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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2497-2604. [PMID: 38752899 DOI: 10.1016/j.jacc.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Fanaroff AC, Dayoub EJ, Yang L, Schultz K, Ramadan OI, Wang GJ, Damrauer SM, Genovese EA, Secemsky EA, Parikh SA, Nathan AS, Kohi MP, Weinberg MD, Jaff MR, Groeneveld PW, Giri JS. Association Between Diagnosis-to-Limb Revascularization Time and Clinical Outcomes in Outpatients With Chronic Limb-Threatening Ischemia: Insights From the CLIPPER Cohort. J Am Heart Assoc 2024; 13:e033898. [PMID: 38639376 PMCID: PMC11179943 DOI: 10.1161/jaha.123.033898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/18/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND The extent and consequences of ischemia in patients with chronic limb-threatening ischemia (CLTI) may change rapidly, and delays from diagnosis to revascularization may worsen outcomes. We sought to describe the association between time from diagnosis to endovascular lower extremity revascularization (diagnosis-to-limb revascularization [D2L] time) and clinical outcomes in outpatients with CLTI. METHODS AND RESULTS In the CLIPPER cohort, comprising patients between 66 and 86 years old diagnosed with CLTI betweeen 2010 and 2019, we used Medicare claims data to identify patients who underwent outpatient endovascular revascularization within 180 days of diagnosis. We described the risk-adjusted association between D2L time and clinical outcomes. Among 1 130 065 patients aged between 66 and 86 years with CLTI, 99 221 (8.8%) underwent outpatient endovascular lower extremity revascularization within 180 days of their CLTI diagnosis. Among patients with D2L time <30 days, there was no association between D2L time and all-cause death or major lower extremity amputation. However, among patients with D2L time >30 days, each additional 10-day increase in D2L time was associated with a 2.5% greater risk of major amputation (hazard ratio, 1.025 [95% CI, 1.014-1.036]). There was no association between D2L time and all-cause death. CONCLUSIONS A delay of >30 days from CLTI diagnosis to lower extremity endovascular revascularization was associated with an increased risk of major lower extremity amputation among patients undergoing outpatient endovascular revascularization. Improving systems of care to reduce D2L time could reduce amputations.
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Affiliation(s)
- Alexander C. Fanaroff
- Cardiovascular Medicine Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Penn Center for Health Incentives and Behavioral EconomicsUniversity of PennsylvaniaPhiladelphiaPA
| | - Elias J. Dayoub
- Cardiovascular Medicine Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
| | - Lin Yang
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
| | - Kaitlyn Schultz
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
| | - Omar I. Ramadan
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Grace J. Wang
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Scott M. Damrauer
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Department of Genetics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
| | - Elizabeth A. Genovese
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Eric A. Secemsky
- Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical SchoolHarvard UniversityBostonMA
| | - Sahil A. Parikh
- Division of Cardiology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNY
| | - Ashwin S. Nathan
- Cardiovascular Medicine Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
| | - Maureen P. Kohi
- Department of RadiologyUniversity of North CarolinaChapel HillNC
| | | | | | - Peter W. Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
- General Internal Medicine Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Jay S. Giri
- Cardiovascular Medicine Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
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Shan LL, Yang LS, Tew M, Westcott MJ, Spelman TD, Choong PF, Davies AH. Quality of Life in Chronic Limb Threatening Ischaemia: Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2022; 64:666-683. [PMID: 35952907 DOI: 10.1016/j.ejvs.2022.07.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 07/12/2022] [Accepted: 07/22/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To assess the comparative effectiveness and temporal changes in quality of life (QoL) outcomes after revascularisation, major lower extremity amputation (MLEA), and conservative management (CM) in chronic limb threatening ischaemia (CLTI). DATA SOURCES MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science. REVIEW METHODS A systematic review and meta-analysis were performed on QoL measured by any QoL instrument in adult patients with CLTI after open surgery (OS), endovascular intervention (EVI), MLEA, or CM. Randomised controlled trials and prospective observational studies published in any language between 1 January 1990 and 21 May 2021 were included. There was a pre-specified measurement time point of six months. Random effects meta-analysis was conducted on total scores for each QoL instrument. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach (PROSPERO registration: CRD42021253953). RESULTS Fifty-five studies with 8 909 patients were included. There was significant heterogeneity in the methods used to measure QoL, and the study characteristics. In particular, 14 different QoL instruments were used with various combinations of disease specific and generic instruments within each study. A narrative summary is therefore presented. Comparative effectiveness data showed there was reasonable certainty that QoL was similar between OS and EVI at six months. Temporal outcomes suggested small to moderate improvements in QOL six months after OS and EVI compared with baseline. Limited data indicated that QoL can be maintained or slightly improved after MLEA or CM. Treatment effects were overestimated owing to small study effects, selective non-reporting, attrition, and survivorship bias. CONCLUSION QoL after OS and EVI appears to be similar. Revascularisation may provide modest QoL benefits, while MLEA or CM can maintain QoL. However, certainty of evidence is generally low or very low, and interpretation is hampered by significant heterogeneity. There is a need for a CLTI specific QoL instrument and methodological standardisation in QoL studies.
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Affiliation(s)
- Leonard L Shan
- Department of Surgery, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia.
| | - Linda S Yang
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Michelle Tew
- Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Mark J Westcott
- Department of Surgery, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Tim D Spelman
- Department of Surgery, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Peter F Choong
- Department of Surgery, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Alun H Davies
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
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Goodney P, Shah S, Hu YD, Suckow B, Kinlay S, Armstrong DG, Geraghty P, Patterson M, Menard M, Patel MR, Conte MS. A systematic review of patient-reported outcome measures patients with chronic limb-threatening ischemia. J Vasc Surg 2022; 75:1762-1775. [PMID: 35085747 PMCID: PMC9524582 DOI: 10.1016/j.jvs.2021.11.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/08/2021] [Indexed: 01/23/2023]
Abstract
Chronic limb-threatening ischemia (CLTI) causes significant morbidity with profound negative effects on health-related quality of life. As the prevalence of peripheral artery disease and diabetes continue to rise in our aging population, the public health impact of CLTI has escalated. Patient-reported outcome measures (PROMs) have become common and important measures for clinical evaluation in both clinical care and research. PROMs are important for the measurement of clinical effectiveness and cost effectiveness and for shared decision-making on treatment options. However, the PROMs used to describe the experience of patients with CLTI are heterogeneous, incomplete, and lack specific applicability to the underlying disease processes and diverse populations. For example, certain PROMs exist for patients with extremity wounds, and other PROMs exist for patients with pain, and still others exist for patients with vascular disease. Despite this multiplicity of tools, no single PROM encompasses all of the components necessary to describe the experiences of patients with CLTI. This significant unmet need is evident from both published reports and contemporary large-scale clinical trials in the field. In this systematic review, we review the current use of PROMs for patients with CLTI in clinical practice and in research trials and highlight the gaps that need to be addressed to develop a unifying PROM instrument for CLTI.
