A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial

Efficacy of Targeted Teaching Program on Patients Care in National Health Service Hospitals

BACKGROUND

Continuous professional development is essential in medical education programs to enhance patient care. Junior doctors in the UK often experience challenges adapting to new specialty-specific standards during their rotations, potentially compromising patient care. A targeted teaching program (TTP) was developed to address this issue. This study evaluates the efficacy of a TTP implemented in a regional vascular surgery unit within the National Health Service on patients' care and safety.

METHODS

This observational study was designed to gather data about patients' management in the vascular department at the Countess of Chester National Health Service Foundation trust in the period between 2019 and 2023. Various clinical audits were completed to assess the impact of TTP on clinical outcomes and to gauge the improvement in health-care delivery standards and adherence to national guidelines.

RESULTS

The TTP significantly improved patient care metrics in our vascular surgery service between 2019 and 2023. Key improvements included antiplatelet medication prescriptions increasing from 86% to 100%, lipid modification therapy from 82.9% to 98%, postamputation pain management from 25% to 92%, and diabetes screening using HbA1c from 32% to 100%. These enhancements demonstrate a marked advancement patient care standards following TTP introduction.

CONCLUSION

Introduction of regular TTP has led to significant improvements in the standard of care for patients by implementing evidence-based practices. Furthermore, it enhanced doctors' knowledge, reduced the adaptation period to new specialties, and positively impacted the national trainee survey. Expanding targeted teaching to other clinical and nonclinical areas is recommended to enhance patient care across various settings.

Health Status Improvement After Peripheral Vascular Intervention: Insights From the LIBERTY 360 Study

Improving health status is a primary indication for peripheral endovascular intervention (PVI) for symptomatic peripheral arterial disease. The data informing mid- and long-term changes and predictors of health status following PVI are limited. LIBERTY 360, a prospective, nonrandomized, multicenter study evaluated outcomes in patients undergoing PVI. Health status measures were assessed at 30-days, 1 and 3-years using EQ-VAS (0-100,100 best health) and VascuQol-25 (1-7,7 best health), stratified by claudication (Rutherford 2-3), and chronic limb-threatening ischemia (CLTI, Rutherford 4-6). Multivariable regression identified predictors of health status at 1-year. Repeated measures models were constructed based on patients with available data through 3 years. Outcomes including major adverse events, all-cause death, major amputation/death, target vessel/lesion revascularization, and major adverse limb events (MALE)/post-operative death were reported. Claudication (n = 501, 41.6%) had higher baseline VascuQol total scores (4.3 ± 1.3) compared to CLTI (n = 703, 58.4%) (3.8 ± 1.4). The VascuQol total score improved at 30-days with claudication (5.4 ± 1.3, p < 0.0001) and CLTI (4.7 ± 1.4, p < 0.0001). Baseline EQ-VAS was higher with claudication (68.3 ± 19.7) than with CLTI (63.1 ± 20.1). EQ-VAS improved at 30-days with claudication (74.9 ± 17.9, p < 0.0001) and CLTI (68.6 ± 19.2, p-value:<0.0001). Improvements were maintained through 3-years. Baseline health status, history of PVI, and comorbidities predicted health status after PVI. While major adverse events rates were high at 3-years, this was driven by target vessel/lesion revascularization with high rates of freedom from major amputation, all-cause death, and MALE in both groups. In conclusion, PVI is associated with mid- long-term improvements in health status across peripheral arterial disease severity. Baseline characteristics were associated with health status at 1-year and may inform patient selection.

Validation of BEST-CLI among patients undergoing primary bypass or angioplasty with or without stenting for chronic limb-threatening ischemia

OBJECTIVE

BEST-CLI established the superiority of single-segment great saphenous vein (ssGSV) conduits for revascularization in patients with chronic limb-threatening ischemia (CLTI); however, the generalizability of these data is unknown. Thus, we aimed to validate the long-term results of open surgical bypass (BPG) vs percutaneous transluminal angioplasty with or without stenting (PTA/S) using the BEST-CLI inclusion and randomization criteria.

METHODS

All patients undergoing a first-time lower extremity revascularization for CLTI at our institution from 2005 to 2022 were retrospectively reviewed. To approximate BEST-CLI, one-to-one propensity score matching was used. Cohort 1 included BPG with ssGSV vs PTA/S; Cohort 2 included BPG without ssGSV vs PTA/S. Primary outcomes included wound healing, major amputation, major reintervention, major amputation/death (amputation/death), and major adverse limb events (MALE) or death (MALE/death) and were evaluated using Kaplan-Meier estimates and log-rank tests.

RESULTS

Of 1946 limbs undergoing a first-time intervention for CLTI between 2005 and 2022, 765 underwent BPG and 1181 underwent PTA/S. After matching, 862 fit Cohort 1 (431 BPG and 431 PTA/S), and 274 fit Cohort 2 (137 BPG and 137 PTA/S). Both cohorts exhibited a median follow-up of 2.7 years. In Cohort 1, major reintervention and MALE/death were both noted to be significantly lower following ssGSV BPG, as compared with PTA/S (at 7 years: 11% vs 24%; P = .001 and 72% vs 78%; P = .03, respectively). These findings correlated with a 53% and 28% reduction in the aforementioned adjusted events (hazard ratio, 0.47; 95% confidence interval, 0.30-0.74 and hazard ratio, 0.82; 95% confidence interval, 0.69-0.98, respectively). These significant differences in major reintervention and MALE/death were not noted in Cohort 2 (at 7 years: 25% vs 24%; P = .92 and 82% vs 80%; P = .31, respectively). Further, neither cohort demonstrated significant differences in complete wound healing (at 6 months, Cohort 1: 47% vs 40%; P = .32; Cohort 2: 40% vs 38%; P = .12), major amputation (at 7 years: Cohort 1: 15% vs 15%; P = .89; Cohort 2: 35% vs 25%; P = .86), or amputation/death (at 7 years, Cohort 1: 70% vs 66%; P = .99; Cohort 2: 78% vs 76%; P = .45).

CONCLUSIONS

Patients undergoing revascularization using ssGSV demonstrate significantly lower rates of major reintervention and MALE/death compared with those undergoing endovascular interventions for CLTI. However, similar outcomes are not seen among patients undergoing revascularization without a suitable ssGSV. These findings correlate with those demonstrated in BEST-CLI, suggesting generalizability.

Research priorities for peripheral artery disease: A statement from the Society for Vascular Medicine

Lower-extremity peripheral artery disease (PAD) affects approximately 236 million people worldwide and at least eight million people in the United States (US). Despite availability of new therapies that prevent major adverse cardiovascular events (MACE), these and major adverse limb events (MALE) remain common and occur more frequently in people with PAD, either with or without coronary artery disease (CAD), compared to people with CAD who do not have PAD. The most effective therapies to prevent cardiovascular events are not identical in people with PAD and those with CAD. Walking impairment and the risk of lower-extremity amputation are significantly greater in people with PAD compared to those without PAD. This report from the Society for Vascular Medicine (SVM) proposes and summarizes high-priority topics for scientific investigation in PAD, with the goal of improving health outcomes in people with PAD. To develop this report, a multidisciplinary team of scientists and clinicians reviewed literature, proposed high-priority topics for scientific investigation, and voted to rank the highest priority topics for scientific investigation. Priorities for clinical scientific investigation include: determine the current prevalence of PAD in the US by age, sex, race, and ethnicity; improve methods to diagnose PAD; develop new medical therapies to eliminate walking impairment; and improve implementation of established therapies to reduce rates of MACE and MALE in people with PAD. Priorities in basic science and translational science investigation include: developing animal models that closely resemble the vascular, skeletal muscle, and platelet pathology in patients with PAD and defining the genetic and epigenetic contributors to PAD and PAD-associated outcomes. Successful investigation of these research priorities will require more well-trained investigators focused on scientific investigation of PAD, greater and more efficient enrollment of diverse patients with PAD in randomized clinical trials, and increased research funding dedicated to PAD.

Outcomes following Deep Venous Arterialization in Medicare patients with Chronic Limb Threatening Ischemia

OBJECTIVES

Despite advances in the management of chronic limb-threatening ischemia (CLTI), a large proportion of these patients are not candidates for traditional revascularization and may be destined for major amputation. Given this medically complex and "no-option" patient population, deep venous arterialization (DVA) has recently been revitalized as a limb salvage technique whereby an arteriovenous fistula in the lower leg is created to supply more oxygenated blood via the venous system to the foot. The recent PROMISE II trial demonstrated a 6-month amputation-free survival (AFS) rate of 66% following DVA. With this trial in mind, our study aims to evaluate the real-world outcomes of this procedure.

METHODS

The study population included all patients undergoing a DVA from January 1, 2021 through December 31, 2023 among fee-for-service (FFS) beneficiaries identified in the Medicare FFS Carrier Claims file. DVA procedures were identified using CPT 0620T. Outcomes included limb salvage, freedom from major adverse limb events (MALE; defined as major amputation or ipsilateral re-intervention), survival, and AFS. Cumulative incidences for outcomes that include death were estimated from traditional Kaplan-Meier methods; for non-death endpoints, outcomes were estimated from the cumulative incidence function, accounting for the competing risk of death.

RESULTS

Between 2021 and 2023, 134 patients underwent a DVA for CLTI. Among these, the median age was 70 years and the majority of patients were male (66%), white (63%), had tissue loss (72%), hypertension (99%), hyperlipidemia (96%), chronic kidney disease (89%), and diabetes (83%). Following a DVA for CLTI, six-month and one-year AFS incidences were 42% and 33%, respectively. One-year incidences of limb salvage, freedom from MALE, and survival were 53%, 36%, and 65%, respectively.

CONCLUSIONS

Among patients with no traditional options for revascularization, our data demonstrate that DVA is a procedure that is, by its nature, performed in high-risk individuals who continue to have a high risk of limb loss and mortality. Importantly, AFS in our analysis is notably worse than that reported in PROMISE II and, as such, raises questions about the generalizability of this procedure in real world practice. Further investigation is needed regarding patient selection criteria for and the clinical utility of the DVA procedure.

