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Chen A, An E, Yan E, He D, Saripella A, Butris N, Tsang J, Englesakis M, Wong J, Alibhai S, Chung F. Incidence of preoperative instrumental activities of daily living (IADL) dependence and adverse outcomes in older surgical patients: A systematic review and meta-analysis. J Clin Anesth 2023; 89:111151. [PMID: 37210810 DOI: 10.1016/j.jclinane.2023.111151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/26/2023] [Accepted: 05/15/2023] [Indexed: 05/23/2023]
Abstract
STUDY OBJECTIVE Instrumental activities of daily living (IADLs) are essential to patient function and quality of life after surgery. In older surgical patients, the incidence of preoperative IADL dependence has not been well characterized in the literature. This systematic review and meta-analysis aimed to determine the pooled incidence of preoperative IADL dependence and the associated adverse outcomes in the older surgical population. DESIGN Systematic review and meta-analysis. SETTING MEDLINE, MEDLINE Epub Ahead of Print and In-Process, In-Data-Review & Other Non-Indexed Citations, Embase/Embase Classic, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews, ClinicalTrials.Gov, the WHO ICTRP (International Clinical Trials Registry Platform) were searched for relevant articles from 1969 to April 2022. PATIENTS Patients aged ≥60 years old undergoing surgery with preoperative IADL assessed by the Lawton IADL Scale. INTERVENTIONS Preoperative assessment. MEASUREMENT The primary outcome was the pooled incidence of preoperative IADL dependency. Additional outcomes included post-operative mortality, postoperative delirium [POD], functional status improvement, and discharge disposition. MAIN RESULTS Twenty-one studies (n = 5690) were included. In non-cardiac surgeries, the pooled incidence of preoperative IADL dependence was 37% (95% CI: 26.0%, 48.0%) among 2909 patients. Within cardiac surgeries, the pooled incidence of preoperative IADL dependence was 53% (95% CI: 24.0%, 82.0%) among 1074 patients. Preoperative IADL dependence was associated with an increased risk of postoperative delirium than those without IADL dependence (44.9% vs 24.4, OR 2.26; 95% CI: 1.42, 3.59; I2: 0%; P = 0.0005). CONCLUSIONS There is a high incidence of IADL dependence in older surgical patients undergoing non-cardiac and cardiac surgery. Preoperative IADL dependence was associated with a two-fold risk of postoperative delirium. Further work is needed to determine the feasibility of using the IADL scale preoperatively as a predictive tool for postoperative adverse outcomes.
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Affiliation(s)
- Alisia Chen
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ekaterina An
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ellene Yan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - David He
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Aparna Saripella
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Nina Butris
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Jinny Tsang
- Department of Immunology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marina Englesakis
- Library & Information Services, University Health Network, Toronto, ON, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Shabbir Alibhai
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network and University of Toronto, Toronto, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
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Mohamed SA, Viknaswaran NL, Doran J, Sanz-Nogués C, Ahmed K, Howard L, Tubassam M, O'Brien T, Walsh SR. Validation of ERICVA Risk Score as a Predictor of One Year Amputation-Free Survival of Patients with Critical Limb Ischemia. Ann Vasc Surg 2021; 75:171-8. [PMID: 33819592 DOI: 10.1016/j.avsg.2021.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/30/2021] [Accepted: 02/03/2021] [Indexed: 11/28/2022]
Abstract
Background The ERICVA score was derived to predict amputation-free survival in patients with critical limb ischemia (CLI). It may be a useful tool to stratify patients in trials of novel interventions to treat CLI but, as yet, it has not been externally validated. Methods A prospective database of CLI patients was developed during prescreening of patients for a phase 1 stem cell therapy clinical trial. The primary outcome was amputation free survival (AFS) at 1 year. Both the full ERICVA scale (11 parameters) and simplified ERICVA scale (5 parameters) were validated. Data analysis was performed by calculation of the area under the receiver operating characteristic (ROC) curve examining the predictive value of the scores. The Chi-square test was used to examine the association between risk group and one-year AFS and the cumulative survival of the three risk groups was compared using Kaplan Meier survival curves. Results A series of 179 CLI patients were included in the analysis. The Chi-square test of independence showed a significant association between the risk group (high, medium and low) and one-year AFS outcome (P = 0.0007). Kaplan-Meier survival curve showed significant difference in one-year AFS between the three risk groups (log-rank P < 0.001). The area under the curve (AUC) was found to be 0.63 and 0.61 for the full and simplified score, respectively. The sensitivity of the full score was 0.44 with specificity of 0.84. The simplified score had a sensitivity of 0.28 and specificity of 0.92. Conclusion The ERICVA risk score system was found to have a fair validity but cannot be considered reliable as a single predictor of one year AFS of CLI patients. The simplified score had an AUC almost identical to the full score and can accordingly replace the full score.
