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Vosgin-Dinclaux V, Bertucat P, Dari L, Webster C, Foussard N, Mohammedi K, Ducasse E, Caradu C. Predictors of major adverse lower limb events in patients with tissue loss secondary to critical limb-threatening ischemia. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 64:34-41. [PMID: 38350775 DOI: 10.1016/j.carrev.2024.01.018] [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: 10/18/2023] [Revised: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND Chronic limb-threatening ischemia (CLTI) is the end-stage of peripheral arterial disease (PAD) posing a high risk for limb loss and mortality. This study aims to evaluate and list possible predictors of major adverse limb events (MALEs) in CLTI patients with tissue loss. METHODS This retrospective study included all Rutherford-Becker stage 5 or 6 patients who required foot debridement and revascularization in our department from January 2016 to December 2018. The limbs were classified according to the TASC II, GLASS and WiFI grading systems. The primary composite outcome was MALEs at 2 years. The secondary outcomes included all-cause mortality, primary patency, freedom from reintervention, and major amputation. Kaplan-Meier estimates were used to determine the event rates, and Cox proportional hazards model with the index MALE as a time-dependent covariate was used to search for MALEs predictors. RESULTS Of 241 included patients, 19 underwent open surgeries (7.9 %) 207 had endovascular interventions (85.9 %) and 15 required a hybrid approach (6.2 %). On univariate analysis, patients who experienced MALEs (n = 111) more often required hemodialysis (25 vs 15; p = .02), presented with more complex lesions (TASC D on femoropopliteal (p = .05) or below the knee (BTK) arteries (p = .006) with increasing infra-inguinal GLASS Stage (p < .0001)), a history of index limb open (p = .009) or endovascular (p = .049) revascularization, an occluded tibial artery (p = .002 for the posterior tibial and p = .052 for the anterior tibial), or a "desert foot" (p = .02). The CRP level was also higher at admission (p = .001). Technical success of BTK revascularization significantly reduced MALEs (p < .0001) along with the number of patent BTK vessels (p = .0007). Independent predictors of MALEs included hemodialysis (HR = 2.00; 95%CI: 1.14 to 3.39), pulsatile arterial pressure (HR = 1.01; 95%CI: 1.00 to 1.03) and the infra-inguinal GLASS Stage (HR = 2.50; 95%CI: 1.17 to 5.82). We could not correlate our results with the WiFI scores for amputation risk and revascularization benefit. CONCLUSION For patients with CLTI at the stage of trophic disorders, with or without a history of index limb revascularization, the GLASS successfully predicted MALEs. Hemodialysis and high pulsatile arterial pressure increased the risk of MALEs. The WiFI score did not demonstrate its interest in this subgroup of patients.
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Affiliation(s)
| | - Paul Bertucat
- Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
| | - Loubna Dari
- Bordeaux University Hospital, Hôpital Saint-André, Vascular Medicine Department, Bordeaux, France
| | - Claire Webster
- Imperial College London, Department of Vascular Surgery, London, UK
| | - Ninon Foussard
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France
| | - Kamel Mohammedi
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France
| | - Eric Ducasse
- Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
| | - Caroline Caradu
- Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France.
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2497-2604. [PMID: 38752899 DOI: 10.1016/j.jacc.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Spinella G, Pisa FR, Boschetti GA, Finotello A, Pane B, Pratesi G, Lanzarone E. Reconsidering the Impact of Endovascular Repair on Short-Term and Mid-Term Outcomes in Peripheral Arterial Disease: A Retrospective Analysis. Ann Vasc Surg 2024; 103:141-150. [PMID: 38395344 DOI: 10.1016/j.avsg.2023.12.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/25/2023] [Accepted: 12/10/2023] [Indexed: 02/25/2024]
Abstract
BACKGROUND The aim of the study is to compare the short-term and medium-term outcomes in patients who underwent open repair (OR) or endovascular repair (ER) for peripheral arterial disease (PAD) also including stratifications based on severity and year of the first intervention. METHODS We conducted an observational retrospective single-center cohort study. We evaluated patients with PAD that primarily underwent ER, OR, minor, and major amputations in a single center from 2005 to 2020. The patients were then subdivided according to the type of intervention (OR versus ER), and stratified according to the International Classification of Diseases 9 code reported in the operating documents and to the year intervention. Mortality, minor, and major amputation rates occurring at 30 days, 2 years, and 5 years after the first intervention were evaluated as primary outcomes and compared between patient groups in both stratifications. Moreover, Kaplan-Maier curves were analyzed for these outcomes. RESULTS One thousand four hundred ninety two patients (67.0% males) with PAD were evaluated. Their clinical presentations were intermittent claudication in 51.4% of cases, rest pain in 16.8%, ulcers in 10.3%, and gangrene in 21.5%. Nine hundred ninety seven (66.8%) underwent OR and 495 (33.2%) ER as first intervention for PAD. No statistical differences were observed in terms of mortality in the 2 groups (OR versus ER, P = 1,000, P = 0.357, and P = 0.688 at 30 days, 2 years, and 5 years, respectively). The rate of minor amputations was significantly higher (P < 0.012, P < 0.002, and P < 0.007 at 30 days, 2 years, and 5 years, respectively) for ER group in any of the observed follow-up periods. Also, we have observed that OR and ER do not have any significant short-term and medium-term major amputation rate differences. CONCLUSIONS In our experience, the impact of ER does not significantly change short-term and mid-term major outcomes in patients with PAD.
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Affiliation(s)
- Giovanni Spinella
- Department of Surgical and Integrated Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Vascular and Endovascular Surgery Clinic, Genoa, Italy.
| | - Fabio Riccardo Pisa
- Department of Surgical and Integrated Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy
| | - Gian Antonio Boschetti
- Vascular Surgery Unit, AULSS 2 Marca Trevigiana, Treviso Regional Hospital, Treviso, Italy
| | | | - Bianca Pane
- Department of Surgical and Integrated Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Vascular and Endovascular Surgery Clinic, Genoa, Italy
| | - Giovanni Pratesi
- Department of Surgical and Integrated Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Vascular and Endovascular Surgery Clinic, Genoa, Italy
| | - Ettore Lanzarone
- Department of Management, Information and Production Engineering, University of Bergamo, Bergamo, Italy
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Rammos C, Zeller T, Piorkowski M, Deloose K, Hertting K, Sesselmann V, Tepe G, Gaines P, Lichtenberg M. The BioMimics 3D Helical Centreline Nitinol Stent in Chronic Limb Threatening Ischaemia and Complex Lesions: Three Year Outcomes of the MIMICS-3D Registry. Eur J Vasc Endovasc Surg 2024; 67:923-932. [PMID: 38447693 DOI: 10.1016/j.ejvs.2024.02.043] [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: 06/05/2023] [Revised: 02/01/2024] [Accepted: 02/29/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE There is a need for improved outcomes in the endovascular treatment of patients suffering from chronic limb threatening ischaemia (CLTI), highly calcified lesions, and chronic total occlusions (CTOs). The helical centreline self expanding BioMimics 3D stent might be particularly useful in these high risk subsets, combining flexibility and fracture resistance with radial strength. Herein, the performance of the BioMimics 3D stent was assessed in these high risk subsets. METHODS MIMICS-3D is a prospective, multicentre, European real world registry. This was a post hoc analysis, comparing patients with CLTI vs. intermittent claudication (IC), lesions with bilateral calcification vs. those without (peripheral arterial calcium scoring system [PACSS] 3,4 vs. PACSS 0 - 2), and CTO vs. no CTO. Propensity score matching was performed to reduce the impact of baseline variables. The 36 month endpoints were clinically driven target lesion revascularisation (CD-TLR), death, major target limb amputation, and stent patency. RESULTS A total of 507 patients were enrolled. At 36 months, patients with CLTI had lower freedom from major amputation than patients with IC (92.6% vs. 100%, p < .001). In terms of primary patency, patients with CTO had lower patency rates than those without (63.9% vs. 77.8%, p = .003), but the difference reduced after propensity score matching (70.5% vs. 76.8%, p = .43). Primary patency was not impaired for patients with PACSS 3,4 or patients with CLTI. Freedom from CD-TLR was not significantly different among the groups and was 73.8% for CLTI vs. 78.9% for IC (p = .15), 77.6% for PACSS 3,4 vs. 78.7% for PACSS 0 - 2 (p = .55), and 75.6% for CTO vs. 81.0% for no CTO (p = .11). CONCLUSIONS The outcome of the MIMICS-3D registry suggests that the BioMimics 3D stent is effective in the endovascular treatment of complex femoropopliteal lesions and in CLTI. Future randomised controlled trials should confirm its non-inferiority or superiority compared with existing alternatives.
