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Coman HF, Stancu B, Andercou OA, Ciocan R, Gherman CD, Rusu A, Gavan NA, Bondor CI, Gavan AD, Bala CG, Necula A, Ana T, Tatiana T, Haldenwang PL. Five-Year Trends of Vascular Disease-Related Amputations in Romania: A Retrospective Database Study. J Clin Med 2024; 13:2549. [PMID: 38731078 PMCID: PMC11084782 DOI: 10.3390/jcm13092549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/15/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Background/Objectives: Lower extremity amputations (LEAs) are a burdensome complication of peripheral artery disease (PAD) and/or arterial embolism and thrombosis (AET). We assessed the trends in PAD- and/or AET-related LEAs in Romania. Methods: This retrospective study (2015-2019) analyzed data on minor and major LEAs in hospitalized patients recorded in the National School for Public Health, Management, and Health Education database. The absolute numbers and incidences of LEAs were analyzed by diagnosis type, year, age, sex, and amputation level. Results: Of 38,590 vascular disease-related amputations recorded nationwide, 36,162 were in PAD and 2428 in AET patients. The average LEA incidence in the general population was 34.73 (minimum: 31.96 in 2015; maximum: 36.57 in 2019). The average incidence of major amputations, amputations above the knee, hip amputations, amputations below the knee, and minor amputations was 16.21 (15.62 in 2015; 16.84 in 2018), 13.76 (13.33 in 2015; 14.28 in 2018), 0.29 (0.22 in 2017; 0.35 in 2019), 2.15 (2.00 in 2015; 2.28 in 2019), and 18.52 (16.34 in 2015; 20.12 in 2019), respectively. Yearly PAD- and/or AET-related amputations were significantly higher in men versus women. The overall number of LEAs increased with age, particularly in patients ≥ 70 years. The increase in the total number of amputations was mainly due to a constant rise in minor amputations for both groups, regardless of gender. Conclusions: PAD- and/or AET-related LEAs in Romania increased from 2015 to 2019, with men having a greater incidence than women. Raising awareness and effective management strategies are needed to prevent LEAs.
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Affiliation(s)
- Horațiu F. Coman
- Vascular Surgery Clinic, Cluj County Emergency Hospital, 400347 Cluj-Napoca, Romania;
| | - Bogdan Stancu
- Second Department of Surgery, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania;
| | - Octavian A. Andercou
- Second Department of Surgery, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania;
| | - Razvan Ciocan
- Department of Surgery—Practical Abilities, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania; (R.C.); (C.D.G.)
| | - Claudia D. Gherman
- Department of Surgery—Practical Abilities, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania; (R.C.); (C.D.G.)
| | - Adriana Rusu
- Department of Diabetes and Nutrition Diseases, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania; (A.R.); (C.G.B.)
| | | | - Cosmina I. Bondor
- Department of Medical Informatics and Biostatistics, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
| | - Alexandru D. Gavan
- Department of Medical Devices, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
| | - Cornelia G. Bala
- Department of Diabetes and Nutrition Diseases, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania; (A.R.); (C.G.B.)
| | - Alexandru Necula
- Faculty of Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania;
| | - Trif Ana
- Vascular Surgery Department, “Nicolae Stăncioiu” Heart Institute, 400001 Cluj-Napoca, Romania;
| | - Trif Tatiana
- Anesthesia and Intensive Care Department, Regional Institute of Gastroenterology & Hepatology “Prof. Dr. Octavian Fodor”, 400394 Cluj-Napoca, Romania;
| | - Peter L. Haldenwang
- Department for Cardiothoracic Surgery, University Hospital Bergmannsheil Bochum, Ruhr-University of Bochum, 44789 Bochum, Germany;
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Oliveira RHDM, Annex BH, Popel AS. Endothelial cells signaling and patterning under hypoxia: a mechanistic integrative computational model including the Notch-Dll4 pathway. Front Physiol 2024; 15:1351753. [PMID: 38455844 PMCID: PMC10917925 DOI: 10.3389/fphys.2024.1351753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/12/2024] [Indexed: 03/09/2024] Open
Abstract
Introduction: Several signaling pathways are activated during hypoxia to promote angiogenesis, leading to endothelial cell patterning, interaction, and downstream signaling. Understanding the mechanistic signaling differences between endothelial cells under normoxia and hypoxia and their response to different stimuli can guide therapies to modulate angiogenesis. We present a novel mechanistic model of interacting endothelial cells, including the main pathways involved in angiogenesis. Methods: We calibrate and fit the model parameters based on well-established modeling techniques that include structural and practical parameter identifiability, uncertainty quantification, and global sensitivity. Results: Our results indicate that the main pathways involved in patterning tip and stalk endothelial cells under hypoxia differ, and the time under hypoxia interferes with how different stimuli affect patterning. Additionally, our simulations indicate that Notch signaling might regulate vascular permeability and establish different Nitric Oxide release patterns for tip/stalk cells. Following simulations with various stimuli, our model suggests that factors such as time under hypoxia and oxygen availability must be considered for EC pattern control. Discussion: This project provides insights into the signaling and patterning of endothelial cells under various oxygen levels and stimulation by VEGFA and is our first integrative approach toward achieving EC control as a method for improving angiogenesis. Overall, our model provides a computational framework that can be built on to test angiogenesis-related therapies by modulation of different pathways, such as the Notch pathway.