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Affiliation(s)
- Philip Goodney
- Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
| | - Samir Shah
- Vascular Surgery, University of Florida, Gainesville, Fla
| | - Yiyuan David Hu
- Geisel School of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Bjoern Suckow
- Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Scott Kinlay
- Cardiovascular Medicine, Boston Medical Center, Boston, Mass
| | - David G Armstrong
- Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, Calif
| | - Patrick Geraghty
- Vascular Surgery, Washington University in St. Louis, St. Louis, Mo
| | | | - Matthew Menard
- Vascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | | | - Michael S Conte
- Vascular Surgery, University of California, San Francisco, San Francisco, Calif
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Scierka LE, Mena-Hurtado C, Shishehbor MH, Spertus JA, Nagpal S, Babrowski T, Bunte MC, Politano A, Humphries M, Chung J, Kirksey L, Alabi O, Soukas P, Parikh S, Faizer R, Fitridge R, Provance J, Romain G, McMillan N, Stone N, Scott K, Fuss C, Pacheco CM, Gosch K, Harper-Brooks A, Smolderen KG. The shifting care and outcomes for patients with endangered limbs - Critical limb ischemia (SCOPE-CLI) registry overview of study design and rationale. IJC HEART & VASCULATURE 2022; 39:100971. [PMID: 35198727 PMCID: PMC8850321 DOI: 10.1016/j.ijcha.2022.100971] [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: 12/06/2021] [Revised: 01/26/2022] [Accepted: 02/02/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Critical limb ischemia (CLI), the most severe form of peripheral artery disease, is associated with pain, poor wound healing, high rates of amputation, and mortality (>20% at 1 year). Little is known about the processes of care, patients' preferences, or outcomes, as seen from patients' perspectives. The SCOPE-CLI study was co-designed with patients to holistically document patient characteristics, treatment preferences, patterns of care, and patient-centered outcomes for CLI. METHODS This 11-center prospective observational registry will enroll and interview 816 patients from multispecialty, interdisciplinary vascular centers in the United States and Australia. Patients will be followed up at 1, 2, 6, and 12 months regarding their psychosocial factors and health status. Hospitalizations, interventions, and outcomes will be captured for 12 months with vital status extending to 5 years. Pilot data were collected between January and July of 2021 from 3 centers. RESULTS A total of 70 patients have been enrolled. The mean age was 68.4 ± 11.3 years, 31.4% were female, and 20.0% were African American. CONCLUSIONS SCOPE-CLI is uniquely co-designed with patients who have CLI to capture the care experiences, treatment preferences, and health status outcomes of this vulnerable population and will provide much needed information to understand and address gaps in the quality of CLI care and outcomes.ClinicalTrials.gov identifier (NCT Number): NCT04710563 https://clinicaltrials.gov/ct2/show/NCT04710563.
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Affiliation(s)
- Lindsey E. Scierka
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Carlos Mena-Hurtado
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Mehdi H. Shishehbor
- Case Western University School of Medicine/Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, United States
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Sameer Nagpal
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | | | - Matthew C. Bunte
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Amani Politano
- Oregon Health & Science University, Portland, OR, United States
| | | | - Jayer Chung
- Baylor College of Medicine, Houston, TX, United States
| | - Lee Kirksey
- Cleveland Clinic, Cleveland, OH, United States
| | | | | | - Sahil Parikh
- Columbia University – Presbyterian, New York, NY, United States
| | - Rumi Faizer
- University of Minnesota, Minneapolis, MN, United States
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia
| | - Jeremy Provance
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Gaëlle Romain
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Neil McMillan
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia
| | - Nancy Stone
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Kate Scott
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Christine Fuss
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Christina M. Pacheco
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Kensey Gosch
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Avis Harper-Brooks
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Kim G. Smolderen
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
- Yale University, Department of Psychiatry, New Haven, CT, United States
- Corresponding author at: 789 Howard Avenue, New Haven, CT 06519, United States.
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7
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Pietzsch JB, Geisler BP, Iken AR, van Wijck IPS, Holewijn S, Reijnen MMPJ. Cost-Effectiveness of Urea Excipient-Based Drug-Coated Balloons for Chronic Limb-Threatening Ischemia from Femoropopliteal Disease in the Netherlands and Germany. Cardiovasc Intervent Radiol 2022; 45:298-305. [PMID: 34984489 DOI: 10.1007/s00270-021-03050-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/18/2021] [Indexed: 11/02/2022]
Abstract
PURPOSE Drug-coated balloons (DCBs) for femoropopliteal peripheral artery disease have been shown to be clinically superior and cost-effective compared to conventional percutaneous transluminal angioplasty (PTA). However, few studies enrolled patients with chronic limb-threatening ischemia (CLTI). Our objective was to study the cost-effectiveness of endovascular treatment with versus without DCB in CLTI patient populations in the Netherlands and Germany. MATERIAL AND METHODS Target lesion revascularization (TLR) and major amputation rates were obtained from the CLTI subgroup of the IN.PACT Global study. Rates for "status quo" treatment involving PTA with primary or bailout stenting were derived from systematic literature search. Costs and cost-effectiveness were calculated using a decision-analytic Markov model considering, in the base case, a 2-year horizon, and strategy-specific quality-adjusted life year (QALY) gains calculated from survival and health state-specific utilities. A willingness-to-pay threshold of €50,000/QALY was assumed, and extensive sensitivity analyses were performed. RESULTS Model-projected 24-month probabilities of TLR were 26.2% and 32.8% for treatment with and without DCB, and probabilities for amputation were 2.8% and 11.9%, respectively. DCB added 0.017 QALYs while saving €1,030 in the Dutch setting and €513 in the German setting, respectively. DCB was found dominant or cost-effective across a wide range of assumptions. CONCLUSION Urea excipient drug-coated balloon therapy for treating CLTI from femoropopliteal artery disease is associated with improved patient outcomes and expected overall cost savings to payers in the Dutch and German healthcare systems, rendering it a cost-effective and likely dominant treatment strategy.
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Affiliation(s)
| | - Benjamin P Geisler
- Wing Tech Inc., Menlo Park, CA, USA.,Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Iris P S van Wijck
- Department of Surgery, Rijnstate Hospital, P.O. Box 9555, 6800, TA, Arnhem, The Netherlands
| | - Suzanne Holewijn
- Department of Surgery, Rijnstate Hospital, P.O. Box 9555, 6800, TA, Arnhem, The Netherlands
| | - Michel M P J Reijnen
- Department of Surgery, Rijnstate Hospital, P.O. Box 9555, 6800, TA, Arnhem, The Netherlands. .,Multi-Modality Medical Imaging Group, TechMed Center, University of Twente, Enschede, The Netherlands.