Outcomes Following Drug-coated Balloons and Drug-eluting Stents in Patients with Peripheral Arterial Disease

BACKGROUND

Drug-coated balloons and drug-eluting stents (DCB/DES) have shown promise in improving outcomes for patients with peripheral artery disease (PAD), however, more real-world analyses are needed to better understand the role of this technology within current practice. As such, we compared our institution's experience with DCB/DES versus percutaneous transluminal angioplasty with or without stenting (PTA/S) for the treatment of PAD.

METHODS

All patients undergoing an infra-inguinal endovascular intervention for PAD at our institution between 2016 to 2022 were retrospectively reviewed. Patients undergoing isolated supra-inguinal or tibial interventions were excluded. Outcomes included primary patency, freedom from major adverse limb events (MALE), limb salvage, and amputation-free survival (AFS). To account for baseline differences, one-to-one propensity score matching was performed between DCB/DES and PTA/S groups. Outcomes were further evaluated using chi-squared, Kaplan-Meier analyses, and Cox regression analyses.

RESULTS

Between 2016 and 2022, 800 patients underwent an endovascular infra-inguinal intervention for PAD: 224 DCB/DES and 576 PTA/S. Prior to matching, DCB/DES patients were younger (69 vs. 72 years), more often male (72% vs. 65%), nonwhite (58%, vs. 34%), had a history of smoking (77% vs. 64%), were more likely to have had a prior ipsilateral intervention (45% vs. 10%), and more often presented with claudication (44% vs. 18%) (all p<.05). After matching, 211 patients were included in each group, where the only remaining difference between DCB/DES and PTA/S was prior ipsilateral intervention (40% vs. 15%, p<.001). Following DCB/DES, Kaplan-Meier analyses demonstrated higher rates of primary patency (65% vs. 54%; p<.01) and higher freedom from MALE (three-year rates: 84% vs 75%; p=.04), correlating with a 38% lower event risk in both outcomes (HR 0.62, 95% CI [0.44-0.89] and HR 0.62 [0.39-0.99], respectively). No differences were noted in rates of limb salvage (three-year rates: 94% vs. 90%, p=.63) or AFS (three-year rates: 78% vs. 71%; p=.13). When stratifying by indication, DCB/DES demonstrated higher rates of freedom from MALE among patients with CLTI (three-year rates: 85% vs. 66%; p=.02).

CONCLUSIONS

Among a matched cohort of patients with PAD undergoing endovascular intervention, DCB/DES, as compared to PTA/S, demonstrated higher rates of primary patency and freedom from MALE, the former treatment effect remaining notable among patients with claudication and the latter among patients with CLTI. These data demonstrate the importance of further analyses on this evolving technology.

Selecting Treatments for Peripheral Artery Disease: Differences Between Registry and a Randomized Controlled Trial Population

INTRODUCTION

Patients enrolled in randomized trials are carefully selected and may have different comorbidities than patients treated in everyday practice.

METHODS

We compared characteristics of 1815 patients enrolled in the Best Endovascular or Surgical Treatment for Critical Limb Ischemia (BEST-CLI, NCT02060630) with 104,877 patients receiving endovascular treatment and 32,120 patients undergoing bypass in the Vascular Quality Initiative's (VQI) registry from 2014 to 2020 using descriptive statistics. We studied mortality by treatment type among patients in both the trial and registry using Cox regression. We adjusted for differences in patient characteristics using inverse probability weighting with propensity scores.

RESULTS

Compared to the BEST-CLI participants, patients in the VQI registry were commonly older, female, and of non-Hispanic ethnicity. Chronic obstructive pulmonary disease and congestive heart failure were more prevalent in VQI, while coronary artery disease and diabetes rates were higher in BEST-CLI. The unadjusted 1-y mortality in VQI was 12.5% following endovascular treatment and 10.2% following bypass. After weighting VQI patients to represent the BEST-CLI sample, the cumulative 5-y mortality was higher in those undergoing endovascular treatment versus bypass (26.3% versus 23.7%, P < 0.001). Bypass was associated with an 8% lower mortality than endovascular treatment (hazard ratio = 0.92, 95% CI:0.87-0.98, P = 0.005). This effect remained across all weighting schemes, even when limiting to patients treated at a BEST-CLI site.

CONCLUSIONS

Patients enrolled in BEST-CLI differ from patients treated in VQI. However, reweighting VQI data to represent BEST-CLI yields similar estimates of treatment effects in VQI data, supporting a role for registry-based analytic models in answering comparative, real-world clinical questions.

New horizons in nuclear cardiology: Imaging of peripheral arterial disease

Lower extremity peripheral artery disease (PAD) is characterized by impairment of blood flow associated with arterial stenosis and frequently coexisting microvascular disease and is associated with high rates of morbidity and mortality. Current diagnostic modalities have limited accuracy in early diagnosis, risk stratification, preprocedural assessment, and evaluation of therapy and are focused on the detection of obstructive atherosclerotic disease. Early diagnosis and assessment of both large vessels and microcirculation may improve risk stratification and guide therapeutic interventions. Single-photon emission computed tomography and positron emission tomography imaging have been shown to be accurate to detect changes in perfusion in preclinical models and clinical disease, and have the potential to overcome limitations of existing diagnostic modalities, while offering novel information about perfusion, metabolic, and molecular processes. This review provides a comprehensive reassessment of radiotracer-based imaging of PAD in preclinical and clinical studies, emphasizing the challenges that arise due to the complex physiology in the peripheral vasculature. We will also highlight the latest advancements, underscoring emerging artificial intelligence and big data analysis, as well as clinically relevant areas where the field could advance in the next decade.

Clinical Outcomes After Distal Bypass in Patients With Chronic Limb-Threatening Ischemia due to Connective Tissue Disease

OBJECTIVES

Chronic limb-threatening ischemia (CLTI) is mostly caused by arteriosclerosis, but is sometimes due to connective tissue disease. However, there is a limited knowledge of clinical outcomes of patients with CLTI with connective tissue disease. The objective of the study was to assess outcomes after distal bypass in these patients using global vascular guidelines.

MATERIAL AND METHODS

Data from distal bypasses performed for CLTI at a single center from 2014 to 2023 were evaluated retrospectively. Clinical outcomes after distal bypass were compared for patients with CLTI with arteriosclerosis (AS group) and those with connective tissue disease (CD group). The primary endpoints were limb salvage and wound healing.

RESULTS

Of the 282 distal bypasses performed for 222 patients with CLTI, 22 were conducted for 21 patients with connective tissue disease (CD group). The connective tissue disease was progressive systemic scleroderma (n = 11 patients), pemphigoid diseases (n = 2), polyarteritis nodosa (n = 2), rheumatoid arthritis (n = 2), and others (n = 4). Compared with the AS group, the CD group included more females (P = .007) and had greater oral steroid use (P < .001) and a higher Global Limb Anatomical Staging System (GLASS) inframalleolar (IM) modifier P2 (P < .001). The mean follow-up period of the whole cohort was 27 ± 22 months with no significant difference between the groups (P = .25), and 22 limbs required major amputation during this period. The 2-year limb salvage rate was significantly lower in the CD group compared to the AS group (75% vs 94%, P = .020). Wound healing was achieved in 220 (78%) limbs, and the 12-month wound healing rate was significantly lower in the CD group (52% vs 86%, P = .006).

CONCLUSION

The low 2-year limb salvage and 12-month wound healing rates in patients with CLTI with connective tissue disease indicate that distal bypass may be challenging in these patients.

Chronic Kidney Disease and Risk of Mortality and Major Adverse Limb Events After Femoral Artery Endovascular Revascularization for Peripheral Artery Disease: The Boston Femoral Artery Endovascular Revascularization Outcomes (Boston FAROUT) Study

BACKGROUND

Chronic kidney disease (CKD) is associated with worse outcomes in peripheral artery disease (PAD). The impact of the severity of CKD on mortality and major adverse limb events (MALE) after endovascular revascularization of the superficial femoral artery (SFA) is unknown.

AIMS

To assess the relationship of increasing severity of CKD on the risk of mortality and MALE in patients after endovascular revascularization of the SFA.

METHODS

We followed a cohort of 202 patients (253 limbs) with SFA endovascular revascularization for claudication or chronic limb-threatening ischemia in two academic centers between 2003 and 2011. Patients were categorized into four Kidney Disease Improving Global Outcomes (KDIGO) categories of increasingly worse CKD based on estimated glomerular filtration rate (eGFR). The primary outcome was all-cause death. Secondary outcomes included cardiovascular death, noncardiovascular death, and MALE. The relationship between CKD severity and outcomes was assessed by hazard ratios (HR) and 95% confidence intervals (95%CI) from cause-specific multivariable Cox proportional hazards models and Fine-Gray competing risks analyses.

RESULTS

During a median follow-up of 9.3 years, there was a graded and increasing risk of all-cause, cardiovascular, and noncardiovascular mortality with worse eGFR (all tests of trend p < 0.001). The lowest eGFR category (< 45 mL/min/1.73 m²) was associated with the highest risk of all-cause mortality (HR = 5.0, 95% CI = 2.4, 10), cardiovascular mortality (HR = 5.8, 95% CI = 1.8, 18), and noncardiovascular mortality (HR = 4.5, 95% CI = 1.9, 11). There was no significant association between CKD severity and MALE or minor revascularization events.

CONCLUSION

The risk of mortality risk after SFA endovascular revascularization incrementally increases with decreasing renal function. However, impaired renal function is not related to the risk of adverse limb events and supports femoral revascularization in these patients.

Meta-Analysis of Randomised Controlled Trials Comparing Bypass and Endovascular Revascularisation for Peripheral Artery Disease

OBJECTIVE

Peripheral artery disease affects approximately 250 million people globally. Multiple randomised controlled trials have compared bypass and endovascular interventions but the optimum revascularisation approach remains unclear. The recently published BEST-CLI and BASIL-2 trials provide current and robust data addressing this question, however their findings are not concordant. This systematic review and meta-analysis provides an overview of the worldwide randomised evidence comparing bypass surgery and endovascular revascularisation in lower limb peripheral artery disease.

METHODS

A comprehensive literature search of MEDLINE, Embase and CENTRAL databases was performed of all time periods up to 7 May 2023 to identify randomised controlled trials comparing bypass and endovascular revascularisation for treating lower limb peripheral artery disease. The primary outcome was major amputation. Secondary outcomes were mortality, re-intervention, 30-day adverse events and 30-day mortality. Odds ratios were calculated and pooled using the random-effects model. Risk of bias was assessed using the Cochrane risk of bias 2 tool.