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Affiliation(s)
| | - Brian H. Annex
- Medical College of Georgia, Augusta University, Augusta, GA, United States
| | - Aleksander S. Popel
- Department of Biomedical Engineering, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
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Trier Heiberg Brix A, Rubin KH, Nymark T, Schmal H, Lindberg-Larsen M. Major lower extremity amputations - risk of re-amputation, time to re-amputation, and risk factors: a nationwide cohort study from Denmark. Acta Orthop 2024; 95:86-91. [PMID: 38305435 PMCID: PMC10836152 DOI: 10.2340/17453674.2024.39963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 01/04/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND AND PURPOSE Re-amputation after lower extremity amputation is frequent. The primary aim of our study was to investigate cumulative re-amputation risk after transtibial amputation (TTA), knee disarticulation (KD), and transfemoral amputation (TFA) and secondarily to investigate time to re-amputation, and risk factors. METHODS This observational cohort study was based on data from the Danish Nationwide Health registers. The population included first-time major lower extremity amputations (MLEA) performed in patients ≥ 50 years between 2010 and 2021. Both left and right sided MLEA from the same patient were included as index procedures. RESULTS 11,743 index MLEAs on 10,052 patients were included. The overall cumulative risks for re-amputation were 29% (95% confidence interval [CI] 27-30), 30% (CI 26-35), and 11% (CI 10-12) for TTA, KD, and TFA, respectively. 58% of re-amputations were performed within 30 days after index MLEA. Risk factors for re-amputation within 30 days were dyslipidemia (hazard ratio [HR] 1.2, CI 1.0-1.3), renal insufficiency (HR 1.2, CI 1.1-1.4), and prior vascular surgery (HR 1.3, CI 1.2-1.5). CONCLUSION The risk of re-amputation was more than twice as high after TTA (29%) and KD (30%) compared with TFA (11%). Most re-amputations were conducted within 30 days of the index MLEA. Dyslipidemia, renal insufficiency, and prior vascular surgery were associated with higher risk of re-amputation.
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Affiliation(s)
- Anna Trier Heiberg Brix
- Department of Orthopedic Surgery and Traumatology, Odense University Hospital, Odense; Department of Clinical Research, University of Southern Denmark, Odense.
| | - Katrine Hass Rubin
- Department of Clinical Research, University of Southern Denmark, Odense; Research Unit OPEN, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Tine Nymark
- Department of Orthopedic Surgery and Traumatology, Odense University Hospital, Odense; Department of Clinical Research, University of Southern Denmark, Odense. Tine
| | - Hagen Schmal
- Department of Orthopedic Surgery and Traumatology, Odense University Hospital, Odense; Department of Orthopedics and Traumatology, University Medical Center Freiburg, Germany
| | - Martin Lindberg-Larsen
- Department of Orthopedic Surgery and Traumatology, Odense University Hospital, Odense; Department of Clinical Research, University of Southern Denmark, Odense
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Ionac S, Rogers SK, Bondor CI, Bowling FL, Dragoi II, Ionac M. Lower Extremity Amputation and Peripheral Revascularisation Rates in Romania and Their Relationship with Comorbidities and Vascular Care. J Clin Med 2023; 13:52. [PMID: 38202058 PMCID: PMC10779533 DOI: 10.3390/jcm13010052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
(1) Background: This retrospective Romanian study aimed to calculate the rate of, and comparison between, amputation and revascularisation for patients with either cardiovascular or diabetic comorbidities. (2) Materials: In our hospital-based database, we analysed patient-level data from a series of 61 hospitals for 2019, which covers 44.9% of the amputation patients for that year. The national database is compiled by the national houses of insurance and was used to follow amputations and revascularisations between 2016 and 2021. (3) Results: During the six-year period, the mean number of amputations and revascularisations was 72.4 per 100,000 inhabitants per year for both groups. In this period, a decline in open-surgical revascularisation was observed from 58.3% to 47.5% in all interventions but was not statistically significant (r = -0.20, p = 0.70). The mean age of patients with amputation (hospital-based database) was 67 years. Of these patients, only 5.1% underwent revascularisation in the same hospital prior to amputation. The most common comorbidities in those undergoing amputations were peripheral arterial disease (76.8%), diabetes (60.8%), and arterial hypertension (53.5%). Most amputations were undertaken by general surgeons (73.0%) and only a small number of patients were treated by vascular surgeons (17.4%). (4) Conclusions: The signal from our data indicates that Romanian patients probably have a high risk of amputation > 5 years earlier than Western European countries, such as Denmark, Finland, and Germany. The prevalence of revascularisations in Romania is 64% lower than in the Western European countries.