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8
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Wardhan R, Michel R, Vasilopoulos T, Yen E. Are the Placement, Maintenance, and Removal of Femoral and Sciatic Catheters Associated With Bleeding Complications in Vascular Patients on Antithrombotics? A Single-Center, Retrospective Cohort Study. Anesth Analg 2022; 134:188-193. [PMID: 34591797 DOI: 10.1213/ane.0000000000005743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Information on the safety of placement, maintenance, and removal of peripheral nerve blocks in the presence of therapeutic or prophylactic antithrombotics is limited to case reports. METHODS In this retrospective, descriptive study, we examined the use of femoral and gluteal or subgluteal sciatic perineural catheters in 146 patients on antithrombotics who received lower limb amputation (LLA) above or below the knee at the University of Florida Health Shands Hospital between January 2015 and December 2019. We searched patient surgical records for complications such as bleeding, nerve damage, infection, and hematoma during placement, maintenance, and removal of the perineural catheters. RESULTS In this cohort of 146 patients on antithrombotics, there was 1 episode of hematoma with an estimated incidence of 1 of 146 (0.68%, 95% confidence interval [CI], 0.02-3.76). This patient developed a hematoma at the location of the femoral catheter and required a blood transfusion. This patient was on aspirin daily and subcutaneous heparin 3 times per day and had a normal coagulation profile during their hospital stay. CONCLUSIONS This report investigates bleeding complications of femoral and sciatic perineural catheters in patients undergoing LLA on antithrombotics. We found that, except for 1 patient, most patients on varying combinations of antithrombotics did not experience bleeding complications related to the femoral and sciatic perineural catheters.
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Affiliation(s)
- Richa Wardhan
- From the Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
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9
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Kodama A, Takahara M, Iida O, Soga Y, Mii S, Kitano I, Deguchi J, Fukui D, Komori K, Azuma N. Health Related Quality of Life Over Time After Revascularisation in Patients With Chronic Limb Threatening Ischaemia. Eur J Vasc Endovasc Surg 2021; 62:777-785. [PMID: 34531117 DOI: 10.1016/j.ejvs.2021.06.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 06/07/2021] [Accepted: 06/30/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Chronic limb threatening ischaemia (CLTI) decreases life expectancy and impairs health related quality of life (HR-QOL). Revascularisation is needed to relieve ischaemia and salvage limbs. Although a major goal of CLTI treatment is maintaining QOL, little information is available about changes of HR-QOL over time after revascularisation. HR-QOL with survival after revascularisation for CLTI was assessed. METHODS The clinical database of the Surgical reconstruction versus Peripheral INtervention in pAtients with critical limb isCHemia (SPINACH), a prospective multicentre observational study, was analysed. Outcome measures were disease specific QOL per the Vascular Quality of Life (VascuQOL) questionnaire and the Short Form (SF) 36 evaluated generic QOL, which were assessed at baseline and three, 12, 24, and 36 months. The outcome measure was change of QOL from baseline. The minimally important difference (half a standard deviation from baseline) was used as the cut off point for improved, worsened, and unchanged QOL. RESULTS Overall QOL was improved in 61% of patients for the VascuQOL and approximately 40% for the SF-36 component summaries at three months. However, these proportion gradually decreased to 21% - 31% at three years. In contrast, the proportion of deceased patients gradually increased over the three year follow up. Multivariable analysis revealed that pre-operative non-ambulatory status was inversely associated with improved QOL for the three month VascuQOL and SF-36 mental component summary, and surgical reconstruction was positively associated with these measurements. Advanced age and renal failure were inversely associated with improved QOL for the SF-36 mental component summary and VascuQOL at one to three years. CONCLUSION Revascularisation improved QOL. However, patients with non-ambulatory status exhibited a negative association with improved QOL at three months, and advanced age and renal failure limited benefits one to three years after revascularisation. Accumulating QOL data will be essential for post-revascularisation QOL estimation. Pre-operative assessment, including estimated QOL, is important in shared decision making for patient oriented outcomes in the treatment of CLTI patients.
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Affiliation(s)
- Akio Kodama
- Division of Vascular Surgery, Department of Surgery, Nagoya University School of Medicine Nagoya, Japan.
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, and Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Osamu Iida
- Cardiovascular Centre, Kansai Rosai Hospital, Amagasaki, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Shinsuke Mii
- Department of Vascular Surgery, Saiseikai Yahata Hopspital, Yahata, Kitakyushu, Japan
| | - Ikuro Kitano
- Wound Treatment Centre, Shin-Suma General Hospital, Kobe, Japan
| | - Juno Deguchi
- Department of Vascular Surgery, Saitama Medical Centre, Kawagoe, Japan
| | | | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University School of Medicine Nagoya, Japan
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Japan
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10
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Roberts DJ, Nagpal SK, Forster AJ, Brandys T, Murphy C, Jennings A, Strauss SA, Vishnyakova E, Lawson J, McIsaac DI. Disability, pain, and wound-specific concerns self-reported by adults at risk of limb loss: A cross-sectional study using the World Health Organization Disability Assessment Schedule 2.0. PLoS One 2021; 16:e0253288. [PMID: 34129633 PMCID: PMC8205167 DOI: 10.1371/journal.pone.0253288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/01/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction There has been limited study of patient-reported outcomes (PROs) in patients at risk of limb loss. Our primary objective was to estimate the prevalence of disability in this patient population using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Materials and methods We recruited patients referred to a limb-preservation clinic. Patients self-reported their disability status using the 12-domain WHODAS 2.0. Severity of disability in each domain was scored from 1 = none to 5 = extreme and the total normalized to a 100-point scale (total score ≥25 = clinically significant disability). We also asked patients about wound-specific concerns and wound-related discomfort or distress. Results We included 162 patients. Reasons for clinic referral included arterial-insufficient (37.4%), postoperative (25.9%), and mixed etiology (10.8%) wounds. The mean WHODAS 2.0 disability score was 35.0 (standard deviation = 16.0). One-hundred-and-nineteen (73.5%) patients had clinically significant disability. Patients reported they had the greatest difficulty walking a long distance (mean score = 4.2), standing for long periods of time (mean score = 3.6), taking care of household responsibilities (mean score = 2.7), and dealing with the emotional impact of their health problems (mean score = 2.5). In the two-weeks prior to presentation, 87 (52.7%) patients expressed concern over their wound(s) and 90 (55.6%) suffered a moderate amount or great deal of wound-related discomfort or distress. In adjusted ordinary least squares regression models, although WHODAS 2.0 disability scores varied with changes in wound volume (p = 0.03) and total revised photographic wound assessment tool scores (p<0.001), the largest decrease in disability severity was seen in patients with less wound-specific concerns and wound-related discomfort and distress. Discussion The majority of people at risk of limb loss report suffering a substantial burden of disability, pain, and wound-specific concerns. Research is needed to further evaluate the WHODAS 2.0 in a multicenter fashion among these patients and determine whether care and interventions may improve their PROs.
