Is infrapopliteal bypass compromised by distal origin of the proximal anastomosis?

Prospective decision analysis for peripheral vascular disease predicts future quality of life

OBJECTIVE

Decision making for peripheral vascular disease can be quite complex as a result of pre-existing compromise of patient functional status, anatomic considerations, uncertainty of favorable outcome, medical comorbidities, and limitations in life expectancy. The ability of prospective decision-analysis models to predict individual quality of life in patients with lower extremity arterial occlusive disease was tested.

METHODS

This was a prospective cohort study. The settings were university and Veterans Administration vascular surgery practices. All 214 patients referred with symptomatic lower extremity arterial disease of any severity over a 2-year period were screened, and 206 were enrolled. A Markov model was compared with standard clinical decision-making. Utility assessment and generalized (Short Form-36; SF-36) and disease-specific (Walking Impairment Questionnaire; WIQ) quality of life were derived before treatment. Estimates of treatment outcome probabilities and intended and actual treatment plans were provided by attending vascular surgeons. The main outcome measures were generalized (SF-36) and disease-specific (WIQ) variables at study entry and at 4 and 12 months.

RESULTS

Primary intervention consisted of amputation for 9, bypass for 42, angioplasty for 8, and medical treatment for 147 patients. Considering all patients, no improvement in mean overall patient quality of life measured by the SF-36 Physical Component Score (27 +/- 8 vs 28 +/- 8; P = .87) or WIQ (39 +/- 22 vs 39 +/- 23; P = .13) was noted 12 months after counseling and treatment by the vascular surgeons. Individually considered SF-36 categories were improved only for Bodily Pain (40 +/- 23 vs 49 +/- 25; P = .03), with the most significant improvement observed among patients with the most severe pain (68 +/- 25 vs 37 +/- 23; P = .02) and among those undergoing bypass (60 +/- 29 vs 31 +/- 22; P = .02). It is noteworthy that when the treatment chosen was incongruent with the Markov model, patients were more likely to report a poorer quality of life at 1 year (Physical Component Score, 25 +/- 8 vs 29 +/- 8; P < .001). The quality of life predicted at baseline by the Markov model correlated positively with the Physical Component Score (r = 0.23), Bodily Pain (r = 0.33), and Fatigue (r = 0.44) and negatively with WIQ (r = -0.08) observed 1 year later.

CONCLUSIONS

Prospective application of an individualized decision Markov model in patients with vascular disease was predictive of patient quality of life at 1 year. The patient's outcome was worse when the treatment received did not follow the model's recommendation. This decision analysis model may be useful to identify patients at risk for poor outcomes with standard clinical decision making.

Compromised bypass graft outcomes after minimal-incision vein harvest

BACKGROUND

Minimal incision techniques for vein harvest may lessen wound complications after lower extremity revascularization, but long-term patency and limb salvage data are limited.

METHODS

This retrospective case-control study used a computerized vascular registry set in an academic vascular surgical practice. All patients undergoing lower extremity revascularization using autogenous reversed great saphenous vein by a single vascular surgeon in a 10-year period were reviewed. Harvest of great saphenous vein via long single incision (SI) in 133 patients was compared with minimal incisions with endoscopy (MIE) in 85, or MI without endoscopy in 106. The main outcome measures were primary and secondary graft patency by Kaplan-Meier life-table analysis and cumulative sum failure (CUSUM). Secondary outcomes of interest were limb salvage and wound complications.