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de Donato G, Benedetto F, Stilo F, Chiesa R, Palombo D, Pasqui E, Panzano C, Pulli R, Novali C, Silingardi R, Grego F, Palasciano G, Setacci C. Evaluation of Clinical Outcomes After Revascularization in Patients With Chronic Limb-Threatening Ischemia: Results From a Prospective National Cohort Study (RIVALUTANDO). Angiology 2021; 72:480-489. [PMID: 33406850 DOI: 10.1177/0003319720980619] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We evaluated the outcomes of revascularization in patients with chronic limb-threatening ischemia (CLTI) treated in real-world settings. This is a prospective multicenter cohort study with 12-month follow-up enrolling patients (n = 287) with CLTI undergoing open, endovascular, or hybrid lower extremity revascularization. The primary end point was amputation-free survival (AFS) at 12 months. Cox proportional analysis was used to determine independent predictors of amputation and restenosis. At 30 days, major adverse cardiovascular and major adverse limb events (MALE) rates were 3.1% and 2.1%, respectively. At 1 year, the overall survival rate was 88.8%, the AFS was 86.6%, and the primary patency was 70.5%. Freedom from MALE was 62.5%. After multivariate analysis, smoking (hazard ratio [HR] = 2.2, P = 0.04), renal failure (HR = 2.3, P = 0.03), Rutherford class (≥5) (HR = 3.2, P = 0.01), and below-the-knee disease (HR = 2.0, P = 0.05) were significant predictors of amputation; iloprost infusion (>10 vials) (HR = 0.64, P = 0.05) was a significant protective factor. Cilostazol administration (HR = 0.77, P = 0.05) was a significant protective factor for restenosis. Results from this prospective multicenter registry offer a consistent overview of clinical outcomes of CLTI patients at 1 year when adequately revascularized. Medical treatment, including statins, cilostazol and iloprost, were associated with improved 1-year freedom from restenosis and amputation.
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Affiliation(s)
| | | | - Francesco Stilo
- Vascular Surgery, University of Rome Campus Biomedico, Italy
| | - Roberto Chiesa
- Vascular Surgery, University of Milano San Rafael, Italy
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He W, Wang P, Chen Q, Li C. Exercise enhances mitochondrial fission and mitophagy to improve myopathy following critical limb ischemia in elderly mice via the PGC1a/FNDC5/irisin pathway. Skelet Muscle 2020; 10:25. [PMID: 32933582 PMCID: PMC7490877 DOI: 10.1186/s13395-020-00245-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 09/01/2020] [Indexed: 12/28/2022] Open
Abstract
Background Elderly populations are susceptible to critical limb ischemia (CLI), but conventional treatments cannot significantly decrease amputation and mortality. Although exercise is an effective “non-pharmacological medicine” targeting mitochondria to improve skeletal muscle function, few studies have focused on the application of exercise in CLI. Methods Elderly male C57BL/6 mice (14 months old) were used to establish a CLI model to assess the effect of exercise on perfusion, performance recovery, apoptosis, mitochondrial function, and mitochondrial turnover in gastrocnemius muscle. The potential underlying mechanism mediated by PGC1a/FNDC5/irisin was confirmed in hypoxic and nutrient-deprived myotubes undergoing electrical pulse stimuli (EPS). Results Exercise significantly accelerated the perfusion recovery and exercise performance in ischemic limbs following CLI. Exercise improved the mitochondrial membrane potential and total ATP production and decreased apoptosis in the ischemic limbs. Exercise increased the formation of mitochondrial derived vesicle-like structures and decreased the mitochondrial length in the ischemic limbs, accompanied by upregulated PGC1a/FNDC5/irisin expression. In vitro, PGC1a/FNDC5/irisin downregulation decreased EPS-elevated PINK1, Parkin, DRP1, and LC3B mRNA levels. The irisin levels in the culture medium were correlated with the expression of mitochondrial fission and mitophagy markers in myotubes. Conclusion Exercise enhanced mitochondrial fission and selective autophagy to promote the recovery of myopathy after CLI in elderly mice through the PGC1a/FNDC5/irisin pathway, supporting the efficacy of exercise therapy in elderly individuals with CLI and demonstrating the potential of targeting PGC1a/FNDC5/irisin as a new strategy for the treatment of CLI.