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Affiliation(s)
- Derek J. Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- * E-mail:
| | - Sudhir K. Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Alan J. Forster
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
- School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Christine Murphy
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Alison Jennings
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shira A. Strauss
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Evgeniya Vishnyakova
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie Lawson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Daniel I. McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Departments of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
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11
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Roberts DJ, Murphy C, Strauss SA, Brandys T, Corrales-Medina V, Zhang J, Lalonde KA, Meulenkamp B, Jennings A, Forster AJ, McIsaac DI, Nagpal SK. Structure, processes, and initial outcomes of The Ottawa Hospital Multi-Specialist Limb-Preservation Clinic and Programme: A unique-in-Canada quality improvement initiative. Int Wound J 2021; 19:326-338. [PMID: 34085390 PMCID: PMC8762562 DOI: 10.1111/iwj.13633] [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] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 11/28/2022] Open
Abstract
In 2017, The Ottawa Hospital initiated a unique-in-Canada quality improvement initiative by opening a novel, multi-specialist limb-preservation clinic. We sought to describe the structure, processes, and initial outcomes of the clinic and evaluate whether it is achieving its mandate of providing high-quality wound clinical care, education, and research. We conducted a descriptive prospective cohort study alongside a nested study of 162 clinic patients requiring serial assessments. There have been 1623 visits, mostly (72.2%) from outpatients. During 17.8% of visits, patients were evaluated by >1 specialist. Therapies provided most often included negative-pressure wound therapy (32.7%), biological wound dressings (21.6%), and total contact casting (18.5%). Furthermore, 1.2% underwent toe/ray amputations or skin grafting in clinic and 22.8% were initiated on antimicrobials. Mixed-effects models suggested that mean wound volumes for those requiring serial assessments decreased by 1.6 (95% confidence interval = -0.86 to -2.27) cm3 between visits. The clinic provided seven rotations to vascular surgery, infectious diseases, dermatology, and palliative care physicians; three nursing preceptorships; and two educational workshops. It also initiated provincial and national vascular health and wound care research initiatives. This study may be used to guide development of other limb-preservation clinics and programmes. Findings support that our programme is achieving its mandate.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Christine Murphy
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Shira A Strauss
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Vicente Corrales-Medina
- Division of Infectious Diseases, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jing Zhang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Karl-André Lalonde
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Bradley Meulenkamp
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Alan J Forster
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,IC/ES, Toronto, Ontario, Canada.,Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada.,School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel I McIsaac
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,IC/ES, Toronto, Ontario, Canada.,School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Departments of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
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12
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Arakelian VS. [Amputation as an anticipated consequence of peripheral artery disease and ways to improve the prognosis of limb salvage]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:182-190. [PMID: 33825747 DOI: 10.33529/angio2021101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Peripheral artery disease is a common and acute social burden worldwide. The main method of treatment of PAD consists in open surgical or endovascular revascularization. However, despite steady growth of the number and quality of interventions, the incidence of lower-limb amputation still remains at a high level. Lower-limb amputation is a severe psychological blow for the patient and leads to significant deterioration of his or her quality of life, as well as has an extremely negative prognosis concerning the frequency of subsequent complications and survival. Consequences of amputations include not only severe disability but also an unfavourable prognosis of life, thus determining the necessity of adequate prevention of such events. Reconstructive and endovascular operations, as well as amputations are associated with a significant increase of the probability of the development of major adverse cardiovascular events, the frequency of repeat hospitalizations and, finally, the cost of treatment. Prescribing pathogenetically substantiated antithrombotic therapy is considered to be one of the methods to improve the results of surgical treatment and prognosis for the patient. Presented in the article is a literature review making it possible to assess the risks and consequences of amputations in patients with PAD, as well as to determine therapy capable of improving the prognosis.
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Affiliation(s)
- V S Arakelian
- Department of Surgery for Arterial Pathology, National Medical Research Centre named after A.N. Bakulev under the RF Ministry of Public Health, Moscow, Russia
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13
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Madabhushi V, Davenport D, Jones S, Khoudoud SA, Orr N, Minion D, Endean E, Tyagi S. Revascularization of intermittent claudicants leads to more chronic limb-threatening ischemia and higher amputation rates. J Vasc Surg 2021; 74:771-779. [PMID: 33775749 DOI: 10.1016/j.jvs.2021.02.045] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 02/25/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is an increasing incidence of peripheral arterial disease (PAD). The most common symptomatic presentation of PAD is intermittent claudication (IC), reproducible leg pain with ambulation. The progression of symptoms beyond IC is rare, and a nonprocedural approach of smoking cessation, supervised exercise therapy, and best medical therapy can mitigate progression of IC. Despite the lack of limb- or life-threatening sequelae of IC, invasive treatment strategies of IC have experienced rapid growth. Within our health care system, PAD is treated by multiple disciplines with varying practice patterns, providing an opportunity to investigate the progression of IC based on treatment strategy. This study aims to compare PAD progression and amputation in patients with IC with and without revascularization. METHODS This institutional review board-approved, single institute retrospective study reviewed all patients with an initial diagnosis of IC between June 11, 2003, and April 24, 2019. Revascularization was defined as endovascular or open. Time to chronic limb-threatening ischemia (CLTI) diagnosis and amputation were stratified by revascularization status using the Kaplan-Meier method. The association between revascularization status and each of CLTI progression and amputation using multivariable Cox regression, adjusting for demographic and clinical potential confounding variables was assessed. RESULTS We identified 1051 patients who met the inclusion criteria. Of these patients, 328 had at least one revascularization procedure and 723 did not. The revascularized group was younger than the nonrevascularized group (60.3 years vs 62.1 years; P = .013). There was no significant difference in sex or comorbidities in the two groups other than a higher rate of diabetes mellitus type 2 (32.3% vs 16.3%; P < .001) and COPD (4.3% vs 1.7%; P = .017) in the revascularized group. Multivariable Cox regression found revascularization of patients with IC to be significantly associated with the progression to CLTI (hazard ratio, 2.9; 95% confidence interval, 2.0-4.2) and amputation (hazard ratio, 4.5; 95% confidence interval, 2.2-9.5). These findings were also demonstrated in propensity-matched cohorts of 218 revascularized and 340 nonrevascularized patients. CONCLUSIONS Revascularization of patients with IC is associated with an increased rate of progression to CLTI and increased amputation rates. Given these findings, further studies are required to identify which, if any, patients with IC benefit from revascularization procedures.
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Affiliation(s)
- Vashisht Madabhushi
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Daniel Davenport
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Stuart Jones
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Sami Abul Khoudoud
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Nathan Orr
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - David Minion
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Eric Endean
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Sam Tyagi
- Department of Surgery, University of Kentucky College of Medicine, Lexington, KY.