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Affiliation(s)
- Stefan Ionac
- CerVasc, Vascular and Endovascular Surgery Research Center, Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Piata Eftimie Murgu 2, 300041 Timisoara, Romania;
| | - Steven K. Rogers
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
- Manchester Academic Vascular Research and Innovation Centre (MAVRIC), Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
| | - Cosmina I. Bondor
- Department of Medical Informatics and Biostatistics, Iuliu Hațeganu University of Medicine and Pharmacy, 6 Pasteur Street, 400349 Cluj-Napoca, Romania
| | - Frank L. Bowling
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
- Manchester Academic Vascular Research and Innovation Centre (MAVRIC), Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
| | - Iulia Iovanca Dragoi
- CerVasc, Vascular and Endovascular Surgery Research Center, Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Piata Eftimie Murgu 2, 300041 Timisoara, Romania;
| | - Mihai Ionac
- Clinic of Vascular Surgery, Victor Babes University of Medicine and Pharmacy, Piata Eftimie Murgu 2, 300041 Timisoara, Romania;
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Oliveira RHM, Annex BH, Popel AS. Endothelial cells signaling and patterning under hypoxia: a mechanistic integrative computational model including the Notch-Dll4 pathway. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.03.539270. [PMID: 37205581 PMCID: PMC10187169 DOI: 10.1101/2023.05.03.539270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Several signaling pathways are activated during hypoxia to promote angiogenesis, leading to endothelial cell patterning, interaction, and downstream signaling. Understanding the mechanistic signaling differences between normoxia and hypoxia can guide therapies to modulate angiogenesis. We present a novel mechanistic model of interacting endothelial cells, including the main pathways involved in angiogenesis. We calibrate and fit the model parameters based on well-established modeling techniques. Our results indicate that the main pathways involved in the patterning of tip and stalk endothelial cells under hypoxia differ, and the time under hypoxia affects how a reaction affects patterning. Interestingly, the interaction of receptors with Neuropilin1 is also relevant for cell patterning. Our simulations under different oxygen concentrations indicate time- and oxygen-availability-dependent responses for the two cells. Following simulations with various stimuli, our model suggests that factors such as period under hypoxia and oxygen availability must be considered for pattern control. This project provides insights into the signaling and patterning of endothelial cells under hypoxia, contributing to studies in the field.
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Affiliation(s)
- Rebeca Hannah M Oliveira
- Department of Biomedical Engineering, School of Medicine, Johns Hopkins University, Baltimore, Maryland, 21205, USA
| | - Brian H Annex
- Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Aleksander S Popel
- Department of Biomedical Engineering, School of Medicine, Johns Hopkins University, Baltimore, Maryland, 21205, USA
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Foussard N, Dari L, Ducasse E, Rigalleau V, Mohammedi K, Caradu C. Lower-limb peripheral arterial disease and amputations in people with diabetes: Risk factors, prognostic value and management. Presse Med 2023; 52:104164. [PMID: 36863662 DOI: 10.1016/j.lpm.2023.104164] [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] [Received: 10/04/2022] [Revised: 12/20/2022] [Accepted: 02/17/2023] [Indexed: 03/04/2023] Open
Abstract
Lower-limb peripheral arterial disease (PAD), is a common manifestation of systemic atherosclerosis, resulting from a partial or complete obstruction of at least one lower-limb arteries. PAD is a major endemic disease with an excess risk of major cardiovascular events and death. It also leads to disability, high rates of lower-limb adverse events and non-traumatic amputation. In patients with diabetes, PAD is particularly frequent and has a worse prognosis than in patients without diabetes. The risk factors of PAD are comparable to those for cardiovascular disease. The ankle-brachial index is usually recommended to screen PAD despite its limited performance in patients with diabetes, affected by the presence of peripheral neuropathy, medial arterial calcification, incompressible arteries and infection. Toe brachial index and toe pressure emerge as alternative screening tools. The management of PAD requires strict control of cardiovascular risk factors including diabetes, hypertension and dyslipidaemia, the use of antiplatelet agents and lifestyle management, to reduce cardiovascular adverse events, but few randomized controlled trials have evaluated the benefits of these treatments in PAD. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in PAD prognosis. Further studies are required to increase our understanding of the pathophysiology of PAD and to evaluate the interest of different therapeutic strategies in the occurrence and progression of PAD in patients with diabetes. Here, we present a narrative and contemporary review to synthesize the key epidemiology findings, screening and diagnosis methods, and major therapeutic advances regarding PAD in patients with diabetes.