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Affiliation(s)
- Wuyang He
- Department of Oncology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Peng Wang
- Department of Geriatric Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 76 Linjiang Road, Chongqing, 400010, China.,Department of Geriatric Cardiology, The Central Hospital of Fuling District, Chongqing, China
| | - Qingwei Chen
- Department of Geriatric Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 76 Linjiang Road, Chongqing, 400010, China.
| | - Chunqiu Li
- Department of Geriatric Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 76 Linjiang Road, Chongqing, 400010, China
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Khan T, Plotkin A, Magee GA, Shin L, Woelfel SL, Ziegler KR, Shih CD, Weaver FA, Armstrong DG, Rowe VL. Functional ambulatory status as a potential adjunctive decision-making tool following wound, level of ischemia, and severity of foot infection assessment. J Vasc Surg 2020; 72:738-746. [PMID: 32273222 DOI: 10.1016/j.jvs.2019.11.064] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 11/12/2019] [Indexed: 11/26/2022]
Abstract
The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System has been developed to stratify amputation risk on the basis of extent of the wound, level of ischemia, and severity of foot infection (WIfI). However, there are no currently validated metrics to assess, grade, and consider functional status, especially ambulatory status, as a major consideration during limb salvage efforts. Therefore, we propose an adjunct to the current WIfI system to include the patient's ambulatory functional status after initial assessment of limb threat. We propose a functional ambulatory score divided into grade 0, ambulation outside the home with or without an assistive device; grade 1, ambulation within the home with or without an assistive device; grade 2, minimal ambulation, limbs used for transfers; and grade 3, a person who is bed-bound. Adding ambulatory function as a supplementary assessment tool can guide clinical decision making to achieve optimal future functional ambulatory outcome, a patient-centered goal as critical as limb preservation. This adjunct may aid limb preservation teams in rapid, effective communication and clinical decision making after initial WIfI assessment. It may also improve efforts toward patient-centered care and functional ambulatory outcome as a primary objective. We suggest a score of functional ambulatory status should be included in future trials of patients with chronic limb-threatening ischemia.