RESULTS

Fourteen cohorts were identified across thirteen studies, enrolling 3840 patients. There was no significant difference in major amputation (OR 1.12; 95% CI 0.80-1.57) or mortality (OR 0.96; 95% CI 0.79-1.17) between the bypass and endovascular groups. Bypass was associated with a significant reduction in re-intervention compared with endovascular treatment (OR 0.57, 95% CI 0.40-0.82).

CONCLUSIONS

These findings suggest that rates of major amputation and mortality are similar following bypass and endovascular interventions. Patients who undergo bypass surgery have a significantly lower re-intervention rate post-operatively.

Efficacy and Safety of Tranexamic Acid in Noncardiac Arterial Procedures: A Systematic Review and Meta-Analysis

BACKGROUND

Noncardiac arterial procedures (NCAPs) are associated with a high risk of bleeding. Tranexamic acid (TXA) is used among surgical disciplines to reduce blood loss; however, its effectiveness and safety in NCAP remain unclear. This review evaluates the efficacy and safety of TXA during NCAP.

METHODS

Systematic review and meta-analysis was performed in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Literature searches in PubMed, Embase, and Cochrane databases (October 2023 and October 2024) identified studies investigating TXA in open and endovascular NCAP. Meta-analyses were conducted using Cochrane's Review Manager.

RESULTS

Five studies (n = 4304) were identified. One randomized controlled trial of TXA in noncardiac surgery (n = 9535), including a vascular cohort (14.8%; n = 699 TXA, n = 700 placebo), showed lower composite bleeding outcomes in the overall cohort receiving TXA (9.5% vs 11.7%; P < 0.001), but not in the vascular cohort (hazard ratio 0.85; 95% confidence interval [CI] 0.64-1.13). Another trial found no difference in blood loss or transfusion rates in 100 patients undergoing open abdominal aortic aneurysm surgery. Both trials reported no increased cardiovascular or thromboembolic complications (TECs) or 30-day mortality. A prospective study showed similar thrombosis-related technical failure rates in traumatic vascular injury patients (TXA 6.3% vs 3.8%, P = 0.14) and no significant differences in bleeding or hematoma (TXA 11.4% vs 4.3%, P = 0.13). In 297 carotid endarterectomy (CEA) patients, TXA significantly reduced postoperative hematoma (7.9% vs 1.3%; P = 0.01) without increasing TEC or stroke. TXA during an intraoperative hemostasis protocol during CEA (TXA n = 8) reported similar results. Meta-analysis showed no significant differences in TEC (risk ratio [RR] 1.10; 95% CI 0.71-1.70) or reoperation rates (RR 0.55; 95% CI 0.19-1.63).

CONCLUSION

TXA does not increase the risk of TEC in NCAP. However, there is currently insufficient evidence that TXA reduces bleeding complications.

The impact of postoperative dual antiplatelet therapy on outcomes of endovascular therapies in patients with chronic limb-threatening ischemia in the Vascular Quality Initiative-Medicare-linked database

OBJECTIVE

The beneficial effects of dual antiplatelet therapy (DAPT) compared with single antiplatelet therapy (SAPT) have been well-established in coronary and carotid endovascular interventions; however, no consensus exists to the role of DAPT in lower extremity endovascular therapies (ETs). We aimed to investigate the impact of postoperative DAPT after ET in patients presenting with chronic limb-threatening ischemia (CLTI) in the Vascular Quality Initiative-Medicare-Linked (Vascular Implant Surveillance and Interventional Outcomes Network) database.

METHODS

The study was a multicenter retrospective analysis of prospectively collected Vascular Quality Initiative-Medicare-linked data. The Vascular Implant Surveillance and Interventional Outcomes Network database was queried for all ETs performed for infrainguinal occlusive disease between 2011 and 2019. The patients were stratified by discharge antiplatelet regimen (DAPT vs SAPT). SAPT patients received either aspirin or P2Y12 inhibitors whereas DAPT patients received both. The primary outcome was 1- and 5-year amputation-free survival (AFS). The secondary outcomes included 1- and 5-year overall survival, limb salvage (freedom from major amputation), and freedom from reintervention. Kaplan-Meier survival estimates and Cox regression were used for analysis.

RESULTS

The study included two cohorts: SAPT (n = 10,086 [41.7%]) and DAPT (n = 14,081 [58.3%]). Patients in SAPT cohort were older than their DAPT counterparts and were more likely to have congestive heart failure and chronic kidney disease. Patients in the DAPT cohort were more likely to have diabetes and coronary artery disease. In survival analyses, compared with SAPT, 1-year AFS in the DAPT cohort was 67.9% vs 63.7% (P < .001) and 5- year AFS was 30.4% vs 24.6% (P < .001). After adjusting for potential confounders, DAPT was associated with reduced hazards of major amputation or death at 1-year (adjusted hazard ratio [aHR], 0.82; 95% confidence interval [CI], 0.75-0.89; P < .001) and 5-year (aHR, 0.91; 95% CI, 0.84-0.99; P = .027). DAPT was also associated with lower hazards of death (aHR, 0.90; 95% CI, 0.81-0.99; P = .048) and major amputation (aHR, 0.86; 95% CI, 0.79-0.93; P < .001) at 1 year but not 5 years. Reintervention was not impacted by the antiplatelet therapy strategy. In our subanalysis, we found superior 5-year overall survival and AFSs in patients receiving DAPT compared with aspirin alone and also in patients receiving P2Y12 inhibitor alone compared with aspirin alone. However, the outcomes of DAPT vs P2Y12 inhibitor alone were not significantly different.

CONCLUSIONS

In this large Medicare-linked national analysis, we found that DAPT is associated with improved AFS up to 5 years after ET in patients with CLTI compared with SAPT. However, there was no difference between DAPT and P2Y12 inhibitor alone. Additionally, P2Y12 inhibitor was associated with improved AFS up to 5 years compared with aspirin. Our findings support the use of DAPT or P2Y12 inhibitor after ETs performed in the lower extremity for CLTI; however, further prospective studies are required to confirm our findings.

Three-Year Outcomes of Chronic Total Occlusion (CTO) versus Non-CTO Femoropopliteal Lesions Treated With Atherectomy Followed by Drug-Coated Balloon Angioplasty

BackgroundEndovascular intervention of the femoropopliteal chronic total occlusions (CTOs) is technically challenging and associated with increased rates of treatment failure and complications. The long-term patency of CTOs of the femoropopliteal segment treated with contemporary tools, such as atherectomy and drug-eluting technology, is not well studied.MethodsWe performed a prospective, single-center analysis of 60 consecutive patients with femoropopliteal disease successfully treated with either directional or orbital atherectomy followed by paclitaxel drug-coated balloon (DCB). Endpoints of interest were freedom from restenosis and revascularization following atherectomy and DCB angioplasty. All patients underwent clinical and imaging evaluation for 3 years to identify evidence of target lesion restenosis (RS) and revascularization (TLR).ResultsThere were 26 patients with CTO and 34 patients with non-CTO lesions. Baseline demographic and clinical characteristics were similar between the CTO and non-CTO groups other than ankle-brachial indices (ABI, 0.73 ± 0.11 vs 0.88 ± 0.14, P < 0.001). Kaplan Meier (KM) analysis for freedom from RS and TLR at 3 years was similar among the 2 groups (log rank p; 0.42, 0.69 respectively). Post-procedure, all patients had improvement of claudication, normalization of ABI indexes and duplex ultrasound velocities.ConclusionFreedom from target lesion restenosis and revascularization at 3 years were similar between CTO and non-CTO lesions treated with atherectomy followed by DCB angioplasty. These findings underscore the importance of optimal vessel preparation to achieve improved patency regardless of lesion morphology.

Highlights of the society for magnetic resonance angiography 2024 conference

The 36th Annual International Meeting of the Society for Magnetic Resonance Angiography (SMRA), held from November 12-15, 2024, in Santiago de Chile, marked a milestone as the first SMRA conference in Latin America. Themed "The Ever-Changing Landscape of MRA", the event highlighted the rapid advancements in magnetic resonance angiography (MRA), including cutting-edge developments in contrast-enhanced MRA, contrast-free techniques, dynamic, multi-parametric, and multi-contrast MRA, 4D flow, low-field solutions and artificial intelligence (AI)-driven technologies, among others. The program featured 174 attendees from 15 countries, including 43 early-career scientists and 30 industry representatives. The conference offered a rich scientific agenda, with 12 plenary talks, 24 educational talks, 98 abstract presentations, a joint SMRA-MICCAI challenge on intracranial artery lesion detection and segmentation and a joint session with the Society for Cardiovascular Magnetic Resonance (SCMR) emphasizing accessibility, low-field MRI, and AI's transformative role in cardiac imaging. The meeting's single-track format fostered engaging discussions on interdisciplinary research and highlighted innovations spanning various vascular beds. This paper summarizes the conference's key themes, emphasizing the collaborative efforts driving the future of MRA, while reflecting on SMRA's vision to advance research, education, and clinical practice globally.

Updates in Arterial Ulcers

Arterial ulcers are a clinical symptom of a complex array of underlying comorbid factors, namely peripheral artery disease (PAD). Chronic limb-threatening ischemia is representative of end-stage PAD. Ulcers of other etiologies can carry an arterial component, mandating recognition of risk factors, a comprehensive history and physical examination, and appropriate diagnostic testing in lower extremity ulcers. The primary therapy for arterial ulcers is re-establishment of in-line arterial flow, achieved by endovascular therapy or open revascularization. Medical management is essential to slow disease progression, and topical therapies are crucial to promote rapid ulcer closure and reduce infection risk.

Streamlined Clinical Management Pathways May Reduce Major Amputations in Patients with Chronic Limb Threatening Ischaemia: A Prospective Cohort Study with Historical Controls

OBJECTIVE

Patient characteristics and patterns of disease in chronic limb threatening ischaemia (CLTI) have markedly changed in recent years. Urgent specialist referral and timely revascularisation are recommended in international guidelines. UK guidelines now recommend revascularisation within five days of referral for inpatients and two weeks in outpatients. This study compared the contemporary one year major amputation incidence in patients with CLTI with a historical cohort at a single UK centre.