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Affiliation(s)
- Christos Rammos
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Centre Essen, University Hospital Essen, Germany.
| | - Thomas Zeller
- Universitätsklinikum Freiburg Herzzentrum, Bad Krozingen, Germany
| | | | - Koen Deloose
- Department of Vascular Surgery, AZ Sint-Blasius Dendermonde, Dendermonde, Belgium
| | - Klaus Hertting
- Department of Cardiology and Angiology, Krankenhaus Buchholz und Winsen GmbH, Buchholz, Germany
| | - Volker Sesselmann
- Department of Angiology, SRH Zentralklinikum Suhl GmbH, Suhl, Germany
| | - Gunnar Tepe
- Department of Diagnostic and Interventional Radiology, RoMed Klinikum Rosenheim, Rosenheim, Germany
| | - Peter Gaines
- Vascular Institute, Sheffield Hallam University, Sheffield, UK
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Chaney M, Joshi G, Cataneo Serrato JL, Rashid M, Jacobs A, Jacobs CE, White JV, Schwartz LB, El Khoury R. The natural history of isolated common femoral endarterectomy for chronic limb-threatening ischemia. J Vasc Surg 2024:S0741-5214(24)01229-1. [PMID: 38823529 DOI: 10.1016/j.jvs.2024.05.050] [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: 01/29/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVE Occlusive disease of the common femoral artery can generate profound lower extremity ischemia as the normal collateral pathways from the profunda to the superficial femoral artery cannot adequately develop. In patients with lifestyle-limiting claudication, isolated endarterectomy of the common femoral artery (CFE) is highly effective. As CFE does not provide direct, in-line flow to the plantar arch, it has been felt to provide inadequate revascularization to patients with chronic limb-threatening ischemia (CLTI). The purpose of this retrospective clinical study was to report and assess the natural history of selected patients with CLTI treated with isolated CFE (without concomitant infrainguinal revascularization). METHODS Consecutive CFE performed in a large, urban hospital for CLTI between 2014-2021 were reviewed. Patient characteristics, limb, and anatomic stages using the Wound, Ischemia, foot Infection (WIfI) and Global Anatomic Staging Systems (GLASS) were tabulated. Limb-specific and survival-related endpoints were analyzed. RESULTS 58 patients presenting with CLTI underwent isolated CFE (mean age 74±10 years; 62% male, 90% current or prior smoker). Comorbidities included diabetes (52%), coronary artery disease (55%), congestive heart failure (22%), and end-stage renal failure on hemodialysis (5%). Patients presented with either rest pain (36%) or tissue loss (64%); the latter group exhibited advanced limb threat (68% in WIfI stage 3 or 4). The majority of patients had associated severe infrainguinal disease (50% GLASS 3). After a median follow-up of 17 months (range 10-29 months), vascular reintervention was required in 7 patients (12%). One patient (2%) required major limb amputation after presentation in WIfI stage 4 (W3I3fI0). Indeed, WIfI stage 4 was a significant univariate predictor of the need for subsequent infrainguinal bypass (p=0.034). CONCLUSIONS Isolated CFE as primary therapy in highly selected patients with CLTI was safe and effective. Index limb stage is predictive of the need for associated infrainguinal revascularization in this complex population.
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Affiliation(s)
- Michael Chaney
- Western Michigan University Homer Stryker, Kalamazoo, MI
| | - Gaurang Joshi
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | | | - Mohammed Rashid
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Abraham Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Chad E Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Lewis B Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Rym El Khoury
- Department of Surgery, Division of Vascular Surgery, NorthShore University Health System, Evanston, IL.
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Jeffcoate W, Boyko EJ, Game F, Cowled P, Senneville E, Fitridge R. Causes, prevention, and management of diabetes-related foot ulcers. Lancet Diabetes Endocrinol 2024:S2213-8587(24)00110-4. [PMID: 38824929 DOI: 10.1016/s2213-8587(24)00110-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 06/04/2024]
Abstract
In this Review, we aim to complement the 2023 update of the guidelines of the International Working Group on the Diabetic Foot. We highlight the complexity of the pathological processes that underlie diabetes-related foot ulceration (DFU) and draw attention to the potential implications for clinical management and outcome. Variation observed in the incidence and outcome of DFUs in different communities might result from differences in study populations and the accessibility of care. Comparing differences in incidence, management, and outcome of DFUs in different communities is an essential component of the quality of disease care. Additionally, these comparisons can also highlight the relationship between DFU incidence, management, and outcome and the structure of local clinical services and the availability of staff with the necessary skills. The clinical outcome is, however, also dependent on the availability of multidisciplinary care and the ability of people with DFUs to gain access to that care.
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Affiliation(s)
| | - Edward J Boyko
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Prue Cowled
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Eric Senneville
- Discipline of Infectious Diseases, The University of Lille, Gustave Dron Hospital, Tourcoing, France
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia; Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, SA, Australia.
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Abdul-Malak OM, Semaan DB, Madigan MC, Sridharan ND, Chaer RA, Siracuse JJ, Eslami MH. Midterm outcomes and predictors of failure of lower extremity bypass to para-malleolar and pedal targets. Ann Vasc Surg 2024:S0890-5096(24)00233-4. [PMID: 38815913 DOI: 10.1016/j.avsg.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/25/2024] [Accepted: 04/09/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVES The frequency of distal lower extremity bypass (LEB) for infra-popliteal critical limb threatening ischemia (IP-CLTI) has significantly decreased. Our goal was to analyze the contemporary outcomes and factors associated with failure of LEB to para-malleolar and pedal targets. METHODS We queried the VQI infra-inguinal database from 2003-2021 to identify LEB to para-malleolar or pedal/plantar targets. Primary outcomes were graft patency, major adverse limb events [vascular re-intervention, above ankle amputation] (MALE), and amputation-free survival at 2 years. Standard statistical methods were utilized. RESULTS We identified 2331 LEB procedures (1265 anterior tibial at ankle/dorsalis pedis, 783 posterior tibial at ankle, 283 tarsal/plantar). The prevalence of LEB bypasses to distal targets has significantly decreased from 13.37% of all LEB procedures in 2003 to 3.51% in 2021 (p<0.001). The majority of cases presented with tissue loss (81.25. Common post-operative complications included major adverse cardiac events (8.9%) and surgical site infections (3.6%). Major amputations occurred in 16.8% of patients at 1 year. Post-operative mortality at 1 year was 10%. On unadjusted Kaplan-Meier survival analysis at 2 years, primary patency was 50.56%±3.6%, MALE was 63.49%±3.27%, and amputation-free survival was 71.71%±0.98%. In adjusted analyses [adjusted for comorbidities, indication, conduit type, urgency, prior vascular interventions, graft inflow vessel (femoral/popliteal), concomitant inflow procedures, surgeon and center volume] conduits other than GSV (p<0.001) were associated with loss of primary patency and increased MALE. High center volume (>5 procedures/year) was associated with improved primary patency (p=0.015), and lower MALE (p=0.021) at 2 years. CONCLUSIONS Despite decreased utilization, open surgical bypass to distal targets at the ankle remains a viable option for treatment of IP-CLTI with acceptable patency and amputation-free survival rates at 2 years. Bypasses to distal targets should be performed at high volume centers to optimize graft patency and limb salvage and minimize re-interventions.