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Affiliation(s)
- Tanzim Khan
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Anastasia Plotkin
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Laura Shin
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Stephanie L Woelfel
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Kenneth R Ziegler
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Chia Ding Shih
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - David G Armstrong
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Vincent L Rowe
- Division of Vascular Surgery and Endovascular Therapy, The Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Shimazoe H, Mii S, Koyanagi Y, Ishida M. Impact of Low Activity of Daily Living on the Prognosis of Patients with Critical Limb Ischemia and Sarcopenia. Ann Vasc Surg 2019; 61:156-164. [PMID: 31394242 DOI: 10.1016/j.avsg.2019.03.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 03/02/2019] [Accepted: 03/11/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND We aimed to investigate the impact of low activity of daily living (ADL) on the long-term outcomes after infrainguinal bypass surgery in patients with critical limb ischemia (CLI) and sarcopenia. METHODS In this multicenter retrospective cohort study, 110 patients with CLI who underwent infrainguinal bypass between April 2011 and September 2016 were divided into 4 groups according to the presence or absence of sarcopenia before surgery and ADL at discharge (Normal group: absence of sarcopenia and normal ADL [Barthel Index ≥60]; Low ADL alone group: absence of sarcopenia and abnormal ADL [Barthel Index <60]; Sarcopenia alone group: presence of sarcopenia and normal ADL; Sarcopenia and low ADL group: presence of sarcopenia and abnormal ADL). Three-year overall survival (OS) and amputation-free survival (AFS) were compared among the 4 groups using the Kaplan-Meier method, and Cox proportional hazards models were used to assess the unadjusted and adjusted associations between patient characteristics and 3-year OS and AFS. RESULTS The Sarcopenia and low ADL group was significantly inferior to the other 3 groups in 3-year OS (versus Normal group, P < 0.001; versus Low ADL alone group, P = 0.005; versus Sarcopenia alone group, P = 0.022) and was significantly inferior to the Normal group and Sarcopenia alone group in 3-year AFS (P < 0.001 and P = 0.027, respectively). In the multivariable analysis, after adjustment for age, sex, ischemic heart disease, and hemodialysis, the presence of both sarcopenia and low ADL was a significant predictor of 3-year OS (hazard ratio [HR] 5.99, 95% confidence interval [CI] 1.92-18.69, P = 0.002) and AFS (HR 3.63, 95% CI 1.27-10.39, P = 0.016). CONCLUSIONS Low ADL at discharge was a significant predictor of 3-year OS and AFS in patients with CLI and sarcopenia, while either sarcopenia alone or low ADL alone did not significantly affect outcomes.
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Affiliation(s)
- Hirofumi Shimazoe
- Department of Rehabilitation, Steel Memorial Yawata Hospital, Kitakyushu, Japan.
| | - Shinsuke Mii
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan
| | - Yasuhiro Koyanagi
- Department of Rehabilitation, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Masaru Ishida
- Department of Vascular Surgery, Steel Memorial Yawata Hospital, Kitakyushu, Japan
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Steunenberg SL, de Vries J, Raats JW, Verbogt N, Lodder P, van Eijck GJ, Veen EJ, de Groot HG, Ho GH, van der Laan L. Important differences between quality of life and health status in elderly patients suffering from critical limb ischemia. Clin Interv Aging 2019; 14:1221-1226. [PMID: 31371929 PMCID: PMC6626895 DOI: 10.2147/cia.s202725] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 05/09/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Critical limb ischemia (CLI) patients are often of advanced age with reduced health status (HS) and quality of life (QoL) at baseline. Physical health is considered as the most affected domain due to reduced mobility and ischemic pain. QoL and HS are often used interchangeably in the current literature. HS refers to objectively perceived physical, psychological, and social functioning and in assessing QoL, change is measured subjectively and can only be determined by the individual since it concerns patients’ evaluation of their functioning. It is important to distinguish between QoL and HS, especially in the concept of shared decision-making when the opinion of the patient is key. Goal of this study was to examine and compare QoL and HS in elderly CLI patients in relation to the used therapy, with a special interest in conservatively treated patients. Methods Patients suffering from CLI and ≥70 years old were included in a prospective study with a follow-up period of 1 year. Patients were divided into three groups; endovascular revascularization, surgical revascularization, and conservative therapy. The WHOQoL-Bref was used to determine QoL, and the 12-Item Short Form Health Survey was used to evaluate HS at baseline, 5–7 days, 6 weeks, 6 months, and 1 year. Results Physical QoL of endovascularly and surgically treated patients showed immediate significant improvement during follow-up in contrast to delayed increased physical HS at 6 weeks and 6 months (P<0.001). Conservatively treated patients showed significantly improved physical QoL at 6 and 12 months (P=0.02) in contrast to no significant improvement in physical HS. Conclusion This study demonstrates that QoL and HS are indeed not identical concepts and that differentiating between these two concepts could influence the choice of treatment in elderly CLI patients. Discriminating between QoL and HS is, therefore, of major importance for clinical practice, especially to achieve shared decision-making.