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Affiliation(s)
- Ninon Foussard
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Loubna Dari
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; Bordeaux University Hospital, Hôpital Saint-André, Vascular Medicine Department, Bordeaux, France
| | - Eric Ducasse
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France; Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
| | - Vincent Rigalleau
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France
| | - Kamel Mohammedi
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France.
| | - Caroline Caradu
- Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
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Houlind KC, Kjellberg J. Variation in lower limb amputation rates: a national scandal. Br J Surg 2023; 110:291-293. [PMID: 36630673 DOI: 10.1093/bjs/znac417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/04/2022] [Indexed: 01/12/2023]
Affiliation(s)
- Kim Christian Houlind
- Department of Vascular Surgery, Kolding Hospital, University Hospitals of Southern Denmark, Kolding, Denmark.,Department of Regional Health Research, University of Southern Denmark, Kolding, Denmark.,Department of Vascular Surgery, Aalborg University Hospital, Kolding, Denmark
| | - Jakob Kjellberg
- VIVE-The Danish Center for Social Science Research, Kolding, Denmark
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Bianchini Massoni C, Strozzi F, Epifani E, Zenunaj G, Ucci A, Paladini I, Gasbarro V, Tusini N, Freyrie A. Real-world outcomes of Cook Zilver PTX in femoro-popliteal district from multicenter experience. INT ANGIOL 2023; 42:9-18. [PMID: 36534022 DOI: 10.23736/s0392-9590.22.04959-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The purpose is to evaluate the follow-up outcomes after femoro-popliteal stenting with Cook Zilver PTX in a multicenter experience. METHODS Collected data from four Units were retrospectively joined and analyzed considering Zilver PTX deployed from August 2009 according to the instruction for use. Patient demographics, preoperative comorbidities, Rutherford classification, arterial characteristics and stent data were considered. Target lesion revascularization (TLR) was defined as reintervention performed for ≥50% diameter stenosis after recurrent clinical symptoms. Primary outcome was the freedom from TLR (ffTLR) and its risk factors. Secondary outcomes were primary patency (PP) of the stent, amputation-free survival (AFS) and their risk factors. RESULTS Considering 203 patients (mean age: 73.5 years ±10.6; male: 66.5%) and 263 stents (median 2 stents/patient, range 1-5stent/patient), chronic limb-threatening ischemia (CLTI) affected 154 patients (75.9%). The length of the treated lesion was <120 mm in 99 (48.8%), ≥120 mm and <200 mm in 65 (32%) and ≥200 mm in 39 (19.2%) cases, respectively; the reference vessel mean diameter was 5.5±0.7 mm; chronic total occlusion was treated in 153 (75.4%) patients, the popliteal artery was involved in 56 (27.6%) cases and prior endovascular intervention was performed in 27 (13.3%) cases. Two or more crural run-off vessels were patent in 124 (61.1%). Mean follow-up was 23.2 months ±21.3. At 1, 2 and 3 years, the ffTLR was 90.6±4.2%, 86.4±6.1% and 80.4±8.3%, respectively, and the PP was 85.6±5.0%, 74.2±7.6% and 72.7±8.2%, respectively. Negative prognostic factor for ffTLR and PP was the reference vessel diameter (P=0.001 and P<0.001, respectively). At 1, 2 and 3 years, the AFS was 81.8±6.0%, 75.5±7.1% and 74.2±7.5% respectively; coronary artery disease (P=0.041) and CLTI (P=0.011) resulted negative prognostic factors. CONCLUSIONS In the real-world practice, around 3/4 of patients were treated for CLTI. The rate of ffTLR is high, and PP is substantially lower. A small vessel diameter (<5 mm) is a negative factor for both ffTLR and PP. The rate of AFS is about 75% at 2 years and CLTI and coronary artery disease are negative prognostic factors.
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Affiliation(s)
- Claudio Bianchini Massoni
- Unit of Vascular Surgery, Department of Medicine and Surgery, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy -
| | - Francesco Strozzi
- Unit of Vascular Surgery, Department of General and Specialist Surgery, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - Enrico Epifani
- Unit of Radiology, Diagnostic Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Gladiol Zenunaj
- Unit of Vascular Surgery, Department of Surgery, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Alessandro Ucci
- Unit of Vascular Surgery, Department of Medicine and Surgery, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Ilaria Paladini
- Unit of Radiology, Diagnostic Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Vincenzo Gasbarro
- Unit of Vascular Surgery, Department of Surgery, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | - Nicola Tusini
- Unit of Vascular Surgery, Department of General and Specialist Surgery, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - Antonio Freyrie
- Unit of Vascular Surgery, Department of Medicine and Surgery, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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Ryu GW, Park YS, Kim J, Yang YS, Ko YG, Choi M. Incidence and Prevalence of Peripheral Arterial Disease in South Korea: Retrospective Analysis of National Claims Data. JMIR Public Health Surveill 2022; 8:e34908. [PMID: 36399371 PMCID: PMC9719060 DOI: 10.2196/34908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 10/01/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Peripheral arterial disease (PAD) causes blood vessel narrowing that decreases blood flow to the lower extremities, with symptoms such as leg pain, discomfort, and intermittent claudication. PAD increases risks for amputation, poor health-related quality of life, and mortality. It is estimated that more than 200 million people worldwide have PAD, although the paucity of PAD research in the East detracts from knowledge on global PAD epidemiology. There are few national data-based analyses or health care utilization investigations. Thus, a national data analysis of PAD incidence and prevalence would provide baseline data to enable health promotion strategies for patients with PAD. OBJECTIVE This study aims to identify South Korean trends in the incidence and prevalence of PAD and PAD treatment, in-hospital deaths, and health care utilization. METHODS This was a retrospective analysis of South Korean national claims data from 2009 to 2018. The incidence of PAD was determined by setting the years 2010 and 2011 as a washout period to exclude previously diagnosed patients with PAD. The study included adults aged ≥20 and <90 years who received a primary diagnosis of PAD between 2011 and 2018; patients were stratified according to age, sex, and insurance status for the incidence and prevalence analyses. Descriptive statistics were used to assess incidence, prevalence, endovascular revascularization (EVR) events, amputations, in-hospital deaths, and the health care utilization characteristics of patients with PAD. RESULTS Based on data from 2011 to 2018, there were an average of 124,682 and 993,048 incident and prevalent PAD cases, respectively, in 2018. PAD incidence (per 1000 persons) ranged from 2.68 to 3.09 during the study period. From 2012 to 2018, the incidence rate in both sexes showed an increasing trend. PAD incidence continued to increase with age. PAD prevalence (per 1000 persons) increased steadily, from 3.93 in 2011 to 23.55 in 2018. The number of EVR events varied between 933 and 1422 during the study period, and both major and minor amputations showed a decreasing trend. Health care utilization characteristics showed that women visited clinics more frequently than men, whereas men used tertiary and general hospitals more often than women. CONCLUSIONS The number of incident and prevalent PAD cases generally showed an increasing trend. Visits to tertiary and general hospitals were higher among men than women. These results indicate the need for attention not only to Western and male patients, but also to Eastern and female patients with PAD. The results are generalizable, as they are based on national claims data from the entire South Korean population, and they can promote preventive care and management strategies for patients with PAD in clinical and public health settings.