METHODS

This was a single centre, observational cohort study with historical controls. A prospective cohort was recruited between May 2019 and March 2022. A historical cohort presenting between 2013 and 2015 inclusive was retrospectively identified. Significant changes in management pathways, including establishing a rapid access limb salvage clinic, occurred between these periods, aiming to expedite time from referral to revascularisation. The one year primary outcome was major amputation, and the secondary outcome was death. Major amputation was analysed by Fine-Gray competing risks models (death as the competing risk), presented as subdistribution hazard ratios (SHRs). One year mortality was analysed by Cox regression, presented as hazard ratios. Analyses were adjusted for propensity score.

RESULTS

A total of 928 patients were included (432 prospective and 496 historical). Proportions of patients presenting with tissue loss (72.2% vs. 71.6%; p = .090) were similar in both cohorts. At one year, 48 patients (11.1%) in the prospective cohort and 124 patients (25.0%) in the historical cohort had undergone a major amputation (p < .001). Risk of major amputation was 57.0% lower in the prospective cohort compared with the historical cohort after adjustment for propensity score (SHR 0.43, 95% confidence interval 0.29 - 0.63; p < .001).

CONCLUSION

An encouraging reduction in major amputation incidence was observed after improvements to CLTI management pathways, but residual confounding is likely. The generalisability of these results is uncertain.

Impact of Bypass Conduit and Early Technical Failure on Revascularization for Chronic Limb-Threatening Ischemia

BACKGROUND

The optimal strategy for lower extremity revascularization (surgical bypass versus endovascular intervention) in patients with chronic limb-threatening ischemia (CLTI) is unclear. We examined the effectiveness of open surgical bypass using single-segment great saphenous vein conduit (SSGSV), alternative conduits (AC), or endovascular interventions (ENDO) among patients with CLTI deemed acceptable for either open surgical bypass or ENDO treatment.

METHODS

This was a planned as-treated analysis of the multicenter BEST-CLI (Best Endovascular Versus Best Surgical Therapy in Patients With Critical Limb Ischemia) randomized controlled trial comparing open surgical bypass and ENDO for CLTI due to infrainguinal peripheral artery disease. Outcomes were tabulated based on the initial revascularization received: SSGSV bypass, AC bypass, and ENDO. Analyses were performed for all treated patients and then excluding those who experienced early technical failure. Multivariable Cox regression models were used. End points included the primary trial outcome (major adverse limb event [MALE] or all-cause death), major amputation, MALE at any time or perioperative (30-day) death, reintervention-amputation-death, and all-cause mortality.

RESULTS

Among 1780 patients with CLTI, treatments received included SSGSV bypass (n=621), AC bypass (n=236), and ENDO (n=923) procedures. There were no significant differences in 30-day mortality, major adverse cardiovascular events, or serious adverse events; subjects treated with ENDO experienced greater MALE within 30 days (13.1% versus 2.7%, 3% for SSGSV, AC; P<0.001). On risk-adjusted analysis, SSGSV bypass was associated with reduced MALE or all-cause death (hazard ratio, 0.65 [95% CI, 0.56-0.76]; P<0.001), major amputation (hazard ratio, 0.70 [95% CI, 0.52-0.94]; P=0.017), MALE or perioperative death (hazard ratio, 0.51 [0.41-0.62]; P<0.001), and reintervention-amputation-death (hazard ratio, 0.69 [95% CI, 0.61-0.79]; P<0.001). AC bypass was associated with reduced MALE or perioperative death and reintervention-amputation-death compared with ENDO. Significant benefits of SSGSV over ENDO remained when excluding patients who experienced early technical failure. There were no significant differences in long-term mortality by initial treatment received. When analyzed by the level of disease treated, the improved outcomes of SSGSV were greatest among patients who underwent femoropopliteal revascularization.

CONCLUSIONS

Analysis of as-treated outcomes from the BEST-CLI trial demonstrates the safety and clinical superiority of bypass with SSGSV among patients with CLTI who were deemed suitable for either open surgical bypass or ENDO revascularization. Assessment of great saphenous vein quality should be incorporated into the evaluation of patients with CLTI who are surgical candidates.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02060630 and NCT02060630.

Revascularisation Options for Chronic Limb Threatening Ischaemia in Diabetes: Implications From Two Recent Trials

Chronic limb-threatening ischaemia (CLTI) is a severe form of peripheral arterial disease (PAD) and is associated with an increased risk of amputation, mortality, and significantly impaired quality of life. International guidelines recommend considering timely revascularisation and optimal medical therapy to improve limb perfusion in individuals with CLTI. The 2 primary revascularization approaches for CLTI are open bypass surgery (BS) and endovascular therapy (EV), however, there is currently no consensus on the best initial treatment strategy for CLTI, leading to uncertainty among clinicians. To shed light on this issue, 2 recent trials, namely best endovascular versus best surgical therapy in patients with CLI (BEST-CLI) and bypass versus angioplasty for severe ischaemia of the leg (BASIL-2), have tried to provide valuable insights. While a definitive conclusion on the optimal revascularisation approach is still pending, these trials offer immediate and clinically relevant information to the diabetic foot multidisciplinary team. The trials encompassed a distinct range of patient cohorts and included participants with varying degrees of medical and physical frailty. Taken together, their findings, highlight the need for an individualised revascularisation strategy which accounts for underlying comorbidities, risk factors, disease severity, availability of suitable bypass conduits, surgical risks, and timely access to procedures. Regardless of the chosen strategy, early referral of patients with diabetes and CLTI to a specialist team within a multidisciplinary environment is crucial. Comprehensive care should encompass essential elements such as adequate debridement, infection control, offloading, glycaemic control, smoking cessation, and patient education. By addressing these aspects, healthcare providers can optimise the management and outcomes for individuals with CLTI and diabetes.

Advanced Wound, Ischemia, and Foot Infection stage is associated with poor outcomes in the BEST-CLI trial

OBJECTIVE

Wound, Ischemia, and foot Infection (WIfI) staging was established to provide objective classification in patients with chronic limb-threatening ischemia (CLTI) and to predict 1-year major amputation risk. Our goal was to validate WIfI staging using data from the Best Endovascular vs Best Surgical Therapy in Patients with CLTI (BEST-CLI) trial.

METHODS

Data from the BEST-CLI Trial, a prospective randomized trial comparing surgical revascularization (OPEN) and endovascular revascularization (ENDO), were used to assess the association of WIfI stage on long-term outcomes in an intention-to-treat analysis. Patients were prospectively allocated to two cohorts, which included patients with and without adequate single-segment greater saphenous vein, respectively. The primary outcome of this analysis was major amputation.

RESULTS

There were 1568 patients analyzed, representing 86% of the entire trial population; of these 35.5%, 29.6%, and 34.9% were categorized as WIfI stage 4, WIfI stage 3, and WIfI stage 1/2, respectively. There were 1223 patients (606 OPEN, 617 ENDO) and 345 patients (OPEN 172, ENDO 173) in cohorts 1 and 2, respectively. On unadjusted Kaplan-Meier analysis, WIfI clinical stages 4 and 3, compared with WIfI stage 1/2, were associated with higher rates of major amputation (21.4%, 16.2% vs 10.7%), death (33.5%, 35.7% vs 24.6%), amputation/death (44.9%, 44.5% vs 31.3%), major adverse limb events (MALEs)/death (34.4%, 33.9% vs 29.5%), and reintervention/amputation/death (69.9% vs 69% vs 60.4%) (P < .05 for all) at 3 years. On risk-adjusted analysis, compared with WIfI stage 1/2, major amputation was associated with WIfI stage 4 (hazard ratio [HR], 2.06; 95% confidence interval [CI], 1.44-2.96; P < .001) and WIfI stage 3 (HR, 1.62; 95% CI, 1.1-2.37; P = .013) stages. Death was associated with WIfI stage 4 (HR, 1.3; 95% CI, 1.03-1.63; P = .027) and WIfI stage 3 (HR, 1.42; 95% CI, 1.13-1.79; P = .003). MALE/death was associated with WIfI stage 4 (HR, 1.29; 95% CI, 1.02-1.63; P = .036. Reintervention amputation/death was associated with WIfI stage 4 (HR, 1.28; 95% CI, 1.09-1.50; P = .03) and WIfI stage 3 (HR, 1.22, 99% CI 1.03-1.43) ; P = .018). When examining OPEN vs ENDO revascularization by each WIfI stage, OPEN intervention was favored in cohort 1 for MALE/death for each stage.

CONCLUSIONS

In BEST-CLI, WIfI stage was strongly associated with major amputations, death, and MALEs/death after revascularization for CLTI. Cohort 1 patients, with an adequate preoperative single segment greater saphenous vein, had lower MALE/death with OPEN intervention across all WIfI stages. This validation of WIfI score in a prospective multicenter trial reinforces its importance in shared-decision making, informed consent, and prognostication.

The Incidence and Consequences of Endovascular Technical Failure in Patients with Chronic Limb-Threatening Ischemia: Results from the Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb-Threatening Ischemia (BEST-CLI) Trial

PURPOSE

To analyze the causes and clinical impacts of endovascular technical failure (ETF) in the Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb-Threatening Ischemia (BEST-CLI) trial, which compared endovascular therapy with bypass surgery in patients with chronic limb-threatening ischemia (CLTI).

MATERIALS AND METHODS

Patients with CLTI were randomized to infrainguinal bypass or endovascular therapy. ETF was defined as the inability to complete the endovascular procedure. Patients with ETF were compared with those without ETF. Causes of ETF and impact on major adverse limb event (MALE), above-ankle amputation, and death were analyzed. ETF occurred in 16% (146 of 896) of endovascular procedures.

RESULTS

Patients who experienced ETF were older (69 years [SD ± 10] vs 67 years [SD ± 10], P = .007), were less frequently Hispanic, and had more complex infrainguinal arterial occlusive disease than those without ETF. ETF had more multilevel arterial occlusions involving a combination of both the superficial femoral artery (SFA)/popliteal segments and tibial segments (52% vs 41%, P = .029); Wound, Ischemia, and foot Infection ischemia Grade 3 (70.3% vs 53.1%, P = .002); and occlusion of the proximal SFA (37% vs 19%, P < .001). Causes of ETF included inability to cross the lesion in 82%. Following ETF, 67% underwent bypass surgery within 2 weeks of ETF. ETF was associated with a higher rate of MALE (81% vs 29%, P < .0001) but similar rates of above-ankle amputation (18.7% vs 16.0%, P = .528) and all-cause death (38.6% vs 29.8%, P = .260) at 3 years compared with no ETF.