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14
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Giannopoulos S, Jeon-Slaughter H, Kahlon RS, Tejani I, Baskar A, Banerjee S, Armstrong EJ. Comparative 12-Month Outcomes of Drug-Coated Balloon Versus Non-Drug-Coated Balloon Revascularization Strategy in Chronic Limb-Threatening Ischemia: Results From the XLPAD Registry. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1276-1284. [PMID: 32249170 DOI: 10.1016/j.carrev.2020.03.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Endovascular therapy is often the preferred first treatment option for chronic limb threatening ischemia (CLTI) patients. Drug coated balloons (DCB) reduce restenosis rates compared to percutaneous transluminal angioplasty (PTA), however DCB use has not been studied systematically in patients with CLTI. Thus, the optimal treatment option for these complex lesions remains controversial. METHODS We report on 327 patients with CLTI treated either with DCB (n = 105) or non-DCB (n = 222) for femoropopliteal disease. Data were retrieved from the Excellence in Peripheral Artery Disease (XLPAD) registry (NCT01904851). Two DCB types were used at the discretion of the operator: Lutonix® (BARD Peripheral Vascular, Inc., Tempe, AZ, USA) and IN.PACT AdmiralTM (Medtronic, Santa Rosa, CA, USA). Odds ratios and the respective 95% confidence interval were synthesized to examine the association between the two groups in terms of all-cause mortality, target limb repeat endovascular or surgical revascularization, target vessel revascularization (TVR), major and minor amputation at 12 months of follow up. RESULTS The mean lesion length was 150.0 mm (SD:123.2) and 151.2 mm (SD:108.3) for the DCB and non-DCB group respectively. No difference between the two groups was detected in terms of all-cause mortality (2.86%vs2.7%,p = .94), target limb repeat endovascular or surgical revascularization (16.19%vs12.61%,p = .25), TVR (16.19%vs.11.71%,p = .26) or minor amputation (15.24%vs10.81%,p = .25) at 12 months of follow up. Although a higher incidence of 12 months major amputation was observed in the DCB group (11%vs.4%,p = .01), after adjusting for several risk factors the odds of major amputation were not statistically different between the DCB and non-DCB groups (OR:1.54;95%CI:0.53-4.51;p = .43). CONCLUSIONS Both DCB and non-DCB strategies are effective modalities for revascularization of patients with CLTI. No differences were identified between the DCB and non-DCB group in terms of late outcomes during 12 months of follow up.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, University of Colorado, Rocky Mountain Regional VA Medical Center, CO, USA
| | - Haekyung Jeon-Slaughter
- Department of Internal Medicine, University of Texas Southwestern Medical Center, VA North Texas Healthcare System, Dallas, TX, USA
| | - Ravi S Kahlon
- Division of Cardiology, University of Colorado, Rocky Mountain Regional VA Medical Center, CO, USA
| | - Ishita Tejani
- Department of Internal Medicine, University of Texas Southwestern Medical Center, VA North Texas Healthcare System, Dallas, TX, USA
| | - Amutha Baskar
- Department of Internal Medicine, University of Texas Southwestern Medical Center, VA North Texas Healthcare System, Dallas, TX, USA
| | - Subhash Banerjee
- Department of Internal Medicine, University of Texas Southwestern Medical Center, VA North Texas Healthcare System, Dallas, TX, USA
| | - Ehrin J Armstrong
- Division of Cardiology, University of Colorado, Rocky Mountain Regional VA Medical Center, CO, USA.
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15
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Mustapha JA, Igyarto Z, O'Connor D, Armstrong EJ, Iorio AR, Driver VR, Saab F, Behrens AN, Martinsen BJ, Adams GL. One-Year Outcomes of Peripheral Endovascular Device Intervention in Critical Limb Ischemia Patients: Sub-Analysis of the LIBERTY 360 Study. Vasc Health Risk Manag 2020; 16:57-66. [PMID: 32103970 PMCID: PMC7020930 DOI: 10.2147/vhrm.s230934] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/30/2019] [Indexed: 12/21/2022] Open
Abstract
Background High-risk patients with advanced peripheral artery disease (PAD), including critical limb ischemia (CLI), are often excluded from peripheral endovascular device intervention clinical trials, leading to difficulty in translating trial results into real-world practice. There is a need for prospectively assessed studies to evaluate peripheral endovascular device intervention outcomes in CLI patients. Methods LIBERTY 360 is a prospective, observational, multi-center study designed to evaluate the procedural and long-term clinical outcomes of peripheral endovascular device intervention in real-world patients with symptomatic lower-extremity PAD. One thousand two hundred and four patients were enrolled and stratified based on Rutherford Classification (RC): RC2-3 (N=501), RC4-5 (N=603), and RC6 (N=100). For this sub-analysis, RC5 and RC6 patients (RC5-6; N=404) were pooled and 1-year outcomes were assessed. Results Procedural complications rarely (1.7%) resulted in post-procedural hospitalization and 89.1% of RC5-6 patients were discharged to home. Considering the advanced disease state in RC5-6 patients, there was a high freedom from 1-year major adverse event rate of 65.5% (defined as target vessel revascularization, death to 30 days, and major target limb amputation). At 1 year, freedom from major amputation was 89.6%. Wounds identified at baseline on the target limb had completely healed in 172/243 (70.8%) of the RC5-6 subjects by 1 year. Additionally, the overall quality of life, as measured by VascuQoL, improved from baseline to 1 year. Conclusion LIBERTY investigated real-world PAD patients with independent oversight of outcomes. This analysis of LIBERTY RC5-6 patients demonstrates that peripheral endovascular device intervention can be successful in CLI patients, with low rates of major amputation and improvement in wound healing and quality of life through 1-year follow-up. LIBERTY 360, https://clinicaltrials.gov/ct2/show/NCT01855412, ClinicalTrials.gov Identifier: NCT01855412.