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Affiliation(s)
| | - Jolanda de Vries
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands.,Department of Medical Psychology, ETZ, Tilburg, The Netherlands
| | - Jelle W Raats
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | | | - Paul Lodder
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands.,Department of Methodology and Statistics, Tilburg University, Tilburg, The Netherlands
| | | | - Eelco J Veen
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | | | - Gwan H Ho
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
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Huang HL, Juang JMJ, Hsieh CA, Chou HH, Jang SJ, Ko YL. Risk stratification for low extremity amputation in critical limb ischemia patients who have undergone endovascular revascularization: A survival tree analysis. Medicine (Baltimore) 2019; 98:e16809. [PMID: 31415395 PMCID: PMC6831177 DOI: 10.1097/md.0000000000016809] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Patients with peripheral artery disease (PAD) are a heterogeneous population and differ in risk of mortality and low extremity amputation (LEA), which complicates clinical decision-making. This study aimed to develop a simple risk scale using decision tree methodology to guide physicians in managing critical limb ischemia (CLI) patients who will benefit from endovascular therapy (EVT).A total of 736 patients with CLI, Rutherford classification (RC) stage ≥4, and prior successful EVT were included. Variables significantly associated with LEA by univariate analysis (P < .05) were selected and put into classification tree analysis using the Classification and Regression Tree (CART) model with a dependent variable, amputation, and depth of tree = 3. Four risk groups were generated according to the order of amputation rate. The amputation-free survival (AFS) times between groups were compared using the Kaplan-Meier curve with the log-rank test.Patients were classified as high risk for amputation (G4) (WBC counts ≥10,000/μl, and platelet-lymphocyte ratio (PLR) ≥130.337); intermediate risk group 1 (G3) (WBC < 10,000/μl and RC stage before EVT > 5); intermediate risk group 2 (G2) (WBC count ≥ 10,000/μl, and PLR < 130.337) and low-risk group (G1) (WBC < 10,000/μl, RC before EVT ≤ 5). G2, G3, and G4 risk groups had shorter AFS time (range, 58.7 to 65.5 months) than the G1 risk group (100 months) (P < .05). Risk of LEA was significantly higher in the G4, G3, and G2 groups than in the G1 group (P ≤ .05). The G4 group had the highest risk of amputation (odds ratio = 6.84, P < .001).This simple risk scale model can help healthcare professionals more easily identify and appropriately treat patients with CLI who are at different levels of risk for LEA following endovascular revascularization.
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Affiliation(s)
- Hsuan-Li Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University
| | - Jyh-Ming Jimmy Juang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
| | - Chien-An Hsieh
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
| | - Hsin-Hua Chou
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Shih-Jung Jang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Lin Ko
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation
- School of Medicine, Tzu Chi University, Hualien, Taiwan
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Martínez M, Sosa C, Velescu A, Llort C, Elosua R, Clarà A. Predictive factors of a poor outcome following revascularization for critical limb ischemia: implications for practice. INT ANGIOL 2018; 37:370-376. [DOI: 10.23736/s0392-9590.18.03986-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Monaro S, West S, Pinkova J, Gullick J. The chaos of hospitalisation for patients with critical limb ischaemia approaching major amputation. J Clin Nurs 2018; 27:3530-3543. [PMID: 29776002 DOI: 10.1111/jocn.14536] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 04/10/2018] [Accepted: 05/08/2018] [Indexed: 01/23/2023]
Abstract