CONCLUSIONS

ETF occurred in 16% of patients with CLTI and was associated with multilevel occlusions and proximal SFA occlusion. ETF was due to inability to cross the lesion in 82%. It did not impact long-term above-ankle amputation or death but was associated with increased major revascularization.

Association between guideline-directed medical therapy and reintervention risk following peripheral vascular interventions in patients with peripheral artery disease

INTRODUCTION

Reintervention following peripheral vascular intervention (PVI) for peripheral artery disease (PAD) is common. Guideline-directed medical therapy (GDMT) is recommended post-PVI, yet its association with reintervention outcomes remains unclear.

METHODS

We analyzed Vascular Quality Initiative registry data linked with Medicare outcome for patients undergoing PVI for PAD (2017-2018). GDMT was defined as the receipt of statin, antiplatelet, and angiotensin-converting enzyme or angiotensin receptor blocker (ACE/ARB) therapy if hypertensive at discharge. Competing risk analyses and conditional risk models assessed the reintervention outcome, and the recurrent reintervention outcomes within 2 years, by GDMT receipt, compliance with each GDMT element, the number of elements received, and GDMT rate across sites and operators in a 1:1 propensity score-matched cohort.

RESULTS

We included 13,244 patients (mean age 72.0 ± 9.9, women 41.0%). The reintervention outcome did not differ by GDMT receipt (cumulative incidence: 43.0% [95% CI 41.0-44.9%] in no GDMT vs 41.2% [95% CI 39.4- 43.0%] in GDMT; subhazard ratio (sHR): 1.03 [95% CI 0.97-1.10]), compliance with GDMT elements, the number of elements received, or site and operator GDMT rates (sHR per 10% increase: 1.00 [95% CI 0.98-1.03] and 1.00 [95% CI 0.98-1.02]) (all p > 0.05). However, a higher operator GDMT rate reduced the recurrent reintervention risk (HR: 0.98 [95% CI 0.97-1.00], p = 0.026).

CONCLUSION

Around 40% of patients undergoing a PVI experience reintervention within 2 years, but the outcome was not reduced with GDMT receipt, and higher GDMT rates by site and operators were not associated with reintervention risk. Future studies should focus on medication adherence, refills, and more granular GDMT data for PAD care surveillance postrevascularization.

Plain versus drug balloon and stenting in severe ischaemia of the leg (BASIL-3): open label, three arm, randomised, multicentre, phase 3 trial

OBJECTIVE

To determine which primary endovascular revascularisation strategy represents the most clinically effective treatment for patients with chronic limb threatening ischaemia who require endovascular femoro-popliteal, with or without infra-popliteal, revascularisation.

DESIGN

Three arm, open label, pragmatic, multicentre, randomised, phase 3 superiority trial (BASIL-3).

SETTING

35 UK NHS vascular units.

PARTICIPANTS

Patients with chronic limb threatening ischaemia who required endovascular femoro-popliteal, with or without infra-popliteal, revascularisation.

INTERVENTIONS

Participants were randomly assigned (1:1:1) to femoro-popliteal plain balloon angioplasty with or without bare metal stenting (PBA±BMS), drug coated balloon angioplasty with or without bare metal stenting (DCBA±BMS), or drug eluting stenting (DES) as their first revascularisation strategy.

MAIN OUTCOME MEASURES

The primary outcome was amputation free survival defined as time to first major amputation or death from any cause. Secondary outcomes included the composite components of the primary outcome, major adverse limb events, major adverse cardiac events, and other prespecified clinical and patient reported outcome measures. Serious adverse events were collected up to 30 days after the first revascularisation procedure.

RESULTS

Between 29 January 2016 and 31 August 2021, 481 participants were randomised (167 (35%) women, mean age 71.8 years (standard deviation 10.8)). Major amputation or death occurred in 106 of 160 (66%) participants in the PBA±BMS group, 97 of 161 (60%) in the DCBA±BMS group, and 93 of 159 (58%) in the DES group (adjusted hazard ratios: PBA±BMS v DCBA±BMS: 0.84, 97.5% confidence interval 0.61 to 1.16, P=0.22; PBA±BMS v DES: 0.83, 0.60 to 1.15, P=0.20). No differences in serious adverse events were reported between the groups.

CONCLUSIONS

Neither DCBA±BMS nor DES conferred significant clinical benefit over PBA±BMS in the femoro-popliteal segment in patients with chronic limb threatening ischaemia undergoing endovascular femoro-popliteal, with or without infra-popliteal, revascularisation.

TRIAL REGISTRATION

ISRCTN registry ISRCTN14469736.

Is Global Limb Anatomic Staging System Classification a Useful Tool in Predicting Lower Limb Revascularization Procedures' Success?

BACKGROUND

GLASS (Global Limb Anatomic Staging System) classification is a classification proposed in 2019 by The Lower Extremity Guidelines Committee of the Society for Vascular Surgery, which aims to identify the anatomic substrate that defines the severity of a lower extremity arterial injury and predict the success rate of possible revascularization. The aim of the study is to demonstrate the usefulness of this classification and if it is a reliable tool in predicting the success of the revascularization procedures for patients with chronic limb-threatening ischemia (CLTI).

METHODS

A retrospective study was conducted on patients undergoing revascularization for CLTI. Glass staging was applied to angiographic data, categorizing them into GLASS 1, 2, or 3 based on the complexity of the femoropopliteal and infrapopliteal lesions. We investigated the clinical characteristics and types of endovascular treatment in correlation with GLASS classification. We also evaluated the technical success of revascularization procedures and the specificity and accuracy of the GLASS classification.

RESULTS

After the first testing, we found out that GLASS classification has a sensitivity of 63% and a specificity of 77%. After the second testing, the sensitivity was 82%. of 77% also. The follow-up of this sample was made after 1 year, with no patients lost to follow-up and with an amputation-free survival of 81.3%.

CONCLUSIONS

GLASS 1 and 2 patients had significantly higher rates of success compared to GLASS 3. GLASS serves as a valuable tool in predicting revascularization success and provides a standardized approach to anatomical complexity, but further studies should integrate more data in order to enhance its predictive capability.

An assessment of the BEST-CLI Trial demonstrates that infrainguinal bypass offers a potential advantage in smokers with chronic limb-threatening ischemia

OBJECTIVE

Smoking is an established risk factor in many pathologies of the cardiovascular system. The Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trial affords an in-depth evaluation into the effect of smoking on patients with chronic limb-threatening ischemia (CLTI). BEST-CLI's prospective, randomized design evaluated outcomes in patients suitable for both open or endovascular intervention and randomized patients between endovascular intervention (ENDO) vs open surgical bypass (OPEN). The outcomes are reported stratified by smoking status.

METHODS

In the BEST-CLI trial, patients were stratified by current smokers (CS) and nonsmokers (NS), which included both previous smokers or never smokers. Endpoints at 4 years include the primary trial outcomes (major adverse limb events [MALE] or all-cause death), as well as above-ankle amputation, all-cause death, major or minor reintervention, major adverse cardiac events (MACE), MALE, and MALE or perioperative death. Multivariable Cox regression models were created with NS serving as the reference group.

RESULTS

Patients received bypass using single-segment saphenous vein (n = 621), bypass using alternative conduits (n = 236), or endovascular procedures (n = 923). There were 641 CSs and 1137 NSs. In the combined cohort of patients receiving ENDO or OPEN, CS status was associated with a higher rate of MALE (hazard ratio [HR], 1.27; 95% confidence interval [CI], 1.05-1.55; P = .02) but a lower rate of all-cause death (HR, 0.80; 95% CI, 0.66-0.97; P = .02) when compared with NS status. In the OPEN group, CSs had a lower rate of all-cause death (HR, 0.74; 95% CI, 0.56-0.98; P = .04) than NSs and no significant difference in MALE (HR, 1.18; 95% CI, 0.85-1.63; P = .34). In the ENDO group, CSs had a higher rate of above-ankle amputation (HR, 1.51; 95% CI, 1.04-2.19; P = .03) and MALE (HR, 1.33; 95% CI, 1.04-1.69; P = .02). Additionally, on subset analysis of the entire cohort, it was found that, when comparing prior smokers to never-smokers, there was a 24% increase in reintervention (P = .05), and when comparing CSs to never smokers, there was a 27% increase in reintervention (P = .04).

CONCLUSIONS

CSs had worse limb outcomes in the BEST-CLI trial. CSs undergoing endovascular revascularization had higher rates of MALE and above-ankle amputations following adjustment. Current smoking did not impact MALE in patients with CLTI undergoing open surgical bypass.

Mortality and amputation outcomes of infrainguinal bypass versus endovascular therapy based on body mass index

OBJECTIVE

Obese patients have higher rates of cardiovascular disease and associated risk factors, but lower rates of peripheral artery disease and better outcomes after revascularization. This results in an obesity paradox, where obese patients have the lowest risk of adverse outcomes following treatment, while underweight and morbidly obese patients are at the highest risk. No previous studies have compared outcomes of endovascular vs open bypass within each body mass index (BMI) group. Our study aims to compare outcomes of peripheral vascular intervention (PVI) with infrainguinal bypass (IIB) stratified by patient BMI group.

METHODS

The Vascular Quality Initiative database was queried for patients presenting with claudication or chronic limb-threatening ischemia (CLTI) undergoing PVI or IIB (using the great saphenous vein) from 2012 to 2023. Patients were categorized into five BMI groups: underweight (BMI ≤ 18.5 kg/m2), normal weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2), obese (BMI 30.0-39.9 kg/m2), and morbidly obese (BMI 40.0-49.9 kg/m2). Multivariable logistic compared 30-day mortality for IIB vs PVI within each BMI group. Cox regression, Kaplan-Meier survival analysis, and log-rank tests assessed 1-year mortality, 1-year amputation, and 1-year amputation/death rates. Subgroup analysis was performed by indication (CLTI or claudication).