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Affiliation(s)
- Gi Wook Ryu
- Department of Nursing, Hansei University, Gunpo-si, Republic of Korea
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul, Republic of Korea
- College of Nursing, Yonsei University, Seoul, Republic of Korea
| | - Young Shin Park
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul, Republic of Korea
| | - Jeewuan Kim
- Department of Statistics and Data Science, Yonsei University, Seoul, Republic of Korea
| | - Yong Sook Yang
- College of Nursing, Yonsei University, Seoul, Republic of Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Mona Choi
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul, Republic of Korea
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Jarl G, Johannesson GA, Carlberg M, Jansson SPO, Hiyoshi A. Editor's Choice - Incidence of Lower Limb Amputations in Sweden from 2008 to 2017. Eur J Vasc Endovasc Surg 2022; 64:266-273. [PMID: 35644457 DOI: 10.1016/j.ejvs.2022.05.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 05/09/2022] [Accepted: 05/22/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE This study examined the recent national and regional incidence of lower limb amputations (LLAs) in Sweden and their annual changes. METHODS This was an observational study using Swedish national register data. All initial amputations were identified in Sweden from 2008 to 2017 in individuals 18 years or older using the national inpatient register. The amputations were categorised into three levels: high proximal (through or above the knee joint), low proximal (through the tibia to through the ankle joint), and partial foot amputations. To examine the national and regional incidence and annual changes, the age, sex, and region specific population count each year was used as the denominator and Poisson regression or negative binomial regression models were used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) adjusted for age and sex. RESULTS The national annual incidence of LLAs was 22.1 per 100 000 inhabitants, with a higher incidence in men (24.2) than in women (20.0). The incidence of LLAs (all levels combined) declined during the study period, with an IRR of 0.984 per year (95% CI 0.973 - 0.994). This was mainly due to a decrease in high proximal amputations (0.985, 95% CI 0.974 - 0.995) and low proximal amputations (0.973, 95% CI 0.962 - 0.984). No change in the incidence of partial foot amputations was observed (0.994, 95% CI 0.974 - 1.014). Such declines in LLA incidence (all levels combined) were observed in nine of the 21 regions. Compared with the national average and with adjustment for age, sex, diabetes, and artery disease, the regional IRR varied from 0.85 to 1.36 for all LLAs, from 0.67 to 1.61 for high proximal amputations, from 0.50 to 1.51 for low proximal amputations, and from 0.13 to 3.68 for partial foot amputations. CONCLUSION The incidence of LLAs has decreased in Sweden. However, regional variations in incidence, time trends, and amputation levels warrant further research.