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Affiliation(s)
- Othman M Abdul-Malak
- Division of Vascular surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA; MedStar Heart and Vascular institute,.
| | - Dana B Semaan
- Division of Vascular surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Michael C Madigan
- Division of Vascular surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Natalie D Sridharan
- Division of Vascular surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Jeffrey J Siracuse
- Division of vascular and endovascular Surgery, Boston University, Boston, MA
| | - Mohammad H Eslami
- Division of Vascular surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Charleston area medical center
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Rajan A, Sima RR, Natarajan S. Endovascular Management of Chronic Limb-Threatening Ischemia (CLTI) in the Elderly: A Focus on Frailty, Wound Healing and Outcomes. Ann Vasc Surg 2024:S0890-5096(24)00229-2. [PMID: 38815902 DOI: 10.1016/j.avsg.2024.03.014] [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: 12/03/2023] [Revised: 02/27/2024] [Accepted: 03/07/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND In India, a significant scarcity of published data exists regarding chronic limb-threatening ischemia (CLTI) and its management, especially among the elderly population. CLTI, often accompanied by frailty poses a significant healthcare challenge. While endovascular interventions offer hope, there remains a dearth of outcome data for this age group. This study seeks to address this critical gap by investigating the impact of frailty on outcomes, emphasizing amputation-free survival (AFS), wound healing, and health-related quality of life (HRQoL). METHODS Our study included 131 elderly CLTI patients aged ≥70 years who underwent infrainguinal endovascular interventions between April 2018 and August 2021, with a follow-up period of 2 years. Among the patients, 93.9% had diabetes mellitus and 82.4% had hypertension. Clinical frailty was assessed using the Clinical Frailty Scale (CFS). Patients were categorized into Group 1 (CFS 1-5) and Group 2 (CFS 6-9). Primary outcomes were AFS, wound healing, HRQoL, and their association with frailty. Secondary outcomes included technical success, procedure-related complications, major adverse limb events (MALE), major adverse cardiovascular events (MACE), vessel patency, re-intervention rates, and mortality rates including peri-procedural and overall mortality. RESULTS Technical success was achieved in 86.3% of patients, with frailty significantly influencing this outcome. Group 2 exhibited reduced technical success (80.8%) compared to Group 1 (93.1%). The major amputation rate was 9.2%, with higher rates in Group 2 [univariate Hazard Ratio (HR): 5.20; p=0.033]. Similarly, Group 2 showed elevated overall mortality [univariate HR: 5.18; p < 0.001]. AFS at 1 and 2 years were 67.9% and 55% respectively, with higher rates in Group 1. Wound healing was achieved in 76.1% of patients (83/109), with frailty significantly associated with delayed wound healing (p < 0.001). Vessel patency at 1 year was observed in 88.8% of patients. HRQoL significantly improved post-intervention, with VascuQol-6 scores increasing from an average of 9 of 24 at baseline to 20 of 24 at 2 years. Frailty score significantly correlated with VascuQol-6 scores at 1 and 2 years (p < 0.0012). Group 1 exhibited higher VascuQol-6 scores compared to Group 2, indicating improved HRQoL during follow-up. CONCLUSION Successful endovascular treatments in high-risk CLTI patients promote improved wound healing and post-treatment quality of life (QoL). Frailty should be assessed before endovascular interventions as it correlates with adverse outcomes, including amputations and mortality. While revascularization holds promise, caution is advised for frailer patients, emphasizing the importance of personalized care and tailored treatments for elderly CLTI patients.
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Affiliation(s)
- Archana Rajan
- Department of Vascular and Endovascular Surgery, Kauvery Hospital, No.199 Luz Church Road, Mylapore, Chennai-600004, India.
| | - Rahul Ralph Sima
- Department of Vascular and Endovascular Surgery, Kauvery Hospital, No.199 Luz Church Road, Mylapore, Chennai-600004, India
| | - Sekar Natarajan
- Department of Vascular and Endovascular Surgery, Kauvery Hospital, No.199 Luz Church Road, Mylapore, Chennai-600004, India
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Brahmandam A, Kim TI, Parziale S, Deng Y, Setia O, Tonnessen BH, Ochoa Chaar CI, Guzman RJ, Aboian E. Intravascular Ultrasound Use is Associated with Improved Patency in Lower Extremity Peripheral Arterial Interventions. Ann Vasc Surg 2024:S0890-5096(24)00223-1. [PMID: 38810722 DOI: 10.1016/j.avsg.2024.03.008] [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: 12/04/2023] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVES Intravascular ultrasound (IVUS) facilitates detailed visualization of endoluminal anatomy not adequately appreciated on conventional angiography. However, it is unclear if IVUS use improves clinical outcomes of peripheral vascular interventions (PVI) for peripheral arterial disease (PAD). This study aimed to evaluate the impact of IVUS on 1-year outcomes of PVI in the vascular quality initiative (VQI). METHODS The VQI-PVI modules were reviewed (2016-2020). All patients with available one-year follow up after lower extremity PVI were included and grouped as IVUS-PVI or non-IVUS PVI based on use of IVUS. Propensity matching (1:1) was performed using demographics and comorbidities. One-year major amputation and patency rates were compared. A generalized estimating equation (GEE) model was used to identify predictors of 1-year outcomes. Subgroup analysis based on Trans-Atlantic Inter-Society Consensus (TASC) classification, treatment length and treatment modalities were performed using same modeling approaches. RESULTS There were 56,633 procedures (non-IVUS PVI=55,302 vs IVUS-PVI=1,331) in 44,042 patients. Propensity matching yielded a total cohort of 1,854 patients matched (1:1), with no baseline differences. LER for claudication was performed in 60.4%, while one-third (33.9%) had chronic limb threatening ischemia (CLTI). IVUS was more commonly used for lesions >15cm in length (46.6% vs 43.3%) and for aortoiliac disease (31.8% vs 27.2%). Rates of atherectomy and stenting were significantly higher with IVUS-PVI (21.1% vs 16.8%), while balloon angioplasty was less common (13.5% vs 24.4%). One-year patency was better with IVUS-PVI (97.7% vs 95.2%, p=0.004). On subgroup analysis, IVUS (OR 2.20, 95% CI 1.29- 3.75) was associated with improved patency in CLTI patients, TASC C or D lesions, and treatment length >15cm. Adjunctive IVUS use during PVI did not significantly impact 1-year amputation (OR 1.7, 95%CI 0.78-3.91). On multivariable regression, adjunctive use of IVUS (OR 2.46 95%CI 1.43-4.25) and aortoiliac interventions (OR 2.91, 95%CI 1.09-7.75) were independent predictors of patency. Treatment modalities such as atherectomy, stenting or balloon angioplasty did not significantly impact patency at 1-year. CONCLUSION IVUS during lower extremity PVI is associated with improved 1-year patency, when compared to angiography alone. Certain subgroups, such as CLTI patients, lesions>15cm, and TASC C or D lesions might benefit from adjunctive use of IVUS.