RESULTS

There were 118,622 patients meeting the study criteria, including 3542 underweight (3%), 33,009 normal weight (28%), 40,582 overweight (34%), 36,494 obese (31%), and 4995 morbidly obese (4%) patients. There was no significant difference in 30-day mortality between PVI and IIB in underweight patients. IIB was associated with lower 30-day mortality in normal weight (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.33-0.62) and obese (aOR, 0.78; 95% CI, 0.24-0.75) patients. Bypass was associated with lower 1-year mortality in all BMI groups, except for morbidly obese patients. It was also associated with a lower risk of 1-year amputation for normal weight (aOR, 0.82; 95% CI, 0.70-0.96) and a lower risk of 1-year amputation/death for normal weight, overweight, and obese patients. Among CLTI patients, bypass was associated with decreased 30-day and 1-year mortality risks in all but underweight patients.

CONCLUSIONS

This study shows significant differences in 30-day and 1-year mortality, amputation, and amputation/death rates between PVI and IIB based on BMI depending on patient BMI. Bypass was associated with better outcomes for normal weight and obese patients, and for CLTI patients across most BMI groups. This finding suggests a long-term survival benefit after IIB compared with PVI, an effect potentiated by symptom severity, except for patients otherwise at a higher operative risk regardless of procedure choice.

Comparison of Bypass Surgery versus Endovascular Interventions for Peripheral Artery Disease through Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE

To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the outcomes of bypass surgery with those of endovascular interventions for the treatment of peripheral artery disease.

MATERIALS AND METHODS

PubMed, Google Scholar, Cochrane Library, and ClinicalTrials.gov were searched until July 2023 for RCTs comparing bypass surgery and endovascular interventions in patients with intermittent claudication or critical limb-threatening ischemia. Primary outcomes included technical success, 30-day morbidity and mortality, 1-year primary patency, and major amputation at 1 year. A random-effects model was employed for pooling odds ratios (ORs) with 95% confidence intervals (CIs). Subgroup and sensitivity analyses and meta-regression were used to explore heterogeneity.

RESULTS

Fourteen RCTs involving 3,856 patients were included. Bypass surgery achieved significantly higher technical success (OR, 8.50; 95% CI, 5.46-13.25) and 1-year primary patency (OR, 1.43; 95% CI, 1.03-1.99), However, it was associated with increased 30-day morbidity (OR, 1.38; 95% CI, 1.03-1.86), 30-day mortality (OR, 1.87; 95% CI, 1.10-3.18), and 1-year major amputation rates (OR, 2.58; 95% CI, 1.13-5.88) compared with endovascular interventions. Differences in 1-year amputation-free survival, primary assisted and secondary patency at 1 year, reintervention rates within 1 year, 30-day major adverse cardiac events, postprocedural change in the ankle-brachial index, and changes in health-related quality of life at 1 year, 1-year clinical improvement, and 1-year all-cause mortality were statistically nonsignificant.

CONCLUSIONS

Bypass surgery resulted in higher technical success and 1-year primary patency; however, endovascular interventions resulted in lower initial morbidity and mortality and major amputations.

Variations in Revascularization Strategies for Chronic Limb-Threatening Ischemia: A Nationwide Analysis of Medicare Beneficiaries

BACKGROUND

Recent data support both surgical-first and endovascular-first revascularization approaches for chronic limb-threatening ischemia (CLTI), but hospital-based practices are poorly described.

OBJECTIVES

This aim of this study was to characterize contemporary variations and outcomes associated with each strategy among U.S. hospitals providing both approaches.

METHODS

Medicare beneficiaries ≥66 years of age with CLTI treated at institutions offering both strategies between October 1, 2015 to December 31, 2021 were analyzed. A marginal Cox regression approach was used, and models were adjusted for patient-level covariates.

RESULTS

Among 196,070 patients at 1,832 institutions, 82.5% underwent endovascular treatment. Patients undergoing endovascular revascularization were older and had a higher comorbidity burden. The adjusted median OR for receiving an endovascular procedure was 2.32 among hospitals (Q1-Q3: 2.24-2.40; P < 0.01), demonstrating high variability in intervention use. Patients undergoing endovascular revascularization at the highest quintile hospitals had a lower rate of major amputation (adjusted HR [aHR]: 0.82; 95% CI: 0.77-0.88; P < 0.01) and a higher rate of repeat procedures (aHR: 1.37; 95% CI: 1.32-1.43; P < 0.01). Patients undergoing surgical bypass at the highest quintile hospitals had a higher rate of major amputation (aHR: 1.21; 95% CI: 1.13-1.29; P < 0.01) and a lower rate of repeat procedures (aHR: 0.73; 95% CI: 0.70-0.76; P < 0.01).

CONCLUSIONS

This study showed large interhospital variability in revascularization strategies, as well as improved outcomes for patients receiving endovascular treatment at higher volume sites. Further work is needed to standardize treatments with the goal of improving limb salvage rates.

The impact of diabetes mellitus on the outcomes of revascularization for chronic limb-threatening ischemia in the BEST-CLI trial

OBJECTIVE

Several observational studies have demonstrated an association between diabetes mellitus (DM) and above-ankle amputation after lower extremity revascularization (LER). However, data from prospective randomized trials is lacking. This analysis compares the outcomes of patients with and without DM enrolled in the Best Endovascular vs Best Surgical Therapy in patients with Chronic Limb-Threatening Ischemia (BEST-CLI) trial.

METHODS

Baseline characteristics were compared between patients with and without DM in the BEST-CLI trial. Cox regression was used to determine the association between DM and major outcomes of major adverse limb events (MALE), reintervention, above-ankle amputation, and all-cause death.

RESULTS

Among 1777 patients who underwent LER, 69.2% had DM. Compared with patients without DM, those with DM were significantly younger, less likely to be White, and more likely to be Hispanic. Patients with DM were more likely to have hypertension, hyperlipidemia, coronary artery disease, congestive heart failure, and renal disease and be on optimal medical therapy (antiplatelets and statins), whereas patients without DM were significantly more likely to be smokers and have chronic obstructive pulmonary disease. Patients with DM were significantly more likely to present with late Wound Ischemia foot Infection (WIfI) stages (3-4) (73.7% vs 45.9%; P < .001) that were driven predominantly by differences in wound and infection grade. Conversely, patients without DM had significantly lower ankle pressures and toe pressures and were significantly more likely to have WIfI ischemia grade 3 compared with patients with DM (60% vs 52.5%; P = .016). At 3 years, patients with DM exhibited higher rates of above-ankle amputation and all-cause death compared with patients without DM. Kaplan-Meier analysis demonstrated significantly higher MALE or all-cause death compared with patients without DM (3-year estimate: 53.5% vs 46.4%; P < .001). After adjusting for potential confounders, regression analysis demonstrated that DM was independently associated with increased above-ankle amputation (1.75 [1.22-2.51]), all-cause death (1.63 [1.31-2.03]), and MALE or all-cause death (1.24 [1.04-1.47]).

CONCLUSIONS

Patients with DM undergoing LER for chronic limb-threatening ischemia experienced a greater incidence of MALE or all-cause death compared with patients without DM. The impact of DM seems to be mediated by more severe wounds and infections at the time of presentation, and a higher prevalence of cardiac and renal disease.

Impact of Age Differences in Chronic Limb-Threatening Ischemia Outcomes in Octogenarians

BACKGROUND

The aging population is a growing challenge for healthcare services and as such multimorbidity and associated aging are the focus of research programs. Chronic limb-threatening ischemia (CLTI) in the older patient is perceived to be associated with high morbidity and mortality but a potentially contentious area with limited evidence.

METHODS

Retrospective review of all consecutive CLTI admissions to a UK tertiary vascular during 2020. Analysis included descriptive statistics and comparisons by age. The primary outcome was survival (by Kaplan-Meier) with secondary outcomes being major adverse limb and cardiovascular events.

RESULTS

One hundred eighty-three patients with a median age of 72 of which 55 (30%) were octogenarians. Fewer octogenarians were diabetic (38.2% vs. 58.6%, P = 0.015), but comorbidities such as previous stroke (25.5% vs. 10.9%, P = 0.015) and atrial fibrillation (36.4% vs. 16.4%, P = 0.004) were increasingly common. 87.3% of octogenarians had moderate or severe frailty compared to 57.8% in those <80 (P = 0.001) (by electronic frailty index). Median survival time was 30 months with no significant difference between groups (P = 0.406). Major adverse cardiovascular event (10.9% vs. 7.81%, P = 0.504) and major adverse limb event (34.5% vs. 24.2% P = 0.261) were comparable between groups. Octogenarians were less likely to have open surgery (10.9% vs. 25.8%, P = 0.024).

CONCLUSIONS

Octogenarians have similar cardiovascular, limb, and survival outcomes following intervention despite being increasingly frail and comorbid. Holistic assessment, perioperative optimization, and risk stratification are important in this group.

Popliteal-distal bypass affords better limb salvage than tibial angioplasty for chronic limb-threatening ischemia

OBJECTIVE

Chronic limb-threatening ischemia (CLTI) due to isolated tibial occlusive disease is treated by either popliteal-distal bypass (PDB) or tibial angioplasty (TA), although there is limited data directly comparing efficacy and outcomes between these two treatment modalities. This study compares 30-day mortality and major adverse limb events following infrapopliteal bypass and TA in patients with CLTI.

METHODS

Patients who underwent PDB for CLTI were extracted from American College of Surgeons National Surgical Quality Improvement Program targeted lower extremity open database, whereas patient with CLTI who underwent isolated TA were identified in the targeted lower extremity endovascular database. Any case with more proximal angioplasty such as femoral/popliteal/iliac was excluded. The time interval was 2011 through 2022. The two groups were comparable in demographics, and preoperative comorbidities were obtained using propensity matching. Mortality, systemic complications, and major adverse limb events were measured. Multivariable logistic regression was used for data analysis. To obtain granular data on the angiographic characteristics of patients undergoing PDB or TA, The George Washington University institutional data from 2014 to 2019 was used as a supplement to the database.

RESULTS

There were 1947 and 3423 cases identified in the bypass and endovascular groups, respectively. After propensity matching for all preoperative variables, 1747 cases remained in each group. Although bypass was associated with higher major adverse cardiovascular events, pulmonary, renal, and wound complications, bypass had significantly better 30-day limb salvage when compared with TA (major amputation rate, 3.32% vs 6.12%; P < .01). Institutional data identified 69 patients with CLTI due to isolated tibial occlusive disease; 25 (36.2%) underwent PDB and 44 (63.8%) underwent TA. Review of angiographic details revealed patients who underwent PDB had better pedal targets (inframalleolar/pedal score of P0 [24.0% vs 15.9%] or P1 [68.0% vs 61.3%]) than TA patients (inframalleolar/pedal score of P2 [22.7% vs 8.0%]).