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Affiliation(s)
- Gustav Jarl
- Department of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | | | - Michael Carlberg
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Stefan P O Jansson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Ayako Hiyoshi
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
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Dimech AP, Galea SA, Cassar K, Grima MJ. Treatment of Peripheral Arterial Occlusive Disease around the Globe: Malta. J Clin Med 2021; 10:5747. [PMID: 34945042 PMCID: PMC8705027 DOI: 10.3390/jcm10245747] [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: 10/20/2021] [Revised: 11/22/2021] [Accepted: 12/06/2021] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Malta is a small island in the middle of the Mediterranean with a population of 514,564 inhabitants and is served by one public tertiary hospital, Mater Dei Hospital. The Vascular unit was set up in 2007. The aim of this review is to analyse the work related to peripheral arterial occlusive disease (PAOD) in Malta with an in-depth focus on amputations and revascularisation procedures since the introduction of the Vascular unit. METHOD Various sources of data have been interrogated to address this subject. Population and prevalence data on obesity and type II diabetes mellitus from 2003 to 2019 was obtained from the National Statistics Office, the World Health Organization, and the International Diabetes Federation, respectively. The Maltese Vascular Register (MaltaVasc), and in-hospital reports from 2003 to 2019 was used to obtain data on revascularisation procedures, major amputations and minor amputation rates in Malta. RESULTS Malta has one of the highest rates of obesity in Europe. In 2015, the prevalence rate was 30.6%. Similarly, data from the International Diabetes Federation Atlas showed that the prevalence rate of T2DM among adults was 14% in 2017. There was a mean of 33 open/hybrid procedures per 100,000 population (28-38, 95% confidence interval) between 2005 and 2009 and a mean of 57 endovascular procedures per 100,000 population (46-68, 95% confidence interval) during the same time-period. From 2009 to 2019, there was a mean of 16 major amputations and 78 minor amputations per 100,000 population. CONCLUSION A significant reduction in major amputation rates with an increase in minor amputation rates and revascularisation rates has been noted since the establishment of the vascular unit in Malta. During this period, there has been an increase in prevalence in obesity and T2DM together with an aging population.
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Affiliation(s)
- Anthony Pio Dimech
- Department of General Surgery, Vascular Unit, Mater Dei Hospital, MSD 2090 L-iMsida, Malta; (A.P.D.); (S.A.G.); (K.C.)
| | - Samuel Anthony Galea
- Department of General Surgery, Vascular Unit, Mater Dei Hospital, MSD 2090 L-iMsida, Malta; (A.P.D.); (S.A.G.); (K.C.)
| | - Kevin Cassar
- Department of General Surgery, Vascular Unit, Mater Dei Hospital, MSD 2090 L-iMsida, Malta; (A.P.D.); (S.A.G.); (K.C.)
- Faculty of Medicine and Surgery, University of Malta, MSD 2080 L-iMsida, Malta
| | - Matthew Joe Grima
- Department of General Surgery, Vascular Unit, Mater Dei Hospital, MSD 2090 L-iMsida, Malta; (A.P.D.); (S.A.G.); (K.C.)
- Faculty of Medicine and Surgery, University of Malta, MSD 2080 L-iMsida, Malta
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, 75185 Uppsala, Sweden
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Søgaard R, Londero LS, Lindholt J. Geographical Variation in the Management of Peripheral Arterial Occlusive Disease: A Nationwide Danish Cohort Study. Eur J Vasc Endovasc Surg 2021; 63:72-79. [PMID: 34872816 DOI: 10.1016/j.ejvs.2021.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 09/27/2021] [Accepted: 10/10/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Equal access for equal needs is a key goal for many healthcare systems but geographical variation research has shown that this is often not the case in areas other than vascular surgery. This study assessed the variation across specialised vascular centres of an entire healthcare system in the costs and outcomes for patients having first time revascularisation for peripheral arterial occlusive disease. METHODS This was a national study of all first time revascularisations performed in the Danish healthcare system between 2009 and 2014. Episodes were identified in the Danish Vascular Registry (n = 10 300) and data on one year follow up in terms of the costs of specialised healthcare (€) and amputation status were acquired from national registers. Generalised gamma and logit regressions were used to predict margins between centres while adjusting for population heterogeneity (age, sex, education, smoking, hypertension, diabetes, use of prophylactic pharmacological therapy, indication and type of revascularisation). Cost effectiveness frontiers were used to identify efficient providers and to illustrate the cost of reducing the system level risk of amputation. RESULTS For each of the indications of chronic limb threatening and acute limb ischaemia, the one year amputation risks varied from 11% to 16% across centres (p = .003, p = .006) whereas for intermittent claudication there was no significant difference across centres. The corresponding costs of care varied across centres for all indications (p = .027, p = .028, p = .030). Linking costs and outcomes, three of seven centres were observed to provide poorer quality at higher costs. Exponentially increasing costs to obtain the maximum reduction of the amputation risk were observed. CONCLUSION The results suggest that there is substantial variation in the clinical management of peripheral arterial occlusive disease across the Danish healthcare system and that this results in very different levels of efficiency - on top of potentially unequal treatment for equal needs. Further research is warranted.
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Affiliation(s)
- Rikke Søgaard
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Denmark; Department of Public Health, Aarhus University, Denmark.