AIMS AND OBJECTIVES To illuminate the hospital experience for patients and families when major amputation has been advised for critical limb ischaemia (CLI). BACKGROUND CLI creates significant burden to the health system and the family, particularly as the person with CLI approaches amputation. Major amputation is often offered as a late intervention for CLI in response to the marked deterioration of an ischaemic limb, and functional decline from reduced mobility, intractable pain, infection and/or toxaemia. While a wealth of clinical outcome data on CLI and amputation exists internationally, little is known about the patient/family-centred experience of hospitalisation to inform preservation of personhood and patient-centred care planning. DESIGN Longitudinal qualitative study using Heideggerian phenomenology. METHODS Fourteen patients and 13 family carers provided a semistructured interview after advice for major amputation. Where amputation followed, a second interview (6 months postprocedure) was provided by eight patients and seven family carers. Forty-two semistructured interviews were audio-recorded and transcribed verbatim. Hermeneutic phenomenological analysis followed. RESULTS Hospitalisation for CLI, with or without amputation, created a sense of chaos, characterised by being fragile and needing more time for care (fragile body and fragile mind, nurse busyness and carer hypervigilance), being adrift within uncontrollable spaces (noise, unreliable space, precarious accommodation and unpredictable scheduling) and being confused by missed and mixed messages (multiple stakeholders, information overload and cultural/linguistic diversity). CONCLUSIONS Patients and families need a range of strategies to assist mindful decision-making in preparation for amputation in what for them is a chaotic process occurring within a chaotic environment. Cognitive deficits increase the care complexity and burden of family advocacy. RELEVANCE TO CLINICAL PRACTICE A coordinated, interprofessional response should improve systems for communication, family engagement, operation scheduling and discharge planning to support preparation, adjustment and allow a sense of safety to develop. Formal peer support for patients and caregivers should be actively facilitated.
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Affiliation(s)
- Susan Monaro
- Concord Repatriation General Hospital, Concord, NSW, Australia.,University of Sydney, Susan Wakil School of Nursing & Midwifery, NSW, Australia
| | - Sandra West
- University of Sydney, Susan Wakil School of Nursing & Midwifery, NSW, Australia
| | - Jana Pinkova
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Janice Gullick
- University of Sydney, Susan Wakil School of Nursing & Midwifery, NSW, Australia
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Klaphake S, de Leur K, Mulder PG, Ho GH, de Groot HG, Veen EJ, van der Laan L. Life Expectancy and Outcome of Different Treatment Strategies for Critical Limb Ischemia in the Elderly Patients. Ann Vasc Surg 2018; 46:241-248. [DOI: 10.1016/j.avsg.2017.06.141] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/20/2017] [Accepted: 06/25/2017] [Indexed: 10/19/2022]
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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] [What about the content of this article? (0)] [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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Jaff MR, Weinberg I. How to Treat Critical Limb Ischemia: The Critical Need for High-Grade Evidence. JACC Cardiovasc Interv 2016; 9:2566-7. [PMID: 28007206 DOI: 10.1016/j.jcin.2016.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 10/12/2016] [Indexed: 11/23/2022]
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Kordzadeh A, Askari A, Panayiotopoulos YP. Validation of the Guy's scoring system in patient selection for femoro-distal bypass grafting to a single calf or pedal artery. Vascular 2015; 24:295-303. [PMID: 26088618 DOI: 10.1177/1708538115591929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES First external validation of a preoperative scoring system (Guy's) in patient selection for femoro-distal bypass grafting to single calf or pedal artery in critical limb ischemia (Fontaine III & IV/Rutherford grade IV, V & VI). MATERIAL AND METHODS A prospective study of 76 (n = 76) consecutive femoro-crural/pedal bypass grafts on 72 individuals (n = 72) from 2008 to 2011 with 36 months mean follow-up was performed. All cases were scored against a previously designed and published scoring system (ranging from 0 to 10) based on: inflow, outflow, graft material, flow type, patent pedal vessels and diabetes mellitus. RESULTS Preoperative score of 0-4 (n = 37) demonstrated the primary patency of 27% at 10.3 months. This value for intermediate group 5-7 (n = 34) was 70.6% at 18.9 months. The high-score group 8-10 (n = 4) showed the longest primary patency (80%) at 27.3 months. Kaplan-Meier survival analysis exhibited a consistent and significant difference in primary assisted, secondary patency and overall limb/foot salvage amongst all individual scoring groups (p < 0.001). CONCLUSION This study validates and complements the Guy's scoring system and provides a platform for the identification of critical limb ischemia patients in whom the result of femoro-crural/distal bypass grafting is so poor that primary amputation may be both clinically and economically more justified.