CONCLUSIONS

PDB was associated with higher morbidity but better limb salvage than endovascular interventions. However, this could be explained by the association with better pedal targets in patients who underwent popliteal-tibial bypass. Prospective studies should be done comparing PDB and TA in cases with similar pedal targets.

Employing magnetic resonance histology for precision chronic limb-threatening ischemia treatment planning

OBJECTIVE

Recent randomized controlled trials have demonstrated a notable prevalence of immediate technical failures in percutaneous vascular interventions (PVIs) for complex arterial lesions associated with chronic limb-threatening ischemia. Current imaging modalities present inherent limitations in identifying these lesions, making it challenging to determine the most suitable candidates for PVI. We present a novel preprocedural magnetic resonance imaging (MRI) histology protocol for identifying lesions that might present a higher rate of immediate and midterm PVI failure.

METHODS

We enrolled 22 patients (13 females, average age 65.8 ± 9.72 years) scheduled for PVI were prospectively and underwent 3T MRI using ultrashort echo time and steady-state free precession contrasts to characterize target lesions before PVI. Lesions were scored as hard if >50% of the lumen was occluded by hard components (calcium/dense collagen) on MRI in the hardest cross-section. Two readers evaluated MRI datasets. Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC)/Global Limb Anatomic Staging System (GLASS)/Wound, Ischemia and Foot infection scoring was performed based on intraprocedural angiograms and chart review. The relationship between MRI scoring, TASC/GLASS scoring, and procedural outcomes was investigated using univariate analysis. Midterm follow-up (revascularization and amputation rates) was recorded at 3 and 6 months after the intervention.

RESULTS

Our cohort of 22 patients yielded 40 target lesions. Five lesions were excluded (two for nondiagnostic image quality; three PVIs were ultimately diagnostic only). Six lesions (17%) were scored as hard. MRI-scored hard lesions had a higher proportion of immediate technical failure (hard vs soft 83% [5/6] vs 3% [1/29]; P < .001). Hard vs soft MRI scoring was the only factor significantly associated with immediate PVI technical success (P < .001), as opposed to TASC/GLASS scoring. Both at 3 months and 6 months after PVI, the reintervention rate was significantly higher among those lesions which were scored hard on MRI (3 months hard, 80% vs soft, 16% [P =.011]; 6 months hard, 80% vs soft, 27%; P = .047).

CONCLUSIONS

MRI histology could be a valuable tool for optimizing PVI patient selection and treatment strategies.

The Value of Restaging WIfI (Wound, Ischemia, and Foot Infection) After Initial Vascular and Podiatric Intervention

BACKGROUND

Wound, ischemia, and foot infection (WIfI) is an important staging system for diabetic patients presenting with chronic limb-threatening ischemia (CLTI) of the lower extremities (LEs). This study examines the clinical implications of restaging WIfI after initial vascular and podiatric interventions.

METHODS

A prospective database of patients undergoing vascular intervention treatment of the LE for tissue loss between 2018 and 2022 was queried. Cases were reviewed and staged preoperatively according to WIfI and then based on the WIfI restaging after primary vascular and podiatric interventions. Three groups were identified as follows: improvement of WIfI score (improved), WIfI unchanged (no change), and deterioration of WIfI score (worsened) groups. In cases of active infection, patients underwent infection control (drainage and/or amputation) followed by revascularization (endovascular or open intervention). In contrast, patients with no active infection underwent revascularization followed by podiatric intervention. Amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; above-ankle amputation of the index limb or significant reintervention [new bypass graft or jump or interposition graft revision]) were evaluated.

RESULTS

One thousand four hundred and four patients (61% male, age 64 ± 12 years, mean ± SD) presented with CLTI underwent initial vascular and/or podiatric LE interventions. On initial presentation, 37% of the patients presented with WIfI stage 3, and 63% presented with WIfI stage 4. The majority of the patients had Global Limb Anatomic Staging System (GLASS) stage III anatomic disease. Fifty-six percent of the patients had a primary infection control procedure, and 78% had a vascular intervention (71% endovascular intervention and 29% open bypass). After completing the primary podiatric and vascular procedures and restaging the WIfI score, 48% of the patients were improved, 32% were unchanged, and 20% were worsened. The postoperative change in WIfI classification impacted both 30-day rate of MALE (5% vs. 9% vs. 24% for the improved, unchanged, and worsened groups, respectively; P = 0.01) and the 30-day rate of major amputation (2% vs. 3% vs. 14% for the improved, unchanged, and upgraded groups, respectively; P < 0.02). At 5 years, freedom from MALE was progressively worse in the improved, unchanged, and worsened groups (47 ± 5% vs. 38 ± 5% vs. 23 ± 9%, respectively; mean ± standard error of the mean (SEM), P = 0.001). The 5-year AFS also deteriorated for the improved, unchanged, and worsened groups (49 ± 5% vs. 33 ± 5% vs. 19 ± 6%, respectively; mean ± SEM, P = 0.001) CONCLUSIONS: Restaging WIfI after primary vascular and podiatric intervention results in significant downgrading of WIfI staging, allows for better differentiation of 30-day outcomes, and influences freedom from MALE and AFS outcomes.

Short Term Outcomes of a Prospective Registry of Popliteal and Infrapopliteal Endovascular Interventions for Chronic Limb Threatening Ischaemia

OBJECTIVE

The prevalence of chronic limb threatening ischaemia (CLTI) is increasing worldwide, resulting in the need for more patients to undergo revascularisation, especially for below the knee pathology. Nevertheless, prospective data on below the knee endovascular interventions are lacking. The aim of the study was to provide large scale, real world data on procedural and short term outcomes of popliteal and infrapopliteal endovascular interventions in patients with CLTI.

METHODS

This study is an analysis of the first 1 000 interventions of the Dutch Chronic Lower Limb Threatening Ischaemia Registry (THRILLER). It includes all patients with CLTI undergoing popliteal or infrapopliteal endovascular revascularisation in seven hospitals in the Netherlands. The primary outcomes were limb salvage and amputation free survival (AFS) at three months estimated by the Kaplan-Meier method. Secondary outcomes were procedural complications and primary patency.

RESULTS

Between February 2021 and July 2023, 1 000 endovascular procedures were performed in 840 patients (947 limbs), treating 486 popliteal and 1 209 tibial lesions. Wound, Ischaemia, and foot Infection (WIfI) stages 1 - 4 were present in 16.8%, 17.2%, 25.4%, and 40.6% of the limbs, respectively. Technical success was hampered by arterial perforation, acute thrombosis, and distal embolisation in 8.7%, 1.0%, and 2.3% of the interventions, respectively. Limb salvage was 100.0%, 96.9%, 94.9%, and 86.1% (p < .001), whereas AFS was 96.9%, 93.2%, 86.6%, and 76.4% for WIfI stages 1 - 4 at three months (p < .001), respectively. Primary patency at the 6 - 8 week visit was 86.4% for popliteal and 74.3% for tibial lesions, respectively.

CONCLUSION

THRILLER presents a large prospective database on outcomes of endovascular CLTI interventions. Popliteal and infrapopliteal endovascular revascularisation for CLTI is safe. Interventions with initial technical success have high rates of limb salvage and survival at three months. The WIfI classification provides a reliable instrument to predict limb salvage and AFS independently at three months.

Long-term Recurrence Risk of Diabetic Foot Ulcers After Healing: A 5-Year Retrospective Cohort Study on the Influence of Hemodialysis and Amputation Levels

This retrospective study aimed to evaluate diabetic foot ulcer (DFU) recurrence rates and associated risk factors, focusing on hemodialysis and specific amputation levels. Patients with diabetes treated for DFU between 2003 and 2019 at a wound-care center in Japan were studied. The primary outcome was DFU recurrence, and the factors evaluated included age, sex, hemodialysis treatment, revascularization type, and amputation level. Among 236 participants (mean age: 65 years; male: 73%; 33% on hemodialysis), DFU recurrence rates were 40.3% and 77.1% at 1 and 5 years, respectively. Hemodialysis was significantly associated with an increased DFU recurrence risk (hazard ratio: 1.92; 95% confidence interval: 1.40-2.64, P < .001). Revascularization did not significantly impact DFU recurrence rates after ulcer healing. Contralateral DFU recurrence was the most frequent, occurring in 45% of cases. Higher DFU recurrence rates were observed at adjacent toes on the same side in patients who underwent great toe amputation and at the treated site in patients who underwent transmetatarsal, Lisfranc, or Chopart amputations. These findings indicate that DFU recurrence poses a higher risk in patients undergoing hemodialysis. Tailored postoperative management focusing on both contralateral and ipsilateral recurrences is essential to minimize recurrence and improve long-term outcomes.

Mid-Term Results of Popliteal-Pedal Inframalleolar Vein Bypasses in Chronic Limb-Threatening Ischemia Patients After Previous Failed Tibial Endovascular Recanalization

BACKGROUND

Inframalleolar bypass still preserves its role in the modern endovascular era. Aim of this study was to evaluate the mid-term outcomes of "short" inframalleolar vein bypasses in patients with chronic limb-threatening ischemia (CLTI) after the previously failed tibial endovascular recanalization.

METHODS

Between January 2015 and December 2021,107 CLTI patients in 3 Italian Departments of Vascular Surgery underwent "short" inframalleolar vein bypass after failed tibial endovascular recanalization. Early (30-day) and 3-year outcomes were evaluated in terms of survival, primary patency, primary assisted patency, secondary patency, and amputation-free survival. Univariate analysis of the perioperative factors affecting outcomes were performed by the means of log-rank test. The associations of procedure variables were sought based on a multivariate Cox regression analysis.

RESULTS

Distal anastomosis (inframalleolar) was mostly performed on dorsal pedis (64, 59.8%). At 30 days, bypass occlusion was recorded in 5 cases (4.6%). The mean follow-up period was 20.5 ± 17.9 months. The estimated 3-year overall survival was 66.7%. Three-year estimates of primary patency, primary assisted patency, secondary patency, and amputation-free survival were 68.5%, 70.1%, 70.2%, and 76.7%, respectively. Multivariate analysis showed a negative association of insulin treatment with primary patency (HR 4.3, P = 0.04), primary assisted patency (HR 5.1, P = 0.02), and secondary patency (HR 5.1, P = 0.02). The negative association of long-term corticosteroid use was also found with primary patency (HR 7.8, P = 0.005), primary assisted patency (HR 8.7, P = 0.003), secondary patency (HR 8.7, P = 0.003), and amputation-free survival (HR 3.9, P = 0.05).