| | | | - Jes Lindholt
- Department of Public Health, Aarhus University, Denmark
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Abry L, Weiss S, Makaloski V, Haynes AG, Schmidli J, Wyss TR. Peripheral artery disease leading to major amputation: Trends in revascularization and mortality over 18 years. Ann Vasc Surg 2021; 78:295-301. [PMID: 34182110 DOI: 10.1016/j.avsg.2021.04.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/09/2021] [Accepted: 04/17/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with peripheral artery disease (PAD) are at risk for amputation. The aim of this study was to assess the type of revascularization prior to and the 30-day mortality rate after major amputation due to PAD. METHODS Retrospective analysis of consecutive patients undergoing major amputation for PAD between 01/2000 and 12/2017 at a tertiary referral center. The number and target level of ipsilateral revascularizations prior to amputation were analyzed per patient and over the years. There were 3 types of revascularization (open, endovascular and combined treatment) at 3 levels: aortoiliac, femoropopliteal and infrapopliteal. Univariate and multivariate logistic regression models were used to assess the association of level of amputation and patient characteristics with 30-day mortality. RESULTS A total of 312 patients (65.7% male) with a mean age of 73.3 ± 11 years underwent 338 major amputations: 70 (21%) above/through knee and 268 (79%) below knee. A median of 2 (interquartile range, IQR 1-4) revascularizations were performed prior to amputation, with a slight decrease of 1.4% per year from 2000-2017 (incidence rate ratio of 0.986 0.974-0.998; Poisson regression analysis, P = 0.021). 16% (53/338) of patients underwent primary amputation without revascularization; this number remained relatively stable throughout the study period. The proportion of exclusively open treatment before amputation decreased substantially from 35% in 2006 to none in 2016, while exclusively endovascular revascularizations were performed increasingly from 17% in 2002 to 64% in 2016. Amputation occurred after a median of 9.5 months (IQR 0.9-67.6 months) if the first revascularization was aortoiliac or femoropopliteal and after 2.1 months (IQR 0.5-13.8 months) if the first intervention was infrapopliteal (P < 0.001) with no significant change over the years (normal linear regression, P= 0.887). Thirty-day mortality was 8.9% (22/247) after below knee and 27.7% (18/65) after above/through knee amputation (adjusted OR 3.84, 95% CI 1.74-8.54, P= 0.001) with a slight increase of mortality over the study period (adjusted OR 1.09, 95% CI 1.018-1.159, Poisson regression analysis, P= 0.021). The uni- and multivariate analysis of patient characteristics did not show an association with mortality, except higher ASA classification (adjusted OR 2.65, 95% CI 1.23-5.72, P= 0.012). CONCLUSIONS Mortality, especially after above/through knee amputation, remains high over the past 2 decades. There is a clear shift towards endovascular treatment of patients with PAD prior to major amputation. In patients needing infrapopliteal revascularizations, amputation was performed much sooner than in those with aortoiliac or femoropopliteal interventions, with no improvement over the years. Strategies to extend limb salvage in these patients should be the focus of further research.
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Affiliation(s)
- Lisa Abry
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Salome Weiss
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vladimir Makaloski
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alan G Haynes
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürg Schmidli
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas R Wyss
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Vascular Surgery, Kantonsspital Winterthur, Winterthur, Switzerland.
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A predictive score for 30-day survival for patients undergoing major lower limb amputation for peripheral arterial obstructive disease. Updates Surg 2021; 73:1989-2000. [PMID: 34120323 PMCID: PMC8500910 DOI: 10.1007/s13304-021-01085-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/07/2021] [Indexed: 11/25/2022]
Abstract
To analyze outcomes following major lower extremity amputations (mLEAs) for peripheral arterial obstructive disease, gangrene, infected non-healing wound and to create a risk prediction scoring system for 30-day mortality. In this single-center, retrospective, observational cohort study. All patients treated with above-the-knee amputation (AKA) or below-the-knee amputation (BKA) between January 1st, 2010 and June 30th, 2018 were identified. The primary outcome of interest was early (≤ 30 days) mortality. Secondary outcomes were postoperative complications and freedom from amputation stump revision/failure. We identified 310 (77.7%) mLEAs performed on 286 patients. There were 188 (65.7%) men and 98 (34.3%) women with a median age of 79 years (IQR, 69–83 years). We performed 257 (82.9%) AKA and 53 (17.1%) BKA. There were 49 (15.8%) early deaths, which did not differ among the age quartiles of this cohort (15.4% vs. 14.3% vs. 15.4% vs. 19.5%, P = 0.826). Binary logistic regression analysis identified age > 80 years (OR 2.24, 95% CI 1.17–4.31; P = 0.015), chronic obstructive pulmonary disease (OR 2.12, 95% CI 1.11–4.06; P = 0.023), and hemodialysis (OR 2.52, 95% CI 1.15–5.52; P = 0.021) to be associated with early mortality. The final score (range 0–10) identified two subgroups with different mortality at 30 days: lower-risk (score < 4, 10.8%), and higher-risk (score ≥ 4: 28.7%; OR 3.2, 95% CI 1.63–6.32; P < 0.001). In our experience, mLEAs still have a 14% mortality rate over the years. Our lower-risk group (score < 4) is characterized by a lower rate of perioperative death and longer survival.