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Affiliation(s)
- Anand Brahmandam
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Tanner I Kim
- Department of Surgery, University of Hawaii John A. Burns School of Medicine, Honolulu, HI
| | - Stephen Parziale
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale University School of Public Health, New Haven, CT
| | - Ocean Setia
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Britt H Tonnessen
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Raul J Guzman
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Edouard Aboian
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT.
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11
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Callegari S, Romain G, Cleman J, Scierka L, Jacque F, Smolderen KG, Mena-Hurtado C. Long-Term Mortality Predictors Using a Machine-Learning Approach in Patients With Chronic Limb-Threatening Ischemia After Peripheral Vascular Intervention. J Am Heart Assoc 2024; 13:e034477. [PMID: 38761075 PMCID: PMC11179837 DOI: 10.1161/jaha.124.034477] [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: 01/16/2024] [Accepted: 04/15/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Patients with chronic limb-threatening ischemia (CLTI) face a high long-term mortality risk. Identifying novel mortality predictors and risk profiles would enable individual health care plan design and improved survival. We aimed to leverage a random survival forest machine-learning algorithm to identify long-term all-cause mortality predictors in patients with CLTI undergoing peripheral vascular intervention. METHODS AND RESULTS Patients with CLTI undergoing peripheral vascular intervention from 2017 to 2018 were derived from the Medicare-linked VQI (Vascular Quality Initiative) registry. We constructed a random survival forest to rank 66 preprocedural variables according to their relative importance and mean minimal depth for 3-year all-cause mortality. A random survival forest of 2000 trees was built using a training sample (80% of the cohort). Accuracy was assessed in a testing sample (20%) using continuous ranked probability score, Harrell C-index, and out-of-bag error rate. A total of 10 114 patients were included (mean±SD age, 72.0±11.0 years; 59% men). The 3-year mortality rate was 39.1%, with a median survival of 1.4 years (interquartile range, 0.7-2.0 years). The most predictive variables were chronic kidney disease, age, congestive heart failure, dementia, arrhythmias, requiring assisted care, living at home, and body mass index. A total of 41 variables spanning all domains of the biopsychosocial model were ranked as mortality predictors. The accuracy of the model was excellent (continuous ranked probability score, 0.172; Harrell C-index, 0.70; out-of-bag error rate, 29.7%). CONCLUSIONS Our random survival forest accurately predicts long-term CLTI mortality, which is driven by demographic, functional, behavioral, and medical comorbidities. Broadening frameworks of risk and refining health care plans to include multidimensional risk factors could improve individualized care for CLTI.
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Affiliation(s)
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program Yale University New Haven CT
| | - Jacob Cleman
- Vascular Medicine Outcomes Program Yale University New Haven CT
| | - Lindsey Scierka
- Vascular Medicine Outcomes Program Yale University New Haven CT
| | - Francky Jacque
- Vascular Medicine Outcomes Program Yale University New Haven CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program Yale University New Haven CT
- Department of Psychiatry Yale School of Medicine New Haven CT
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12
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Smeltz AM, Newton EJ, Kumar PA, Isaak RS, Doyal A, Fernando RJ, Vanneman MW, Augoustides JGT. 2023 Update on Vascular Anesthesia. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00321-5. [PMID: 38862283 DOI: 10.1053/j.jvca.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/11/2024] [Indexed: 06/13/2024]
Abstract
The authors thank thank the editors for this opportunity to review the recent literature on vascular surgery and anesthesia and provide this clinical update. The last in a series of updates on this topic was published in 2019.1 This review explores evolving discussions and current trends related to vascular surgery and anesthesia that have been published since then. The focus is on the major points discussed in the recent literature in the following areas: carotid artery surgery, infrarenal aortic surgery, peripheral vascular surgery, and the preoperative evaluation of vascular surgical patients.
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Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily J Newton
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Priya A Kumar
- Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS; Outcomes Research Consortium, Cleveland, OH
| | - Robert S Isaak
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Alexander Doyal
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Wake Forest University, Winston-Salem, NC
| | - Matthew W Vanneman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
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13
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Marcaccio CL, Schermerhorn ML. Using Administrative Data to Better Treat Chronic Limb Threatening Ischemia. Ann Vasc Surg 2024:S0890-5096(24)00204-8. [PMID: 38754578 DOI: 10.1016/j.avsg.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 01/17/2024] [Indexed: 05/18/2024]
Abstract
Chronic limb threatening ischemia (CLTI) is the most severe manifestation of peripheral arterial disease and represents a particularly high-risk subgroup of patients. As such, efforts to better understand this complex patient population through well-designed clinical research studies are critical to improving CLTI care. Prospective randomized clinical trials (RCTs) remain the gold standard in clinical research, but these trials are resource-intensive and have highly selective patient populations, which limit their feasibility and generalizability. Alternatively, retrospective studies are less expensive than RCTs, have a larger sample size, and are more generalizable owing to a broader patient population. Health care administrative data provide rich sources of information that may be used for research purposes and are increasingly being used for the study of vascular surgery conditions, including CLTI. Although administrative data are collected for billing purposes, they may be leveraged to study a broad range of topics in vascular surgery including those related to health care delivery, epidemiology, health disparities, and outcomes. This review provides an overview of administrative data available for CLTI research, the strengths and limitations of these data sources, current areas of investigation, and future opportunities for further study with the goal of improving outcomes in this high-risk population.
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Affiliation(s)
- Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Wang H, Zuo H, Pan D, Cao Y, Zhang Y, Liu D, Guo L, Guo J. An in vitro feasibility study of 355 nm laser atherectomy for the treatment of peripheral atherosclerotic lesions. JOURNAL OF BIOPHOTONICS 2024:e202400110. [PMID: 38740541 DOI: 10.1002/jbio.202400110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 03/28/2024] [Accepted: 04/19/2024] [Indexed: 05/16/2024]
Abstract
In this study, we utilized a novel 355 nm laser to ablate porcine aortas in the presence of physiological saline and contrast agent. Subsequently, we investigated the shape and depth of the resulting injuries. After ablating bovine tendons and aortas with the laser, we analyzed the size and quantity of particles postablation. Finally, we conducted ablation experiments using human ex vivo plaques. The analysis revealed minimal damage to porcine aortas within 2 s of exposure to the 355 nm laser. The degree of injury in the presence of contrast agent was higher than that in the presence of physiological saline but significantly lower than the damage caused by 308 nm laser. Regardless of whether it was bovine tendon or porcine aorta tissue, the proportion of particles <25 μm postlaser ablation exceeded 99%. Lastly, the 355 nm laser successfully opened three types of plaques: chronically occluded, stent restenosis, and stale thrombosis.