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Affiliation(s)
- Jihad A Mustapha
- College of Osteopathic Medicine, Michigan State University, E. Lansing, MI, USA.,Advanced Cardiac & Vascular Amputation Prevention Centers, Grand Rapids, MI, USA
| | | | - David O'Connor
- Hackensack University Medical Center, Hackensack, NJ, USA
| | - Ehrin J Armstrong
- Denver VA Medical Center, Denver, CO, USA.,Anschutz Medical Campus, University of Colorado, Denver, CO, USA
| | - Anthony R Iorio
- Foot Center of New York, New York College of Podiatric Medicine, New York, NY, USA
| | - Vickie R Driver
- Department of Orthopedics, Brown University School of Medicine, Providence, RI, USA
| | - Fadi Saab
- Advanced Cardiac & Vascular Amputation Prevention Centers, Grand Rapids, MI, USA
| | | | | | - George L Adams
- North Carolina Heart and Vascular, Rex Hospital, UNC School of Medicine, Raleigh, NC, USA
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16
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Monaro S, West S, Gullick J. The body with chronic limb‐threatening ischaemia: A phenomenologically derived understanding. J Clin Nurs 2020; 29:1276-1289. [DOI: 10.1111/jocn.15151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/31/2019] [Accepted: 11/24/2019] [Indexed: 01/25/2023]
Affiliation(s)
- Susan Monaro
- Concord Repatriation General Hospital Concord NSW Australia
- Faculty of Medicine and Health Sydney Nursing School University of Sydney Camperdown NSW Australia
| | - Sandra West
- Faculty of Medicine and Health Sydney Nursing School University of Sydney Camperdown NSW Australia
| | - Janice Gullick
- Faculty of Medicine and Health Sydney Nursing School University of Sydney Camperdown NSW Australia
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17
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Castillo-Avila R, Arias-Vázquez P, González-Castro T, Tovilla-Zárate C, Juárez-Rojop I, López-Narváez M, Fresán A. Evaluation of the quality of life in individuals with amputations in relation to the etiology of their amputation. A case-control study. Physiother Theory Pract 2020; 37:1313-1320. [PMID: 31928287 DOI: 10.1080/09593985.2020.1712752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: Several studies indicate that limb amputations have a negative influence in the quality of life of those individuals who underwent amputation surgery. The aims of this study were to evaluate the quality of life in Mexican individuals with limb amputations compared with a control group, to identify demographic and clinical differences related to the etiology of the amputation, and to determine if they are associated with the quality of life observed in these patients. Methods: All participants were recruited from the Hospital "Dr Gustavo A. Rovirosa Pérez". The quality of life of all participants was evaluated using SF-36. Results: Individuals with amputations of vascular or trauma etiology, showed a diminished health-related quality of life when compared with the control group (p < .001). We observed that individuals with amputations due to trauma were younger, mostly single, with more upper limb amputations and with a shorter period since amputation at the current assessment in comparison to individuals with amputations. Conclusions: Although limb amputation represents a surgical procedure necessary to preserve the life of a person, our results support that it negatively impacts the health-related quality of life of these individuals. Regardless of the etiology of the amputation, rehabilitation programs are primarily focused on reintegrating individuals to their everyday life. However, these programs may have poor results when patients have a poor quality of life. Therefore, quality of life assessment and early inclusion in programs that aim to improve the quality of life of individuals with amputations should be always taken into consideration.
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Affiliation(s)
- Rosa Castillo-Avila
- División Académica Multidisciplinaria de Comalcalco, Universidad Juárez Autónoma de Tabasco, Comalcalco, Tabasco, México
| | - Pedro Arias-Vázquez
- División Académica Multidisciplinaria de Comalcalco, Universidad Juárez Autónoma de Tabasco, Comalcalco, Tabasco, México
| | - Thelma González-Castro
- División Académica Multidisciplinaria de Jalpa de Méndez, Universidad Juárez Autónoma de Tabasco, Jalpa de Méndez, Tabasco, México.,División Académica de Ciencias de la Salud, Universidad Juárez Autónoma de Tabasco, Villahermosa, Tabasco, México C.P
| | - Carlos Tovilla-Zárate
- División Académica Multidisciplinaria de Comalcalco, Universidad Juárez Autónoma de Tabasco, Comalcalco, Tabasco, México
| | - Isela Juárez-Rojop
- División Académica de Ciencias de la Salud, Universidad Juárez Autónoma de Tabasco, Villahermosa, Tabasco, México C.P
| | - María López-Narváez
- Hospital General de Yajalón "Dr. Manuel Velazco Siles", Secretaría de Salud, Yajalón, Chiapas, México C.P
| | - Ana Fresán
- Subdirección de Investigaciones Clínicas, Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Ciudad de México, Tlalpan, México C.P
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18
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Reijnen MMPJ, van Wijck I, Zeller T, Micari A, Veroux P, Keirse K, Lee SW, Li P, Voulgaraki D, Holewijn S. Outcomes After Drug-Coated Balloon Treatment of Femoropopliteal Lesions in Patients With Critical Limb Ischemia: A Post Hoc Analysis From the IN.PACT Global Study. J Endovasc Ther 2019; 26:305-315. [PMID: 30931726 PMCID: PMC6628633 DOI: 10.1177/1526602819839044] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To report a post hoc analysis performed to evaluate 1-year
safety and efficacy of the IN.PACT Admiral drug-coated balloon (DCB) for the
treatment of femoropopliteal lesions in subjects with critical limb ischemia
(CLI) enrolled in the IN.PACT Global study (ClinicalTrials.gov
identifier NCT01609296). Materials and Methods: Of 1535 subjects
enrolled in the study, 156 participants (mean age 71.8±10.4; 87 men) with CLI
(Rutherford categories 4,5) were treated with DCB angioplasty in 194
femoropopliteal lesions. This cohort was compared to the 1246 subjects (mean age
68.2±10.0 years; 864 men) with intermittent claudication (IC) treated for 1573
lesions. The CLI cohort had longer lesions (13.9±10.6 vs 11.9±9.4 cm, p=0.009)
and a higher calcification rate (76.8% vs 67.7%, p=0.011). Major adverse events
[MAE; composite of all-cause mortality, clinically-driven target lesion
revascularization (CD-TLR), major (above-ankle) target limb amputation, and
thrombosis at the target lesion site], lesion and vessel revascularization
rates, and EuroQol-5D were assessed through 1 year. The Kaplan-Meier method was
used to estimate survival, CD-TLR, and amputation events; estimates are
presented with the 95% confidence intervals (CI). Results:
Estimates of 12-month freedom from major target limb amputation were 98.6% (95%
CI 96.7% to 100.0%) in subjects with CLI and 99.9% (95% CI 99.8% to 100.0%) in
subjects with IC (p=0.002). Freedom from CD-TLR through 12 months was 86.3% (95%
CI 80.6% to 91.9%) in CLI subjects and 93.4% (95% CI 91.9% to 94.8%) in IC
subjects (p<0.001). The MAE rate through 12 months was higher in CLI subjects
(22.5% vs 10.7%, p<0.001), and CLI patients had poorer overall survival
(93.0%, 95% CI 88.9% to 97.2%) than IC subjects (97.0%, 95% CI 96.0% to 97.9%,
p=0.011). Health status significantly improved in all domains at 6 and 12 months
in both groups. Conclusion: Treatment of femoropopliteal disease
with DCB in CLI patients is safe through 12-month follow-up, with a low major
amputation rate of 1.4%. The rates of MAE and CD-TLR were higher in CLI subjects
and reinterventions were required sooner. Additional research is needed to
evaluate long-term outcomes of DCB treatment for femoropopliteal lesions in CLI
patients.