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Affiliation(s)
- Ali Kordzadeh
- Department of Vascular and Endovascular Surgery, Mid Essex Hospital Services NHS Trust, Broomfield Hospital, Essex, UK
| | - Alan Askari
- Department of Vascular and Endovascular Surgery, Mid Essex Hospital Services NHS Trust, Broomfield Hospital, Essex, UK
| | - Yiannis P Panayiotopoulos
- Department of Vascular and Endovascular Surgery, Mid Essex Hospital Services NHS Trust, Broomfield Hospital, Essex, UK
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Lejay A, Choquet P, Thaveau F, Singh F, Schlagowski A, Charles AL, Laverny G, Metzger D, Zoll J, Chakfe N, Geny B. A new murine model of sustainable and durable chronic critical limb ischemia fairly mimicking human pathology. Eur J Vasc Endovasc Surg 2015; 49:205-12. [PMID: 25579876 DOI: 10.1016/j.ejvs.2014.12.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 12/04/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To establish a chronic mouse model of critical limb ischemia (CLI) with in vivo and ex vivo validation, closely mimicking human pathology. METHODS Swiss mice (n = 28) were submitted to sequential unilateral femoral (day 0) and iliac (day 4) ligatures. Ischemia was confirmed by clinical scores (tissue and functional damages) and methoxyisobutylisonitrile (MIBI) scintigraphies at days 0, 4, 6, 10, 20, and 30. At days 10, 20, and 30, muscle mitochondrial respiration, calcium retention capacity (CRC), and production of reactive oxygen species (ROS) were investigated, together with transcripts of mitochondrial biogenesis and antioxidant enzymes. Histological analysis was also performed. RESULTS Clinical and functional damage confirmed CLI. MIBI scintigraphies showed hypoperfusion of the ischemic limb, which remained stable until day 30. Mitochondrial respiration was impaired in ischemic muscles compared with controls (Vmax = 7.93 ± 0.99 vs. 10.09 ± 2.87 mmol/L O2/minute/mg dry weight [dw]; p = .01), together with impaired CRC (7.4 ± 1.6 mmol/L minute/mg dw vs. 11.9 ± 0.9 mmol/L minute/mg dw; p < .001) and biogenesis (41% decrease in peroxisome proliferator-activated receptor gamma coactivator [PGC]-1α, 49% decrease in PGC-1β, and 41% decrease in nuclear respiratory factor-1). Ischemic muscles also demonstrated increased production of ROS under electron paramagnetic resonance (0.084 ± 0.029 vs. 0.051 ± 0.031 mmol/L minute/mg dw; p = .03) and with dihydroethidium staining (3622 ± 604 arbitrary units of fluorescence vs. 1224 ± 324; p < .01), decreased antioxidant enzymes (32% decrease in superoxide dismutase [SOD]1, 41% decrease in SOD2, and 49% decrease in catalase), and myopathic features (wider range in fiber size, rounded shape, centrally located nuclei, and smaller cross-sectional areas). All defects were stable over time. CONCLUSION Sequential femoral and iliac ligatures closely mimic human functional, clinical, scintigraphic, and skeletal muscle mitochondrial characteristics, and could prove useful for testing therapeutic approaches.