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Affiliation(s)
- Hui Wang
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hui Zuo
- Shenzhen Vivolight Medical Device & Technology Co. Ltd, Shenzhen, Guangdong Province, China
| | - Dikang Pan
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yihui Cao
- Shenzhen Vivolight Medical Device & Technology Co. Ltd, Shenzhen, Guangdong Province, China
| | - Yiqun Zhang
- Shenzhen Vivolight Medical Device & Technology Co. Ltd, Shenzhen, Guangdong Province, China
| | - Duan Liu
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lianrui Guo
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianming Guo
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Rumba R, Krievins D, Ezite N, Lacis A, Mouttet L, Vavere AL, Zarins CK. Endovascular Transvenous versus Open Femoropopliteal Bypass. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:777. [PMID: 38792960 PMCID: PMC11123046 DOI: 10.3390/medicina60050777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/18/2024] [Accepted: 05/05/2024] [Indexed: 05/26/2024]
Abstract
Background and Objectives: Lower extremity arterial disease is one of the most prevalent manifestations of atherosclerosis. The results from numerous studies regarding the best revascularization method of an occluded superficial femoral artery have been conflicting. The aim of this study was to compare the patency of transvenous endovascular with open femoropopliteal bypass, both with vein and prosthetic grafts. To our knowledge, a direct patency comparison between transvenous endovascular and open femoropopliteal bypass has not been published. This could help elucidate which method is preferable and in which cases. Materials and Methods: Patients with complex TASC-C and D SFA lesions were offered endovascular transvenous or open bypass. A total of 384 consecutive patients with PAD requiring surgical treatment were evaluated for inclusion in this study. Three-year follow-up data were collected for 52 endovascular procedures, 80 prosthetic grafts, and 44 venous bypass surgeries. Bypass patency was investigated by Duplex US every 6 months. Kaplan-Meier plots were used to analyze primary, primary-assisted, and secondary patency for endovascular transvenous, autovenous, and prosthetic bypasses. Results: Primary, primary-assisted, and secondary patency in venous group at 3 years was 70.5%, 77.3%, and 77.3%, respectively. In the endovascular transvenous group, primary, primary-assisted, and secondary patency at 3 years was 46.2%, 69.2%, and 76.9%, respectively. The lowest patency rates at 3 years were noted in the prosthetic graft group with 22.5% primary, 26.6% primary-assisted, and 28.2% secondary patency. Conclusions: The saphenous vein is the best graft to perform in above-the-knee femoropopliteal bypass. Transvenous endovascular bypass is a viable option with comparable primary-assisted and secondary patency. Primary patency is substantially lower for endovascular transvenous compared to venous bypass. Patients treated with endovascular transvenous bypass will require a significant number of secondary procedures to provide optimal patency. Prosthetic grafts should only be used if no other option for bypass is available.
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Affiliation(s)
- Roberts Rumba
- Vascular Surgery Department, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (R.R.)
| | - Dainis Krievins
- Vascular Surgery Department, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (R.R.)
| | - Natalija Ezite
- Diagnostic Radiology, Diagnostic and Interventional Radiology Centre, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia
| | - Aigars Lacis
- Vascular Surgery Department, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (R.R.)
| | - Ludovic Mouttet
- Department of Surgical and Interventional Sciences, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G 2M1, Canada
| | - Anda L. Vavere
- Faculty of Medicine, University of Latvia, 1004 Riga, Latvia
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Patrone L, Falcone G, Coscas R, Lichaa H, Antaredja M, Fanelli F, Blessing E. Retrograde Peroneal Artery Approach to Treat Infra-Inguinal Arterial Chronic Total Occlusions: A Multicentre Experience and Technical Considerations. J Clin Med 2024; 13:2770. [PMID: 38792312 PMCID: PMC11121828 DOI: 10.3390/jcm13102770] [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: 03/25/2024] [Revised: 04/19/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024] Open
Abstract
Background/Objectives: Retrograde access of the peroneal artery (PA) is considered technically challenging and at risk of bleeding. The aim of this multicentre retrospective study was to assess the safety, feasibility, and technical success of this access route for infrainguinal endovascular recanalizations. Methods: We retrospectively analyzed 186 consecutive patients treated over a 7-year period (May 2014-August 2021) who underwent endovascular recanalization of infra-inguinal lesions using a PA access route. In all cases, retrograde PA access was obtained following a failed attempt to cross the occlusion via the antegrade route. Results: Among the 186 patients, 120 were males (60.5%) and the mean age was 76.8 ± 10.7 years old (44-94 years). One hundred and thirteen patients (60.7%) suffered from chronic limb threatening ischemia (CLTI). All patients presented with chronic total occlusions (CTO) and a failed conventional antegrade recanalization attempt. Retrograde access was performed under angiographic guidance in 185 cases (99.5%). It was successfully established in 171 cases (91.9%). The total rate of retrograde puncture-related complications was 2.1% (two puncture site bleedings of which one necessitated fasciotomy and two cases of arteriovenous fistulas managed conservatively). The Major Adverse Event (MAE) rate at 30 days was 1.6% (3/186). Conclusions: Retrograde recanalization of challenging infra-inguinal lesions via PA is safe and effective in experienced hands.
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Affiliation(s)
- Lorenzo Patrone
- West London Vascular and Interventional Centre, Northwick Park Hospital, Harrow HA1 3UJ, UK;
| | - Gianmarco Falcone
- Interventional Radiology Department, Ospedale Careggi, 50134 Firenze, Italy; (G.F.); (F.F.)
| | - Raphael Coscas
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, 92104 Boulogne-Billancourt, France;
| | - Hady Lichaa
- Tennessee Health Science Center, Ascension Saint Thomas Heart, Nashville, TN 37203, USA;
| | - Muliadi Antaredja
- Department of Angiology, Clinic for Vascular Medicine, University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, 20251 Hamburg, Germany;
| | - Fabrizio Fanelli
- Interventional Radiology Department, Ospedale Careggi, 50134 Firenze, Italy; (G.F.); (F.F.)
| | - Erwin Blessing
- Department of Angiology, Clinic for Vascular Medicine, University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, 20251 Hamburg, Germany;
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17
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Fanaroff AC, Dayoub EJ, Yang L, Schultz K, Ramadan OI, Wang GJ, Damrauer SM, Genovese EA, Secemsky EA, Parikh SA, Nathan AS, Kohi MP, Weinberg MD, Jaff MR, Groeneveld PW, Giri JS. Association Between Diagnosis-to-Limb Revascularization Time and Clinical Outcomes in Outpatients With Chronic Limb-Threatening Ischemia: Insights From the CLIPPER Cohort. J Am Heart Assoc 2024; 13:e033898. [PMID: 38639376 PMCID: PMC11179943 DOI: 10.1161/jaha.123.033898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/18/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND The extent and consequences of ischemia in patients with chronic limb-threatening ischemia (CLTI) may change rapidly, and delays from diagnosis to revascularization may worsen outcomes. We sought to describe the association between time from diagnosis to endovascular lower extremity revascularization (diagnosis-to-limb revascularization [D2L] time) and clinical outcomes in outpatients with CLTI. METHODS AND RESULTS In the CLIPPER cohort, comprising patients between 66 and 86 years old diagnosed with CLTI betweeen 2010 and 2019, we used Medicare claims data to identify patients who underwent outpatient endovascular revascularization within 180 days of diagnosis. We described the risk-adjusted association between D2L time and clinical outcomes. Among 1 130 065 patients aged between 66 and 86 years with CLTI, 99 221 (8.8%) underwent outpatient endovascular lower extremity revascularization within 180 days of their CLTI diagnosis. Among patients with D2L time <30 days, there was no association between D2L time and all-cause death or major lower extremity amputation. However, among patients with D2L time >30 days, each additional 10-day increase in D2L time was associated with a 2.5% greater risk of major amputation (hazard ratio, 1.025 [95% CI, 1.014-1.036]). There was no association between D2L time and all-cause death. CONCLUSIONS A delay of >30 days from CLTI diagnosis to lower extremity endovascular revascularization was associated with an increased risk of major lower extremity amputation among patients undergoing outpatient endovascular revascularization. Improving systems of care to reduce D2L time could reduce amputations.