CONCLUSIONS

Short" vein bypasses to the foot arteries in CLTI patients yielded good mid-term overall patency and limb salvage rates after a failed tibial endovascular recanalization. Insulin-dependent diabetes mellitus and long-term corticosteroid use seemed to affect the outcomes.

Clinical Outcomes following Invasive Treatment of Femoropopliteal Artery Disease: A Retrospective Single-Center Cohort Study

PURPOSE

To identify predictors of clinical success in invasive treatment for femoropopliteal arterial disease aiding clinical decision-making.

MATERIALS AND METHODS

A retrospective analysis was performed on 676 consecutive patients who underwent a first episode of invasive treatment for femoropopliteal disease, either endovascular therapy (EVT) or femoropopliteal bypass (FPB), between 2004 and 2015. Primary end points were primary and secondary clinical patency and amputation rate. Kaplan-Meier curves were used to evaluate clinical patency. A Cox proportional hazard model explored predictors of primary end points.

RESULTS

Most patients (58%) underwent EVT as primary intervention, while 42% underwent FPB. Median follow-up was 43 months. The only independent predictor for loss of primary clinical patency was critical limb-threatening ischemia (CLTI) (P = .008; hazard ratio [HR], 1.25; 95% CI, 1.07-1.47). Secondary clinical patency was positively associated with FPB surgery (P = .037; HR, 0.66; 95% CI, 0.44-0.97), a higher pre-interventional ankle-brachial index (P = .029; HR, 0.43; 95% CI, 0.20-0.92), more distal runoff vessels (P = .036; HR, 0.77; 95% CI, 0.60-0.98), and the absence of ischemic heart disease (P = .006; HR, 1.69; 95% CI, 1.16-2.47). In patients with CLTI, chronic renal failure predicted loss of primary and secondary clinical patency and increased amputation risk.

CONCLUSIONS

In this cohort, CLTI was independently associated with decreased primary clinical patency in invasive treatment for femoropopliteal disease. Secondary clinical patency was positively associated with FPB, higher ankle-brachial index, more runoff vessels, and the absence of ischemic heart disease.

The Impact of Small Artery Disease (SAD) and Medial Arterial Calcification (MAC) Scores on Chronic Wound and Amputation Healing: Can It Tell Us More?

BACKGROUND

In 2021, Ferraresi et al. created a novel scoring system based on the impact of small artery disease (SAD) and medial arterial calcification (MAC) on wound healing. SAD and MAC scores functioned similar to Wound, Ischemia, and foot Infection (WIfI) but with minimal resource expenditure. Despite its potential, few studies have expanded on the original dataset. We aim to validate SAD's impact and MAC's impact on wound healing outcomes and determine their utility in relation to current predictive models.

METHODS

Single-institution retrospective review was used to identify amputations for chronic (>1 month) podiatric wounds between 2015 and 2020. Foot X-ray (MAC) or angiography (SAD) < 6 months of index procedure was required. Primary outcomes included major amputation, wound healing, major adverse limb events, and amputation-free survival (AFS). Statistical analysis included chi-squared, 1-way analysis of variance, nonparametric correlation, Kaplan-Meier, Cox regression, and Akaike/Bayesian Inclusion Criteria model comparison.

RESULTS

Of 136 limbs, 67 received SAD scores (0-2) and 128 received MAC scores (0-2). SAD cohorts exhibited similar comorbidity profiles with exception of coronary disease, heart failure, and chronic kidney disease. MAC cohorts were notably disparate in prevalence of multiple conditions. High mean SAD/MAC scores were seen in severe (3-vessel) below-ankle disease (P = 0.001∗ [SAD], P = 0.041∗ [MAC]). Both SAD and MAC correlated with lower mean toe pressure (P = 0.043∗ [SAD], P ≤ 0.001∗ [MAC]), while only MAC correlated with higher overall WIfI score (P = 0.029∗). No significant procedural differences were noted. However, higher readmission rates (73.9% [2] vs. 46.9% [0], P = 0.014∗) and all-cause mortality (65.2% [2] vs. 26.0% [0], P = 0.002∗) were noted with higher MAC. Survival analysis revealed higher 1-year major amputation rates (P = 0.036∗), impaired wound healing (P < 0.001∗), and lower AFS (P = 0.001∗) with increasing MAC severity. Additionally, MAC-2 patients underwent amputation at faster rates than MAC-0 patients (hazard ratio 5.25, 95% confidence interval [1.82, 9.77]) with longer times to wound healing (hazard ratio 0.21, 95% confidence interval [0.08, 0.53]). Model comparison suggested a combination of WIfI and MAC could improve accuracy of predicted time to major amputation, wound healing, and AFS.

CONCLUSIONS

MAC scoring showed significant promise both as individual predictor and adjunct to current predictive models of long-term wound healing outcomes. Routine use of MAC scoring in chronic limb-threatening ischemia evaluation, especially when noninvasive testing is unavailable, could promote timely referral for intervention and efficient resource utilization in limited-resource or critical care settings. Furthermore investigation is necessary to determine MAC's impact on revascularization and how scoring can be used to guide surgical decision-making.

Radial Access Approach to Peripheral Vascular Interventions: A Scientific Statement From the American Heart Association

Transradial arterial access has transformed the field of coronary interventions, where it has several advantages over femoral access, such as reduced bleeding and access site complications, improved patient comfort, shorter time to ambulation after the procedure, reduced length of hospital stay, and potentially reduced mortality rates. Because of these benefits, as well as the concurrent expanding indications for various endovascular therapies, there is growing interest in adopting radial access for peripheral vascular interventions. However, radial access can present challenges, and specialized equipment for peripheral interventions through this route are under development. Nevertheless, a growing number of studies, largely comprising single-center and registry data, have broadly suggested that transradial arterial access is likely to be safe and associated with reduced bleeding and local access site complications for most peripheral interventions compared with transfemoral access. Large, prospective randomized trials are lacking, and the question of any effect on mortality rates has not been addressed. Whereas the field of transradial arterial access for peripheral vascular interventions is in development, it is clear that this approach, at least with available equipment, will not be suitable for all patients, and careful case selection is paramount. Furthermore, the remaining knowledge gaps must be addressed, and robust outcome data obtained, to allow full understanding of the factors that determine optimal patient, lesion, and equipment selection. Nevertheless, the use of transradial arterial access for peripheral vascular interventions holds great promise, particularly if the necessary technologic advances are rapid and favorable clinical trial data continue to emerge.

Comparison of Endovascular Interventions for the Treatment of Superficial Femoral Artery Disease: A Network Meta-analysis

Background

To understand the relative safety and efficacy of endovascular treatment modalities used for superficial femoral artery (SFA) disease, we performed a network meta-analysis to compare outcomes between percutaneous transluminal angioplasty (PTA), atherectomy (A), bare metal stent (BMS), brachytherapy/radiotherapy, covered stent graft (CSG), cutting balloon angioplasty (CBA), drug-coated balloon (DCB), drug-eluting stent (DES), and intravascular lithotripsy (L).

Methods

We performed a systematic literature search of PubMed from January 2000 to January 2023 to identify randomized trials comparing endovascular interventions for the treatment of SFA disease. The primary end points were technical success and 12-month primary patency.

Results

In total, 57 studies (9089 patients) were included. The mean age of the included patients was 68.4 years, 41.4% had diabetes, 18.3% had critical limb ischemia, and 81.3% had de novo lesions. A mean of 1.2 lesions were treated per patient. Technical success was superior for CSG, BMS, and A+DCB compared with PTA, while A+DCB and CSG were superior to DCB. All interventions except brachytherapy alone had superior primary patency compared with PTA. There were no significant differences in 12-month mortality or major amputation. All interventions except L+DCB, PTA+A, and CBA were superior to PTA regarding target lesion revascularization, while only DCB, DES, and BMS were better than PTA at improving Rutherford classification.

Conclusions

In SFA disease, PTA alone is mostly inferior to other endovascular techniques. This comparison of other endovascular techniques will be valuable for endovascular device selection in the treatment of SFA disease.

Comparison of endovascular infrapopliteal revascularisation strategies based on the angiosome model in diabetics with CLTI

Background: Infrapopliteal endovascular interventions (EVT) strategies in diabetic patients are still in debate because the lesions are more likely to be diffuse with a different pattern of collateral arteries ranging from reduced to normal caliber. The aim of this all-comers study was to analyse the outcome of two different infrapopliteal EVT strategies (Group I: angiosome-based direct revascularization - DR vs. Group II: complete (direct + indirect) revascularization strategy - CR) in diabetic patients with chronic limb-threatening ischemia (CLTI) in 2 time-periods. Furthermore we analysed the outcome if DR or CR failed and only indirect revascularization (IR) or no revascularization was possible. Both groups were differentiated in patients with collaterals, defined as an intact pedal arch (immediate or after pedal PTA). Patients and methods: The database includes 91 consecutive EVT with two intrapopliteal interventional strategies performed in 68 diabetic patients (pts. 24 female, 44 male, mean age 73±10 years) between 2013-2016 and 2017-2022. Positive clinical outcome was defined as wound healing with or w/o minor amputation, combined with a symptom improvement to Rutherford category 0 or 1 after 6 months. The clinical outcome proportions were compared using the Fisher's exact test. Results: Successful DR (59%) and successful CR (47%) strategy demonstrated a similar positive clinical outcome (92.6% vs. 90.5%; p=0.594). Indirect revascularization (Group I: 26%; Group II: 44%) showed a significantly lower positive outcome in comparison to a successful DR as well as CR strategy (33.3% vs. 92.6%, p=0.0003; 40% vs 90.5%, p=0.001). IR outcome improved by the presence of collaterals (66.7% vs. 30.8%). Conclusions: In case of successful intervention, both strategies (DR and CR) yielded a similarly high proportion of positive clinical outcome. The role of collaterals and the pedal arch on the clinical outcome are important in patients in whom only IR was possible.