RESULTS

No differences were observed between MIE, MI, and SI patients for demographic data, risk factors, or primary indications, including claudication, rest pain, ischemic ulcer, and gangrene. Endoscopic vein harvest patients were significantly more likely than MI or SI to be women and more likely to use tobacco. Primary patency at 5 years was better after SI vein harvest (59%) than with either MI (33%, P = .004) or MIE (44%, P = .045) techniques, although both MI groups had a higher proportion of bypass grafts to the popliteal artery. Similarly, cumulative secondary patency was better after SI (66%) than with MI (47%, P = .045), but not MIE (58%, P = .45). Differences in limb salvage at 5 years in SI (73%) were not statistically superior to either MI (59%, P = .24) or MIE (58%, P = .13). No learning curve for MI or MIE vein grafts was evident by CUSUM for primary patency at 12 months. No differences in wound complication rates were observed for SI (9%), MI (10%), or MIE (6%) grafts (P = .54).

CONCLUSIONS

Graft patency and limb salvage deteriorated during the time when MI or MIE techniques of great saphenous vein harvest were adopted. This observation raises concern about the advisability of limiting the extent of the incision at the potential cost of compromised outcomes without an obvious advantage in limiting wound complications.

Meta-analysis of popliteal-to-distal vein bypass grafts for critical ischemia

BACKGROUND

Several studies have described the use of popliteal-to-distal bypass grafts, mostly in patients with diabetes mellitus who show tissue loss and represent a high-risk population. The study objective was to conduct meta-analysis to assess the long-term primary and secondary patency and foot preservation after popliteal-to-distal bypass grafts.

METHODS

Data was retrieved from studies published from 1981 through 2004 that were identified from an electronic database. Thirty-one series that used survival analysis reported a 1-year graft patency rate and included at least 15 bypasses. Data from life tables, survival curves, and texts were used to calculate an interval success rate for each month in each series of grafts. Monthly success rates were combined across series to obtain a pooled estimate of success for each month, according to a random-effects protocol for meta-analysis. Pooled survival curves were then constructed for graft patency and foot preservation.

RESULTS

The 5-year pooled estimate +/- standard error was 63.1% +/- 4.3% for primary patency, 70.7% +/- 4.6% for secondary patency, and 77.7% +/- 4.3% for foot preservation. There was a superiority trend favoring reversed vein grafts and tibial bypasses that became more apparent in sensitivity analysis. No publication bias was detected.

CONCLUSION

The popliteal-to-distal vein bypass is a tool of high efficiency in the treatment of severe, chronic critical ischemia in the lower extremity.

Prospective decision analysis modeling indicates that clinical decisions in vascular surgery often fail to maximize patient expected utility

BACKGROUND

Applied prospectively to patients with peripheral arterial disease, individualized decision analysis has the potential to improve the surgeon's ability to optimize patient outcome.

METHODS

A prospective, randomized trial comparing Markov surgical decision analysis to standard decision-making was performed in 206 patients with symptomatic lower extremity arterial disease. Utility assessment and quality of life were determined from individual patients prior to treatment. Vascular surgeons provided estimates of probability of treatment outcome, intended and actual treatment plans, and assessment of comfort with the decision (PDPI). Treatment plans and PDPI evaluations were repeated after each surgeon was made aware of model predictions for half of the patients in a randomized manner.

RESULTS

Optimal treatments predicted by decision analysis differed significantly from the surgeon's initial plan and consisted of bypass for 30 versus 29%, respectively, angioplasty for 28 versus 11%, amputation for 31 versus 6%, and medical management for 34 versus 54% (agreement 50%, kappa 0.28). Surgeon awareness of the decision model results did not alter the verbalized final plan, but did trend toward less frequent use of bypass. Patients for whom the model agreed with the surgeon's initial plan were less likely to undergo bypass (13 versus 30%, P < 0.01). Greater surgeon comfort was present when the initial plan and model agreed (PDPI score 47.5 versus 45.6, P < 0.005).

CONCLUSIONS

Individualized application of a decision model to patients with peripheral arterial disease suggests that arterial bypass is frequently recommended even when it may not maximize patient expected utility.