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Affiliation(s)
- Alexander C. Fanaroff
- Cardiovascular Medicine Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Penn Center for Health Incentives and Behavioral EconomicsUniversity of PennsylvaniaPhiladelphiaPA
| | - Elias J. Dayoub
- Cardiovascular Medicine Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
| | - Lin Yang
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
| | - Kaitlyn Schultz
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
| | - Omar I. Ramadan
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Grace J. Wang
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Scott M. Damrauer
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Department of Genetics, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
| | - Elizabeth A. Genovese
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Eric A. Secemsky
- Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical SchoolHarvard UniversityBostonMA
| | - Sahil A. Parikh
- Division of Cardiology, Vagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNY
| | - Ashwin S. Nathan
- Cardiovascular Medicine Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
| | - Maureen P. Kohi
- Department of RadiologyUniversity of North CarolinaChapel HillNC
| | | | | | - Peter W. Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
- General Internal Medicine Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Jay S. Giri
- Cardiovascular Medicine Division, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Health EconomicsPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
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Zarrintan S, Rahgozar S, Ross EG, Farber A, Menard MT, Conte MS, Malas MB. Endovascular therapy versus bypass for chronic limb-threatening ischemia in a real-world practice. J Vasc Surg 2024:S0741-5214(24)01093-0. [PMID: 38718850 DOI: 10.1016/j.jvs.2024.04.067] [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: 11/09/2023] [Revised: 04/26/2024] [Accepted: 04/29/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE The recent Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) study showed that bypass was superior to endovascular therapy (ET) in patients with chronic limb-threatening ischemia (CLTI) deemed suitable for either approach who had an available single-segment great saphenous vein (GSV). However, the superiority of bypass among those lacking GSV was not established. We aimed to examine comparative treatment outcomes from a real-world CLTI population using the Vascular Quality Initiative-Medicare-linked database. METHODS We queried the Vascular Quality Initiative-Medicare-linked database for patients with CLTI who underwent first-time lower extremity revascularization (2010-2019). We performed two one-to-one propensity score matchings (PSMs): ET vs bypass with GSV (BWGSV) and ET vs bypass with a prosthetic graft (BWPG). The primary outcome was amputation-free survival. Secondary outcomes were freedom from amputation and overall survival (OS). RESULTS Three cohorts were queried: BWGSV (N = 5279, 14.7%), BWPG (N = 2778, 7.7%), and ET (N = 27,977, 77.6%). PSM produced two sets of well-matched cohorts: 4705 pairs of ET vs BWGSV and 2583 pairs of ET vs BWPG. In the matched cohorts of ET vs BWGSV, ET was associated with greater hazards of death (hazard ratio [HR] = 1.34, 95% confidence interval [CI], 1.25-1.43; P < .001), amputation (HR = 1.30, 95% CI, 1.17-1.44; P < .001), and amputation/death (HR = 1.32, 95% CI, 1.24-1.40; P < .001) up to 4 years. In the matched cohorts of ET vs BWPG, ET was associated with greater hazards of death up to 2 years (HR = 1.11, 95% CI, 1.00-1.22; P = .042) but not amputation or amputation/death. CONCLUSIONS In this real-world multi-institutional Medicare-linked PSM analysis, we found that BWGSV is superior to ET in terms of OS, freedom from amputation, and amputation-free survival up to 4 years. Moreover, BWPG was superior to ET in terms of OS up to 2 years. Our study confirms the superiority of BWGSV to ET as observed in the BEST-CLI trial.
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Affiliation(s)
- Sina Zarrintan
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of California San Diego (UCSD), San Diego, CA
| | - Shima Rahgozar
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of California San Diego (UCSD), San Diego, CA
| | - Elsie G Ross
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of California San Diego (UCSD), San Diego, CA
| | - Alik Farber
- Department of Surgery, Division of Vascular & Endovascular Surgery, Boston University School of Medicine, Boston, MA
| | - Matthew T Menard
- Department of Surgery, Division of Vascular & Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael S Conte
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of California San Francisco (UCSF), San Francisco, CA
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular & Endovascular Surgery, University of California San Diego (UCSD), San Diego, CA.
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Neville RF. Management of peripheral arterial disease in the context of a multidisciplinary limb program. Front Cardiovasc Med 2024; 11:1368655. [PMID: 38751662 PMCID: PMC11094204 DOI: 10.3389/fcvm.2024.1368655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/11/2024] [Indexed: 05/18/2024] Open
Abstract
Peripheral artery disease (PAD) continues to increase in prevalence worldwide due to risk factors such as advanced age, diabetes mellitus, and obesity. Critical limb ischemia (CLTI) is the advanced form of PAD that can result in a lack of healing and limb loss as the most devastating consequence. Patients with PAD, especially CLTI, benefit from multidisciplinary care to optimize outcomes by reducing cardiovascular morbidity and mortality and preventing lower extremity amputation. Collaboration between various specialties allows a focus on problems involved in treating the patient with PAD including prevention, screening, medical care, wound care, infection, and revascularization when needed. Although there is no clear definition or consensus on the structure of the PAD team, certain guidelines are applicable to most clinical scenarios emphasizing "provider champions" in leading a clinical program. A vascular specialist (vascular surgery, interventional radiology, interventional cardiology) and a soft tissue specialist (podiatry, plastic surgery) are the typical "champions," often involving orthopedics, general surgery, vascular medicine, diabetology/endocrinology, infectious disease, nephrology, and rehabilitation medicine. The team should also include wound nurses, nutritionists, occupational therapists, orthotists, pharmacists, physical therapists, prosthetists, and social workers. This paper presents a brief overview of the structure of the multidisciplinary team with key components and functions of such a team to optimize treatment outcomes for PAD and CLTI.