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Affiliation(s)
| | - Iris van Wijck
- 1 Department of Vascular Surgery, Rijnstate, Arnhem, the Netherlands
| | - Thomas Zeller
- 2 University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Antonio Micari
- 3 Department of Cardiology, Humanitas Gavazzeni, Bergamo, Italy
| | | | - Koen Keirse
- 5 Department of Vascular Surgery, Regional Hospital Heilig Hart Tienen, Belgium
| | - Seung-Whan Lee
- 6 Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Pei Li
- 7 Medtronic, Plymouth, MN, USA
| | | | - Suzanne Holewijn
- 1 Department of Vascular Surgery, Rijnstate, Arnhem, the Netherlands
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Peters CML, de Vries J, Lodder P, Steunenberg SL, Veen EJ, de Groot HGW, Ho GH, van der Laan L. Quality of Life and not Health Status Improves After Major Amputation in the Elderly Critical Limb Ischaemia Patient. Eur J Vasc Endovasc Surg 2019; 57:547-553. [PMID: 30826247 DOI: 10.1016/j.ejvs.2018.10.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 10/17/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVES A patient-oriented appraisal of treatment has become extremely important, particularly in elderly patients with critical limb ischaemia (CLI). Quality of life (QoL) is an important patient-reported outcome in vascular surgery. Frequently, the physical domain of QoL questionnaires represents an 'objective' evaluation of performing activities, which is expected to be impaired after major limb amputation. However, an objective appraisal of physical function is an assessment of health status (HS) and not of QoL. Little is known about the subjective appraisal of physical health (QoL). The goal of this study was to evaluate, prospectively, QoL in relation to HS in elderly CLI patients undergoing major limb amputation. METHODS Patients suffering from CLI aged 70 years or older were included in a prospective observational cohort study with a follow-up period of 1 year. Patients were divided according to having had an amputation or not. The World Health Organization Quality Of Life-BREF (WHOQOL-BREF) was used to asses QoL. The 12-Item Short Form Health Survey (SF-12) was used to measure HS. These self-reported questionnaires were completed five times during follow-up. RESULTS Two-hundred patients were included of whom 46 underwent a major limb amputation within one year. Amputees had a statistically significant improvement of their physical QoL after six months (14.0 vs. 9.0 (95% CI -7.84;-1.45),p = 0.005) and after a one-year follow-up (14.0 vs. 9.0 (95% CI -9.58;-1.46),p = 0.008). They did not however show any statistically significant difference in HS. For non-amputees, both physical QoL and HS improved. An instant statistically significant improvement of the physical QoL appeared 1 week after inclusion (12.0 vs. 10.9 (95% CI -1.57;-0.63),p<0.001). Similarly, statistically significant improvement in the physical HS first occurred at 1 week follow-up (29.0 vs. 28.9 (95% CI -5.78; -2.23),p = 0.003). CONCLUSIONS There is a clear difference between patients' functioning (HS) and the patients' appraisal of functioning (QoL). In elderly CLI patients, this study clearly suggests a discrepancy between the physical QoL (WHOQOL-BREF) and HS (SF-12) measurements in vascular amputees. This raises the question, which outcome measurement is the most relevant for elderly CLI patients. Individual treatment goals should be kept in mind when assessing the HS or QoL outcome of patients undergoing hospital care. With respect to shared decision making, distinctive and subjective QoL questionnaires, like the WHOQOL-BREF, provide a very important outcome measurement and should be used in future research.
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Affiliation(s)
- Chloé M L Peters
- Department of Surgery, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands.
| | - Jolanda de Vries
- Department of Medical and Clinical Psychology, Tilburg University, Warandelaan 2, 5037 AB Tilburg, The Netherlands; Department of Medical Psychology, Elisabeth-Two Cities Hospital, Doctor Deelenlaan 5, 5042 AD Tilburg, The Netherlands.
| | - Paul Lodder
- Department of Medical and Clinical Psychology, Tilburg University, Warandelaan 2, 5037 AB Tilburg, The Netherlands; Department of Methodology and Statistics, Tilburg University, Warandelaan 2, 5037 AB Tilburg, The Netherlands.
| | - Stijn L Steunenberg
- Department of Surgery, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands.
| | - Eelco J Veen
- Department of Surgery, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands.
| | - Hans G W de Groot
- Department of Surgery, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands.
| | - Gwan H Ho
- Department of Surgery, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands.
| | - Lijckle van der Laan
- Department of Surgery, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands.
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Seretny M, Colvin LA. Pain management in patients with vascular disease. Br J Anaesth 2018; 117 Suppl 2:ii95-ii106. [PMID: 27566812 DOI: 10.1093/bja/aew212] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2016] [Indexed: 12/29/2022] Open
Abstract
Vascular disease covers a wide range of conditions, including arterial, venous, and lymphatic disorders, with many of these being more common in the elderly. As the population ages, the incidence of vascular disease will increase, with a consequent increase in the requirement to manage both acute and chronic pain in this patient population. Pain management can be complex, as there are often multiple co-morbidities to be considered. An understanding of the underlying pain mechanisms is helpful in the logical direction of treatment, particularly in chronic pain states, such as phantom limb pain or complex regional pain syndrome. Acute pain management for vascular surgery presents a number of challenges, including coexisting anticoagulant medication, that may preclude the use of regional techniques. Within the limited evidence base, there is a suggestion that epidural analgesia provides better pain relief and reduced respiratory complications after major vascular surgery. For carotid endarterectomy, there is again some evidence supporting the use of local anaesthetic analgesia, either by infiltration or by superficial cervical plexus block. Chronic pain in vascular disease includes post-amputation pain, for which well-known risk factors include high pain levels before amputation and in the immediate postoperative period, emphasizing the importance of good pain control in the perioperative period. Complex regional pain syndrome is another challenging chronic pain syndrome with a wide variety of treatment options available, with the strongest evidence being for physical therapies. Further research is required to gain a better understanding of the underlying pathophysiological mechanisms in pain associated with vascular disease and the best analgesic approaches to manage it.
