicolle University Hospital, Rouen, France
| | - Ludovic Berger
- Department of Vascular Surgery, Côte de Nacre University Hospital, Caen, France
| | - Djelloul Gouicem
- Department of Vascular Surgery, Côte de Nacre University Hospital, Caen, France
| | - Maxime Hendricks
- Department of Vascular Surgery, Côte de Nacre University Hospital, Caen, France
| | - Didier Plissonnier
- Department of Vascular Surgery, Charles Nicolle University Hospital, Rouen, France
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Huang HL, Jimmy Juang JM, Chou HH, Hsieh CA, Jang SJ, Cheng ST, Ko YL. Immediate results and long-term cardiovascular outcomes of endovascular therapy in octogenarians and nonoctogenarians with peripheral arterial diseases. Clin Interv Aging 2016; 11:535-43. [PMID: 27217735 PMCID: PMC4862757 DOI: 10.2147/cia.s106119] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
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.
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Affiliation(s)
- Hsuan-Li Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Jyh-Ming Jimmy Juang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsin-Hua Chou
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chien-An Hsieh
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Shih-Jung Jang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Shih-Tsung Cheng
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Lin Ko
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
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Siracuse JJ, Menard MT, Eslami MH, Kalish JA, Robinson WP, Eberhardt RT, Hamburg NM, Farber A. Comparison of open and endovascular treatment of patients with critical limb ischemia in the Vascular Quality Initiative. J Vasc Surg 2016; 63:958-65.e1. [DOI: 10.1016/j.jvs.2015.09.063] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 09/18/2015] [Indexed: 10/22/2022]
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Lejay A, Delay C, Georg Y, Schwein A, Gaertner S, Thaveau F, Geny B, Chakfe N. Endovascular Surgery, Open Surgery, and Primary Amputation in Nonagenarians Presenting with Critical Limb Ischemia. Ann Vasc Surg 2016; 32:25-33. [DOI: 10.1016/j.avsg.2015.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 10/22/2022]
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Debus ES, Manzoni D, Behrendt CA, Heidemann F, Grundmann RT. [Endovascular versus conventional vascular surgery--old-fashioned thinking? Part 2: carotid artery stenosis and peripheral arterial occlusive disease]. Chirurg 2016; 87:308-15. [PMID: 26801751 DOI: 10.1007/s00104-015-0149-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- E S Debus
- Klinik und Poliklinik für Gefäßmedizin, Universitäres Herzzentrum Hamburg, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - D Manzoni
- Klinik und Poliklinik für Gefäßmedizin, Universitäres Herzzentrum Hamburg, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - C-A Behrendt
- Klinik und Poliklinik für Gefäßmedizin, Universitäres Herzzentrum Hamburg, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - F Heidemann
- Klinik und Poliklinik für Gefäßmedizin, Universitäres Herzzentrum Hamburg, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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Islam J, Robbs JV. Comparison between superficial femoral artery stenting and bypass surgery in severe lower-limb ischaemia: a retrospective study. Cardiovasc J Afr 2015; 26:34-7. [PMID: 25784315 PMCID: PMC4814758 DOI: 10.5830/cvja-2014-074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 11/27/2014] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- J Islam
- Department of Vascular Surgery, Grey's Hospital, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa.
| | - J V Robbs
- University of KwaZulu-Natal, and Entabeni Hospital, Durban, South Africa
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Saarinen E, Vuorisalo S, Kauhanen P, Albäck A, Venermo M. The Benefit of Revascularization in Nonagenarians with Lower Limb Ischemia is Limited by High Mortality. Eur J Vasc Endovasc Surg 2015; 49:420-5. [DOI: 10.1016/j.ejvs.2014.12.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 12/23/2014] [Indexed: 10/24/2022]
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Jones DW, Siracuse JJ, Graham A, Connolly PH, Sedrakyan A, Schneider DB, Meltzer AJ. Safety and effectiveness of endovascular therapy for claudication in octogenarians. Ann Vasc Surg 2014; 29:34-41. [PMID: 25194550 DOI: 10.1016/j.avsg.2014.07.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 07/03/2014] [Accepted: 07/27/2014] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Douglas W Jones
- Department of Vascular and Endovascular Surgery, New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY.
| | - Jeffrey J Siracuse
- Department of Vascular and Endovascular Surgery, New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY
| | - Ashley Graham
- Department of Vascular and Endovascular Surgery, New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY
| | - Peter H Connolly
- Department of Vascular and Endovascular Surgery, New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY
| | - Art Sedrakyan
- Department of Public Health, New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY
| | - Darren B Schneider
- Department of Vascular and Endovascular Surgery, New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY
| | - Andrew J Meltzer
- Department of Vascular and Endovascular Surgery, New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY
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Carter MJ. Economic evaluations of guideline-based or strategic interventions for the prevention or treatment of chronic wounds. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2014; 12:373-389. [PMID: 24615160 PMCID: PMC4110411 DOI: 10.1007/s40258-014-0094-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
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.