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Affiliation(s)
- Richard F. Neville
- Inova Schar Heart and Vascular, Section of Vascular Surgery, Department of Surgery, Fairfax Inova Medical Center, Falls Church, VA, United States
- Vascular, Wound and Hyperbaric Medicine Services, Inova Health System, Falls Church, VA, United States
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20
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Trenkler C, Blessing E, Jehn A, Karcher J, Schoefthaler C, Schmidt A, Korosoglou G. Retrospective Case Control Matched Comparison of the Antegrade Versus Retrograde Strategy After Antegrade Recanalisation Failure in Complex de novo Femoropopliteal Occlusive Lesions. Eur J Vasc Endovasc Surg 2024; 67:799-808. [PMID: 38182107 DOI: 10.1016/j.ejvs.2023.12.037] [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: 08/06/2023] [Revised: 12/04/2023] [Accepted: 12/29/2023] [Indexed: 01/07/2024]
Abstract
OBJECTIVE To investigate dissection severity, need for bailout stenting and limb outcomes in patients undergoing antegrade vs. retrograde revascularisation. METHODS Consecutive patients who underwent either antegrade or retrograde revascularisation after failed antegrade recanalisation of long femoropopliteal chronic total occlusion (CTO) due to symptomatic peripheral artery disease between January 2017 and June 2022 were studied. Retrospective case control matching was used to adjust for lesion length and calcification using the peripheral artery calcification scoring system (PACSS). Procedural outcomes included severity of dissection (Type A to F dissections, numerically graded on a scale from 0 - 6 with increasing severity) after angioplasty and number and location of stents needed to be implanted during the index procedure. Additionally, clinically driven target lesion revascularisation (CD-TLR) and major (above ankle) amputation rates were assessed during follow up. RESULTS A total of 180 patients were analysed who underwent antegrade (n = 90) or retrograde after failed antegrade (n = 90) recanalisation. The median patient age was 76.0 (interquartile range [IQR] 67.0, 82.0) years and 76 (42.2%) were female. Moreover, 78 patients (43.3%) had intermittent claudication, whereas 102 (56.7%) had chronic limb threatening ischaemia (CLTI). The mean lesion length was 30.0 (IQR 24.0, 36.0) cm with moderate to severe (3.0 [IQR 2.0, 4.0]) lesion calcification. Dissection severity after angioplasty was higher in the antegrade than retrograde after failed antegrade recanalisation group (4.0 [IQR 3.0, 4.0] vs. 3.0 [IQR 2.0, 4.0]; p < .001). Additionally, the number of stents in all segments and the rate of bailout stenting in popliteal segments was significantly higher with the antegrade strategy (2.0 [IQR 1.0, 3.0] vs. 1.0 [IQR 0, 2.0], p < .010; and 37% vs. 14%, p < .001). During a median follow up of 1.48 (IQR 0.63, 3.09) years, CD-TLR rates (p = .90) and amputation rates in patients with CLTI (p = .15) were not statistically significant. CONCLUSION In complex femoropopliteal CTOs, retrograde after failed antegrade recanalisation, is safe for endovascular revascularisation, which in experienced hands may result in less severe dissections and lower rates of stent placement. However, considering the relatively short follow up, CD-TLR and amputation rates were not statistically different between the two approaches. [German Clinical Trials Register: DRKS00015277.].
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Affiliation(s)
- Christian Trenkler
- Department of Cardiology, Vascular Medicine & Pneumology, GRN Hospital Weinheim, Weinheim, Germany
| | - Erwin Blessing
- Department of Angiology, University Heart and Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Amila Jehn
- Department of Cardiology, Vascular Medicine & Pneumology, GRN Hospital Weinheim, Weinheim, Germany
| | - Jan Karcher
- Department of Cardiology, Vascular Medicine & Pneumology, GRN Hospital Weinheim, Weinheim, Germany
| | - Christoph Schoefthaler
- Department of Cardiology, Vascular Medicine & Pneumology, GRN Hospital Weinheim, Weinheim, Germany
| | - Andrej Schmidt
- Department of Interventional Angiology, University Hospital Leipzig, Leipzig, Germany
| | - Grigorios Korosoglou
- Department of Cardiology, Vascular Medicine & Pneumology, GRN Hospital Weinheim, Weinheim, Germany.
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21
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Cervin A. The Occluded Prosthetic Bypass Graft: What To Do? Eur J Vasc Endovasc Surg 2024; 67:797-798. [PMID: 37683999 DOI: 10.1016/j.ejvs.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/28/2023] [Accepted: 09/04/2023] [Indexed: 09/10/2023]
Affiliation(s)
- Anne Cervin
- Department of Vascular Surgery, Sahlgrenska University Hospital and Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden
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22
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Zaka A, Mutahar D, Ponen K, Abtahi J, Mridha N, Williams AB, Kamali M, Kovoor JG, Bacchi S, Gupta AK, Psaltis PJ, Bhamidipaty V. Prognostic value of left ventricular systolic function before vascular surgery: a systematic review. ANZ J Surg 2024; 94:826-832. [PMID: 38305060 DOI: 10.1111/ans.18866] [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: 10/03/2023] [Revised: 12/21/2023] [Accepted: 01/08/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Vascular surgery carries a high risk of post-operative cardiac complications. Recent studies have shown an association between asymptomatic left ventricular systolic dysfunction and increased risk of major adverse cardiovascular events (MACE). This systematic review aims to evaluate the prognostic value of left ventricular function as determined by left ventricular ejection fraction (LVEF) measured by resting echocardiography before vascular surgery. METHODS This review conformed to PRISMA and MOOSE guidelines. PubMed, OVID Medline and Cochrane databases were searched from inception to 27 October 2022. Eligible studies assessed vascular surgery patients, with multivariable-adjusted or propensity-matched observational studies measuring LVEF via resting echocardiography and providing risk estimates for outcomes. The primary outcomes measures were all-cause mortality and congestive heart failure at 30 days. Secondary outcome included the composite outcome MACE. RESULTS Ten observational studies were included (4872 vascular surgery patients). Studies varied widely in degree of left ventricular systolic dysfunction, symptom status, and outcome reporting, precluding reliable meta-analysis. Available data demonstrated a trend towards increased incidence of all-cause mortality, congestive heart failure and MACE in patients with pre-operative LVEF <50%. Methodological quality of the included studies was found to be of moderate quality according to the Newcastle Ottawa Checklist. CONCLUSION The evidence surrounding the prognostic value of LVEF measurement before vascular surgery is currently weak and inconclusive. Larger scale, prospective studies are required to further refine cardiac risk prediction before vascular surgery.
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Affiliation(s)
- Ammar Zaka
- Department of Cardiology, Department of Vascular Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Daud Mutahar
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Kreyen Ponen
- Department of Cardiology, Department of Vascular Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Johayer Abtahi
- Department of Cardiology, Department of Vascular Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Naim Mridha
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Aman B Williams
- Department of Cardiology, Department of Vascular Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Mohammed Kamali
- Department of Cardiology, Department of Vascular Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Joshua G Kovoor
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Aashray K Gupta
- Department of Cardiology, Department of Vascular Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Peter J Psaltis
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Venu Bhamidipaty
- Department of Cardiology, Department of Vascular Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
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Morisaki K, Matsuda D, Guntani A, Kawanami S, Yoshino S, Inoue K, Honma K, Yamaoka T, Mii S, Yoshizumi T. Validation of JCLIMB, SPINACH, and VQI Calculators for Prediction of Two Year Survival in Patients With Chronic Limb Threatening Ischaemia After Infra-Inguinal Surgical or Endovascular Revascularisation. Eur J Vasc Endovasc Surg 2024; 67:777-783. [PMID: 38141957 DOI: 10.1016/j.ejvs.2023.12.023] [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: 06/25/2023] [Revised: 10/20/2023] [Accepted: 12/18/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE This study aimed to evaluate three survival prediction models: the JAPAN Critical Limb Ischaemia Database (JCLIMB), Surgical Reconstruction Versus Peripheral Intervention in Patients With Critical Limb Ischaemia (SPINACH), and Vascular Quality Initiative (VQI) calculators. METHODS Multicentre data of patients who underwent infrainguinal revascularisation for chronic limb threatening ischaemia between 2018 and 2021 were analysed retrospectively. The prediction models were validated using a calibration plot analysis with the intercept and slope. The discrimination was evaluated using area under the curve (AUC) analysis. The observed two year overall survival (OS) was evaluated by the Kaplan - Meier method. The two year OS predicted by each model at < 50%, 50 - 70%, and > 70% was defined as high, medium, and low risk, respectively. RESULTS A total of 491 patients who underwent infra-inguinal revascularisation were analysed. The rates of surgical revascularisation, endovascular therapy, and hybrid therapy were 26.5%, 70.1%, and 5.5%, respectively. The average age was 75.6 years, and the percentages of patients with diabetes mellitus and dialysis dependent end stage renal disease were 66.6% and 44.6%, respectively. The tissue loss rate was 85.7%. The intercept and slope were -0.13 and 1.18 for the JCLIMB, 0.11 and 0.82 for the SPINACH, and -0.15 and 1.10 for the VQI. The AUC for the two year OS of JCLIMB, SPINACH, and VQI were 0.758, 0.756, and 0.740, respectively. The observed two year OS rates of low, medium, and high risk using the JCLIMB calculator were 80.1%, 61.1%, and 28.5%, respectively (p < .001), using the SPINACH calculator were 81.0%, 57.0%, and 38.1%, respectively (p < .001), and using the VQI calculator were 77.8%, 45.8%, and 49.6%, respectively (p < .001). CONCLUSION The JCLIMB, SPINACH, and VQI survival calculation models were useful, although the OS predicted by the VQI model appeared to be lower than the observed OS.