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Affiliation(s)
- M Seretny
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK
| | - L A Colvin
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK
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Affiliation(s)
- Alik Farber
- From the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston
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Khor BYC, Price P. The comparative efficacy of angiosome-directed and indirect revascularisation strategies to aid healing of chronic foot wounds in patients with co-morbid diabetes mellitus and critical limb ischaemia: a literature review. J Foot Ankle Res 2017; 10:26. [PMID: 28670345 PMCID: PMC5490238 DOI: 10.1186/s13047-017-0206-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/06/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Ischaemic ulcerations have been reported to persist and/or deteriorate despite technically successful revascularisations; a higher incidence of which affects patients with diabetes and critical limb ischaemia. In the context of wound healing, it is unclear if applications of the angiosome concept in 'direct revascularisation' (DR) would be able to aid the healing of chronic foot ulcerations better than the current 'best vessel' or 'indirect revascularisation' (IR) strategy in patients with co-morbid diabetes and critical limb ischaemia. METHODS A literature search was conducted in eight electronic databases, namely AMED, CINAHL, The Cochrane Library, ProQuest Health & Medicine Complete, ProQuest Nursing & Allied Health Source, PubMed, ScienceDirect and TRIP database. Articles were initially screened against a pre-established inclusion and exclusion criteria to determine eligibility and subsequently appraised using the Newcastle-Ottawa Scale. RESULTS Five retrospective studies of varying methodological quality were eligible for inclusion in this review. Critical analysis of an aggregated population (n = 280) from methodologically stronger studies indicates better wound healing outcomes in subjects who had undergone DR as compared to IR (p < 0.001; p = 0.04). DR also appears to result in a nearly twofold increase in probability of wound healing within 12 months (hazard ratio, 1.97; 95% CI, 1.34-2.90). This suggests that achieving direct arterial perfusion to the site of ulceration may be important for the healing of chronic diabetic foot ulcerations. CONCLUSION Incorporating an angiosome-directed approach in the lower limb revascularisation strategy could be a very useful adjunct to a solely indirect approach, which could increase the likelihood of wound healing. With the limited data currently available, findings appear promising and merit from further investigation. Additional research to form a solid evidence base for this revised strategy in patients with co-morbid diabetes and critical limb ischaemia is warranted.
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Affiliation(s)
- Benedictine Y. C. Khor
- Department of Podiatry, Galloway Community Hospital, NHS Dumfries & Galloway, Stranraer, UK
| | - Pamela Price
- Department of Podiatry, Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK
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Steunenberg SL, te Slaa A, Ho GH, Veen EJ, de Groot HG, van der Laan L. Dementia in Patients Suffering from Critical Limb Ischemia. Ann Vasc Surg 2017; 38:268-273. [DOI: 10.1016/j.avsg.2016.05.136] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 05/26/2016] [Accepted: 05/29/2016] [Indexed: 01/13/2023]
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Steunenberg SL, Raats JW, te Slaa A, de Vries J, van der Laan L. Quality of Life in Patients Suffering from Critical Limb Ischemia. Ann Vasc Surg 2016; 36:310-319. [DOI: 10.1016/j.avsg.2016.05.087] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 05/09/2016] [Accepted: 05/28/2016] [Indexed: 11/28/2022]
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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: 0.5] [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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Boden J, Lassance-Soares RM, Wang H, Wei Y, Spiga MG, Adi J, Layman H, Yu H, Vazquez-Padron RI, Andreopoulos F, Webster KA. Vascular Regeneration in Ischemic Hindlimb by Adeno-Associated Virus Expressing Conditionally Silenced Vascular Endothelial Growth Factor. J Am Heart Assoc 2016; 5:e001815. [PMID: 27231018 PMCID: PMC4937238 DOI: 10.1161/jaha.115.001815] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 04/19/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Critical limb ischemia (CLI) is the extreme manifestation of peripheral artery disease, a major unmet clinical need for which lower limb amputation is the only option for many patients. After 2 decades in development, therapeutic angiogenesis has been tested clinically via intramuscular delivery of proangiogenic proteins, genes, and stem cells. Efficacy has been modest to absent, and the largest phase 3 trial of gene therapy for CLI reported a worsening trend of plasmid fibroblast growth factor. In all clinical trials to date, gene therapy has used unregulated vectors with limited duration of expression. Only unregulated extended expression vectors such as adeno-associated virus (AAV) and lentivirus have been tested in preclinical models. METHODS AND RESULTS We present preclinical results of ischemia (hypoxia)-regulated conditionally silenced (CS) AAV-human vascular endothelial growth factor (hVEGF) gene delivery that shows efficacy and safety in a setting where other strategies fail. In a BALB/c mouse model of CLI, we show that gene therapy with AAV-CS-hVEGF, but not unregulated AAV or plasmid, vectors conferred limb salvage, protection from necrosis, and vascular regeneration when delivered via intramuscular or intra-arterial routes. All vector treatments conferred increased capillary density, but organized longitudinal arteries were selectively generated by AAV-CS-hVEGF. AAV-CS-hVEGF therapy reversibly activated angiogenic and vasculogenic genes, including Notch, SDF1, Angiopoietin, and Ephrin-B2. Reoxygenation extinguished VEGF expression and inactivated the program with no apparent adverse side effects. CONCLUSIONS Restriction of angiogenic growth factor expression to regions of ischemia supports the safe and stable reperfusion of hindlimbs in a clinically relevant murine model of CLI.
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Affiliation(s)
- Jeffrey Boden
- Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, FL Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Roberta Marques Lassance-Soares
- Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, FL Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Huilan Wang
- Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, FL Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Yuntao Wei
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Maria-Grazia Spiga
- Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, FL
| | - Jennipher Adi
- Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, FL
| | - Hans Layman
- Department of Bioengineering, University of Miami Miller School of Medicine, Miami, FL
| | - Hong Yu
- Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, FL Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Roberto I Vazquez-Padron
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Fotios Andreopoulos
- Department of Bioengineering, University of Miami Miller School of Medicine, Miami, FL
| | - Keith A Webster
- Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, FL Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, FL Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Thomas AR, Raats JW, Lensvelt MMA, de Groot HGW, Veen EJ, van der Laan L. Conservative Treatment in Selected Patients with Severe Critical Limb Ischemia. World J Surg 2016; 39:2090-5. [PMID: 25894404 DOI: 10.1007/s00268-015-3069-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the outcome of conservative treatment of severe critical limb ischemia (CLI) classified as Rutherford 5/6. BACKGROUND The preferred therapy for CLI is either endovascular revascularization or bypass surgery. With a growing aged population with more serious comorbidities, these therapies are not always a viable option. Primary amputation leads to decreased mobility and a reduced quality of life. There is a lack of literature regarding the outcome of conservative therapy. METHODS Hospital charts were reviewed of all patients who were diagnosed with Rutherford classification 5-6 and received conservative treatment and lacked interventional options. Outcome measures were mortality, complete wound closure, and limb salvage rate. RESULTS 38 patients were included with a median age of 80 years (range 57-97). The amputation rate during follow-up was 16%. In 58% of patients, complete wound closure was achieved. All-cause mortality was 58% with a 2-year survivability rate of 55%. CONCLUSIONS Conservative management in our selected patients with CLI results in a moderate rate of wound closure and acceptable amputation rates albeit with a high mortality rate. For patients not eligible for endovascular revascularization or bypass surgery, conservative treatment could be a viable option besides primary limb amputation.
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Affiliation(s)
- Adriaan R Thomas
- Department of Surgery, Amphia Hospital, P.O. Box 90518, 4800 RK, Breda, The Netherlands,
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