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Ghoneim B, Elwan H, Eldaly W, Khairy H, Taha A, Gad A. Management of critical lower limb ischemia in endovascular era: experience from 511 patients. Int J Angiol 2014; 23:197-206. [PMID: 25317033 PMCID: PMC4172447 DOI: 10.1055/s-0034-1382825] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
This study aims at the assessment of the achievability of the endovascular treatment of patients with critical limb ischemia (CLI) and the role of bypass in such patient. This is a prospective study conducted on patients with chronic atherosclerotic critical lower limb ischemia presenting to us over a period of 3 years. Patients presenting with nonsalvageable limbs requiring primary major amputation and nonatherosclerotic causes of CLI were excluded. Endovascular treatment was the first choice modality of treatment in revascularization of all patients. Open surgery was offered selectively for patient whom endovascular failed or complicated and for long TransAtlantic Inter-Society Consensus (TASC) II lesions in fit patients. This study included 511 cases of CLI, and the mean age was 64.5 years. Patients with Rutherford IV, V, and VI were 19.25, 60.5, and 19.25%, respectively. The TASC II aortoiliac lesions were as follows: A, B, C, and D in 33.7, 12,15.7, and 38.6%, respectively, and infrainguinal lesions were A, B, C, and D in 3.7, 19, 35.4, and 68.3%, respectively. A total of 78.3% of patients were treated by endovascular totally, while 16% were treated by surgery from the start, 3.7% of endovascular cases were converted to open surgery after failure of endovascular treatment, and 2% was offered hybrid treatment. Crossing of lesions by subintimal and intraluminal was 12.5 and 87.5%, respectively. Technical success in endovascular was 94%; however, we could successfully revascularize 96.8% of all CLI presented in this study by either surgery or endovascular. On 24 months follow-up, primary patency, secondary patency, and limb salvage by percutaneous transluminal angioplasty are 77.8, 84.7, and 90.7%, respectively. Revascularization by endovascular achieves high technical success and limb salvage in CLI, hence should be considered as preferred choice of treatment. However, both endovascular and surgery should not be counteracting each other and using both can revascularize 96.6% of CLI.
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Affiliation(s)
- Baker Ghoneim
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Hussein Elwan
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Waleed Eldaly
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Hussein Khairy
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Ahmad Taha
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Amr Gad
- Vascular Surgery Unit, Faculty of Medicine, Cairo University, Giza, Egypt
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Ambler GK, Dapaah A, Al Zuhir N, Hayes PD, Gohel MS, Boyle JR, Varty K, Coughlin PA. Independence and mobility after infrainguinal lower limb bypass surgery for critical limb ischemia. J Vasc Surg 2014; 59:983-987.e2. [DOI: 10.1016/j.jvs.2013.10.077] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 10/15/2013] [Accepted: 10/16/2013] [Indexed: 11/30/2022]
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Bosma J, Vahl A, Wisselink W. Systematic Review on Health-Related Quality of Life After Revascularization and Primary Amputation in Patients With Critical Limb Ischemia. Ann Vasc Surg 2013; 27:1105-14. [DOI: 10.1016/j.avsg.2013.01.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 01/19/2013] [Accepted: 01/28/2013] [Indexed: 11/17/2022]
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Muscari I, Iacoponi F, Cantarini L, Lucherini OM, Simonini G, Brizi MG, Vitale A, Frediani B, Cimaz R, Galeazzi M. The diagnostic evaluation of patients with potential adult-onset autoinflammatory disorders: our experience and review of the literature. Autoimmun Rev 2012; 12:10-3. [PMID: 22878268 DOI: 10.1016/j.autrev.2012.07.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Hereditary periodic fever syndromes (HPFSs) are a group of inherited disorders of the innate immune system caused by mutations of genes involved in the regulation or activation of the inflammatory response, which belong to the category of autoinflammatory disorders. Most HPFs typically have an onset in pediatric age, while a limited number of patients experience disease onset during adulthood. The relative rarity and lack of information on adult-onset autoinflammatory diseases make it likely that genetic testing is often inconclusive. Recently, we have identified a set of variables related to the probability of detecting gene mutations in MEFV, responsible for familial Mediterranean fever, and TNFRSF1A, responsible for tumor necrosis factor receptor-associated periodic syndrome. In addition, we have proposed a diagnostic score for identifying those patients at high risk of carrying mutations in these genes. However, before the score can be recommended for application, further evaluation by means of longitudinal studies on different ethnicities and different populations deriving from other geographical areas is needed in order to definitively verify both its sensitivity and its specificity. The present manuscript offers our suggestions on how to establish a differential diagnosis for adult-onset HPFs, as well as a review of the literature, and we also provide a score revision available online.
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