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Stoberock K, Kaschwich M, Nicolay SS, Mahmoud N, Heidemann F, Rieß HC, Debus ES, Behrendt CA. The interrelationship between diabetes mellitus and peripheral arterial disease - a systematic review. VASA 2020; 50:323-330. [PMID: 33175668 DOI: 10.1024/0301-1526/a000925] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This systematic review examined the interrelationship between concomitant diabetes mellitus (DM) and peripheral arterial disease (PAD). The objective was to determine differences in the prevalence as well as in the outcomes in diabetic vs. non-diabetic PAD patients. The current review followed a study protocol that was published online in German in 2017. The search included societal practice guidelines, consensus statements, systematic reviews, meta-analyses, and observational studies published from 2007 to 2020 reporting symptomatic PAD and concomitant DM in patients undergoing invasive open-surgical and endovascular revascularizations. German and English literature has been considered. Eligibility criteria were verified by three independent reviewers. Disagreement was resolved by discussion involving a fourth reviewer. 580 articles were identified. After exclusion of non-eligible studies, 61 papers from 30 countries remained, respectively 850,072 patients. The included studies showed that PAD prevalence differed between diabetic vs. non-diabetic populations (20-50% vs. 10-26%), and further by age, gender, ethnicity, duration of existing diabetes, and geographic region. The included studies revealed worse outcomes regarding perioperative complications, amputation rate, and mortality rate in diabetic patients when compared to non-diabetic patients. In both groups, the amputation rates decreased during the research period. This review emphasizes an interrelationship between PAD and DM. To improve the outcomes, early detection of PAD in diabetic patients, and vice versa, should be recommended. The results of this systematic review may help to update societal practice guidelines.
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Affiliation(s)
- Konstanze Stoberock
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark Kaschwich
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Shiva Sophia Nicolay
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nazeh Mahmoud
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Heidemann
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henrik C Rieß
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eike Sebastian Debus
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian-Alexander Behrendt
- Department of Vascular Medicine, Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Missed Opportunities for Timely Recognition of Chronic Limb Threatening Ischaemia in Patients Undergoing a Major Amputation: A Population Based Cohort Study Using the UK's Clinical Practice Research Datalink. Eur J Vasc Endovasc Surg 2020; 60:703-710. [PMID: 32718828 DOI: 10.1016/j.ejvs.2020.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 04/09/2020] [Accepted: 05/05/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Opportunities for timely recognition of chronic limb-threatening ischaemia (CLTI) within primary care, such as performing cardiovascular assessment during clinical consultation, are possibly being missed. This study aimed to investigate for potential "missed opportunities" within primary care. METHODS This was a population based cohort study, using the UK's Clinical Practice Research Datalink (CPRD). Patients undergoing a major amputation for CLTI between 1 January 2000 and 31 December 2016 were included. Primary care consultation and patient clinical data within the one year period prior to amputation were extracted from the CPRD. Dates of last primary care consultation and cardiovascular assessment prior to amputation were evaluated. Timings of latest cardiovascular assessments were stratified into "recent" (7-90 days before amputation) and "late" (> 91 days). RESULTS In total, 3 260 patients were included. In the year prior to amputation, patients attended a median of 19 (range 9-32) primary care consultations; however, prescription of secondary preventive medications was poor (antiplatelet 49.7%; lipid lowering agent 40.7%). Overall, 2 175 patients (66.7%) attended a primary care consultation 7-30 days before their amputation. However, only 416 (12.8%) underwent a cardiovascular assessment within this period, with 2 073 (63.6%) undergoing no assessment within 90 days of their amputation. Of these 2 073 patients, 1 230 (59.3%) had a primary care consultation 7-30 days before their procedure. Patients undergoing "late" assessment were younger (p = .003), with higher systolic (p = .008) and diastolic (p = .001) blood pressures than those undergoing "recent" assessment. Differences were also observed between assessment timings by deprivation (p = .003) and ethnicity (p = .006). CONCLUSION Missed opportunities for timely recognition potentially exist and may be related to age, deprivation, and ethnicity. Further work is required to investigate these factors, as well as individual amputations to identify the causes precipitating amputation. Greater emphasis on the medical management of peripheral arterial disease and identifying cardiovascular risk factors in patients who may not fit the "at risk" stereotype, are also required.
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Lower Limb Amputations and Revascularisation Procedures in the Hungarian Population: A 14 Year Retrospective Cohort Study. Eur J Vasc Endovasc Surg 2020; 59:447-456. [DOI: 10.1016/j.ejvs.2019.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 10/13/2019] [Accepted: 10/31/2019] [Indexed: 12/13/2022]
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Lindholt JS, Cassimjee I, Monareng TT, Abdool-Carrim ATO. New vascular guidelines for treating acute and chronic limb-threatening ischaemia. Br J Surg 2020; 107:165-166. [PMID: 31971621 DOI: 10.1002/bjs.11470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 11/19/2019] [Indexed: 11/10/2022]
Affiliation(s)
- J S Lindholt
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Odense.,Vascular Research Unit, Viborg Hospital, Clinical Institute, Aarhus University, Aarhus, Denmark
| | - I Cassimjee
- Division of Vascular Surgery, Department of Surgery, University of the Witwatersrand, 9 Guild Road, Johannesburg, South Africa
| | - T T Monareng
- Division of Vascular Surgery, Department of Surgery, University of the Witwatersrand, 9 Guild Road, Johannesburg, South Africa
| | - A T O Abdool-Carrim
- Division of Vascular Surgery, Department of Surgery, University of the Witwatersrand, 9 Guild Road, Johannesburg, South Africa
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