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Affiliation(s)
- Marissa J Carter
- Strategic Solutions, Inc., 1143 Salsbury Ave, Cody, WY, 82414, USA,
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Saarinen E, Sugano N, Biancari F, Albäck A, Lepäntalo M, Inoue Y, Venermo M. Therapeutic approach to CLI with tissue loss--a comparative prospective cohort study in Finland and Japan. Ann Vasc Surg 2014; 28:1426-31. [PMID: 24530571 DOI: 10.1016/j.avsg.2014.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 01/23/2014] [Accepted: 01/23/2014] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Eva Saarinen
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland.
| | - Norihide Sugano
- Division of Vascular Surgery, Department of Surgery, Tokyo Medical and Dental University Hospital Faculty of Medicine, Tokyo, Japan
| | - Fausto Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Anders Albäck
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Mauri Lepäntalo
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Yoshinori Inoue
- Division of Vascular Surgery, Department of Surgery, Tokyo Medical and Dental University Hospital Faculty of Medicine, Tokyo, Japan
| | - Maarit Venermo
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland
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Hawkins AT, Schaumeier MJ, Smith AD, Hevelone ND, Nguyen LL. When to Call it a Day: Incremental Risk of Amputation and Death after Multiple Revascularization. Ann Vasc Surg 2014; 28:35-47. [DOI: 10.1016/j.avsg.2013.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 08/21/2013] [Accepted: 09/02/2013] [Indexed: 10/25/2022]
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Barshes NR, Kougias P, Ozaki CK, Pisimisis G, Bechara CF, Henson HK, Belkin M. Cost-effectiveness of Revascularization for Limb Preservation in Patients with Marginal Functional Status. Ann Vasc Surg 2014; 28:10-7. [DOI: 10.1016/j.avsg.2013.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 08/08/2013] [Accepted: 08/15/2013] [Indexed: 11/26/2022]
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Linnakoski H, Uurto I, Suominen V, Vakhitov D, Salenius J. Comparison of above-the-knee prosthetic femoro-popliteal bypass versus percutaneous transluminal angioplasty and stenting for treatment of occlusive superficial femoral artery disease. Scand J Surg 2013; 102:227-33. [DOI: 10.1177/1457496913501591] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
| | - I. Uurto
- Tampere University Medical School, Tampere, Finland
- Division of Vascular Surgery, Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - V. Suominen
- Tampere University Medical School, Tampere, Finland
- Division of Vascular Surgery, Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - D. Vakhitov
- Tampere University Medical School, Tampere, Finland
- Division of Vascular Surgery, Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - J. Salenius
- Tampere University Medical School, Tampere, Finland
- Division of Vascular Surgery, Department of Surgery, Tampere University Hospital, Tampere, Finland
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Rollins KE, Jackson D, Coughlin PA. Meta-analysis of contemporary short- and long-term mortality rates in patients diagnosed with critical leg ischaemia. Br J Surg 2013; 100:1002-8. [PMID: 23649310 DOI: 10.1002/bjs.9127] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2013] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- K E Rollins
- Department of Vascular Surgery, Addenbrooke's Hospital, Cambridge, UK
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Gazzaruso C, Coppola A, Collaviti S, Saluzzo CM, Furlani F, Gallotti P, Clerissi J, Solerte BS, Giustina A. Percutaneous transluminal angioplasty for critical limb ischemia in very elderly diabetic patients. Aging Clin Exp Res 2013; 25:225-8. [PMID: 23739911 DOI: 10.1007/s40520-013-0033-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 08/21/2012] [Indexed: 10/27/2022]
Abstract
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).
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Response to the letter: Lejay A, Thaveau F, Georg Y, Bajcz C, Kretz JG, Chakfé N. Autonomy following revascularisation in 80-year-old patients with critical limb ischemia. Eur J Vasc Endovasc Surg 2012;44:562-7. Eur J Vasc Endovasc Surg 2013; 45:693-5. [PMID: 23540805 DOI: 10.1016/j.ejvs.2013.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 02/15/2013] [Indexed: 11/20/2022]
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Balaz P, Rokosny S, Bafrnec J, Björck M. The Role of Hybrid Procedures in the Management of Peripheral Vascular Disease. Scand J Surg 2012; 101:232-7. [DOI: 10.1177/145749691210100402] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- P. Balaz
- Vascular and Transplant Surgery Department, IKEM Prague, Czech Republic
| | - S. Rokosny
- Vascular and Transplant Surgery Department, IKEM Prague, Czech Republic
| | - J. Bafrnec
- Vascular and Transplant Surgery Department, IKEM Prague, Czech Republic
| | - M. Björck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
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Peña-Cortés R, Sanz-Pastor N, Fernández-Samos R, Alonso-Argüeso G, Ortega-Martín J, Vaquero-Morillo F. Tratamiento de la isquemia crítica de las extremidades inferiores. Cirugía distal y endovascular. ANGIOLOGIA 2012. [DOI: 10.1016/j.angio.2012.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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de Leur K, van Zeeland MLP, Ho GH, de Groot HGW, Veen EJ, van der Laan L. Treatment for Critical Lower Limb Ischemia in Elderly Patients. World J Surg 2012; 36:2937-43. [DOI: 10.1007/s00268-012-1758-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fernández-Samos Gutiérrez R. El modelo angiosoma en la estrategia de revascularización de la isquemia crítica. ANGIOLOGIA 2012. [DOI: 10.1016/j.angio.2012.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Arvela E, Venermo M, Söderström M, Albäck A, Lepäntalo M. Outcome of Infrainguinal Single-Segment Great Saphenous Vein Bypass for Critical Limb Ischemia is Superior to Alternative Autologous Vein Bypass, Especially in Patients With High Operative Risk. Ann Vasc Surg 2012; 26:396-403. [DOI: 10.1016/j.avsg.2011.08.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 07/26/2011] [Accepted: 08/01/2011] [Indexed: 11/16/2022]
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Setacci C, de Donato G, Teraa M, Moll F, Ricco JB, Becker F, Robert-Ebadi H, Cao P, Eckstein H, De Rango P, Diehm N, Schmidli J, Dick F, Davies A, Lepäntalo M, Apelqvist J. Chapter IV: Treatment of Critical Limb Ischaemia. Eur J Vasc Endovasc Surg 2011; 42 Suppl 2:S43-59. [DOI: 10.1016/s1078-5884(11)60014-2] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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