Intraoperative superficial femoral artery balloon angioplasty and popliteal to distal bypass graft: an option for combined open and endovascular treatment of diabetic gangrene

PURPOSE

The purpose of this study was to evaluate the results of combining intraoperative balloon angioplasty (IBA) of the superficial femoral artery (SFA) with distal bypass graft originating from the popliteal artery as a method of lower extremity revascularization in diabetic patients with gangrene.

METHODS

Among 380 infrainguinal bypass grafts performed over a 6-year period, there were 110 reversed saphenous vein bypass grafts to the tibial or pedal arteries to treat diabetic patients with gangrene. Diffuse infrainguinal disease was treated with femoral-distal bypass graft (long; n = 46). Popliteal-distal bypass graft was performed when the inflow femoral artery was not significantly diseased (short; n = 52). Focal SFA stenosis and severe infrageniculate disease were treated with combined IBA of the SFA and distal bypass graft originating from the popliteal artery (combined; n = 12). Follow-up was performed with duplex scan surveillance of both the bypass graft and IBA sites. Treatment groups were compared with life-table analysis.

RESULTS

There were no perioperative graft failures or amputations. The perioperative mortality rate was 1% (1 of 110). The 2-year primary patency rates were similar in the three groups: 72% in the long bypass graft group, 82% in the short bypass graft group, and 76% in the combined group (P =.8, log-rank test). SFA IBA sites developed recurrent stenosis in two patients, at 7 and 48 months; both were detected with surveillance and treated with percutaneous transluminal balloon angioplasty. The overall 5-year rate of primary patency was 63%, secondary patency was 78%, limb salvage was 81%, and survival was 35%. There were no significant differences among the three treatment groups with respect to these outcomes.

CONCLUSION

Results with the combined procedure were similar to those achieved with either femoral-distal bypass graft or popliteal-distal bypass graft without SFA IBA. These data suggest that IBA of the inflow SFA may be combined with popliteal to distal bypass graft and that this technique is a reasonable alternative to longer, femoral-origin bypass graft in selected diabetic patients with gangrene.

Justification of intervention for limb-threatening ischemia: a surgical decision analysis

Intervention for vascular occlusive disease of the distal lower extremity in elderly patients will inevitably be scrutinized as medical resources decline. The authors applied surgical decision analysis to three treatment options: revascularization, amputation and expectant management. The appropriate outcome probabilities were derived from our experience with revascularization to the tibial and pedal vessels, and utility scores were obtained by formalized patient assessment. Revascularization was predicted to improve patient outcome by 1.10 quality-adjusted life-years compared with primary amputation and by 1.16 quality-adjusted life-years compared with expectant management. To gain one additional quality-adjusted life-years, revascularization would cost $5280 more than expectant management, but $33,900 less than primary amputation. Sensitivity analysis predicted revascularization to be the least costly treatment per quality-adjusted life-years as long as 1-month patency exceeds 11%. Revascularization for limb-threatening ischemia of the distal lower extremity is justified and can be performed at a reasonable cost.

Racial differences in operation for peripheral vascular disease: results of a population-based study

Operation for non-coronary atherosclerotic peripheral vascular occlusive disease may vary among race and gender groups. Using a state-wide registry, the authors identified all operations performed for infrarenal peripheral vascular disease over a 12-month period in a single south-eastern state. Procedures performed included reconstruction for aortoiliac (n=641) and infrainguinal (n=1129) disease and major amputation (n=1077). The incidence for patients over age 50 was calculated using census data. Operation for aortoiliac disease was significantly more likely for white patients (relative risk 3.79, 95% C.I. 2.84-5.15), but less likely for infrainguinal peripheral vascular disease (relative risk 0.64, 95% C.I. 0.56-0.73) and amputation (relative risk 0.17, 95% C.I. 0.15-0.19). Trends toward lower operative mortality in blacks with aortoiliac disease (10.6% versus 12.0%), PVD (3.2% versus 3.5%), and amputation (5.5 versus 8.7%) failed to attain statistical significance. Patient race was associated with the type and location of operation performed for peripheral vascular disease.