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Affiliation(s)
- Koichi Morisaki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Daisuke Matsuda
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Atsushi Guntani
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan
| | - Shogo Kawanami
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinichiro Yoshino
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kentaro Inoue
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenichi Honma
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Shinsuke Mii
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Siracuse JJ, Menard MT, Rosenfield K, Conte MS, Powell R, Hamburg N, Doros G, Strong MB, Farber A. Characterization of cardiovascular serious adverse events after bypass or endovascular revascularization for limb-threatening ischemia in the BEST-CLI trial. J Vasc Surg 2024:S0741-5214(24)00987-X. [PMID: 38626847 DOI: 10.1016/j.jvs.2024.04.025] [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: 03/08/2024] [Revised: 04/02/2024] [Accepted: 04/09/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVE Cardiovascular complications after revascularization to treat chronic limb-threatening ischemia (CLTI) are a major concern that guides treatment. Our goal was to assess periprocedural cardiac and vascular serious adverse events (SAEs) in the Best Endovascular vs Best Surgical Therapy in Patients with CLTI (BEST-CLI) trial. METHODS BEST-CLI was a prospective randomized trial comparing surgical (OPEN) and endovascular (ENDO) revascularization for patients with CLTI. Thirty-day SAEs, classified as cardiac or vascular, were analyzed. Adverse events are defined as serious when they affect safety in the trial, require prolonged hospitalization, result in significant disability or incapacitation, are life-threatening, or result in death. Interventions were analyzed in a per protocol fashion. RESULTS In the BEST-CLI trial, 850 OPEN and 896 ENDO interventions were evaluated. Forty (4.7%) and 34 (3.8%) patients experienced at least one cardiac SAE after OPEN and ENDO intervention, respectively (P = .35). Overall, there were 53 cardiac SAEs (0.06 per patient) after OPEN and 40 (0.045 per patient) after ENDO interventions. Cardiac SAEs in the OPEN arm were classified as related to ischemia (50.9%), arrhythmias (17%), heart failure (15.1%), arrest (13.2%), and heart block (3.8%); in the ENDO arm, they were classified as ischemia (47.5%), heart failure (17.5%), arrhythmias (15%), arrest (15%), and heart block (5%). Approximately half of SAEs were classified as severe for both OPEN and ENDO. SAEs were definitely or probably related to the procedure in 30.2% and 25% in the OPEN and ENDO arms, respectively (P = .2). Vascular SAEs occurred in 58 (6.8%) and 86 (9.6%) of patients after OPEN and ENDO revascularization, respectively (P = .19). In total, there were 59 (0.07 per patient) and 87 (0.097 per patient) vascular SAEs after OPEN and ENDO procedures. Vascular SAEs in the OPEN arm were classified as distal ischemia/infection (44.1%), bleeding (16.9%), occlusive (15.3%), thromboembolic (15.3%), cerebrovascular (5.1%), and other (3.4%); in the ENDO arm, they were distal ischemia/infection (40.2%), occlusive (31%), bleeding (12.6%), thromboembolic (8%), cerebrovascular (1.1%), and other (4.6%). SAEs were classified as severe for OPEN in 45.8% and ENDO in 46%. SAEs were definitely or probably related to the procedure in 23.7% and 35.6% in the OPEN and ENDO arms (P = .35), respectively. CONCLUSIONS Patients undergoing OPEN and ENDO revascularization experienced similar degrees of cardiac and vascular SAEs. The majority were not related to the index intervention, but approximately half were severe.
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Affiliation(s)
- Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA.
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kenneth Rosenfield
- Section of Vascular Medicine and Intervention Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Richard Powell
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Naomi Hamburg
- Division of Cardiovascular Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | | | - Michael B Strong
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
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25
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Rymer JA, Patel MR. Health-Related Quality of Life Instruments in Chronic Limb-Threatening Ischemia: Evolution of Defining Quality of Life in a Complex Disease State. Circulation 2024; 149:1254-1257. [PMID: 38620090 DOI: 10.1161/circulationaha.123.067812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Affiliation(s)
- Jennifer A Rymer
- Division of Cardiology, Department of Medicine, and Duke Clinical Research Institute, Duke University School of Medicine, Duke University, Durham, NC
| | - Manesh R Patel
- Division of Cardiology, Department of Medicine, and Duke Clinical Research Institute, Duke University School of Medicine, Duke University, Durham, NC
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Latkovskis G, Krievins D, Zellans E, Kumsars I, Krievina A, Angena A, Jegere S, Erglis A, Lacis A, Zarins C. Ischemia-Guided Coronary Revascularization Following Lower-Extremity Revascularization Improves 5-Year Survival of Patients With Chronic Limb-Threatening Ischemia. J Endovasc Ther 2024:15266028241245909. [PMID: 38616613 DOI: 10.1177/15266028241245909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
PURPOSE To determine whether diagnosis of asymptomatic (silent) coronary ischemia using coronary computed tomography (CT)-derived fractional flow reserve (FFRCT) together with targeted coronary revascularization of ischemia-producing coronary lesions following lower-extremity revascularization can reduce adverse cardiac events and improve long-term survival of patients with chronic limb-threatening ischemia (CLTI). MATERIALS AND METHODS Prospective cohort study of CLTI patients with no cardiac history or symptoms undergoing elective lower-extremity revascularization. Patients with pre-operative coronary computed tomography angiography (CTA) and FFRCT evaluation with selective post-operative coronary revascularization (FFRCT group) were compared with patients with standard pre-operative evaluation and no post-operative coronary revascularization (control group). Lesion-specific coronary ischemia was defined as FFRCT≤0.80 distal to a coronary stenosis with FFRCT≤0.75 indicating severe ischemia. Endpoints included all-cause death, cardiac death, myocardial infarction (MI) and major adverse cardiovascular (CV) events (MACE=CV death, MI, stroke, or unplanned coronary revascularization) during 5 year follow-up. RESULTS In the FFRCT group (n=111), FFRCT analysis revealed asymptomatic (silent) coronary ischemia (FFRCT≤0.80) in 69% of patients, with severe ischemia (FFRCT≤0.75) in 58%, left main ischemia in 8%, and multivessel ischemia in 40% of patients. The status of coronary ischemia in the control group (n=120) was unknown. Following lower-extremity revascularization, 42% of patients in FFRCT had elective coronary revascularization with no elective revascularization in controls. Both groups received guideline-directed medical therapy. During 5 year follow-up, compared with control, the FFRCT group had fewer all-cause deaths (24% vs 47%, hazard ratio [HR]=0.43 [95% confidence interval [CI]=0.27-0.69], p<0.001), fewer cardiac deaths (5% vs 26%, HR=0.18 [95% CI=0.07-0.45], p<0.001), fewer MIs (7% vs 28%, HR=0.21 [95% CI=0.10-0.47], p<0.001), and fewer MACE events (14% vs 39%, HR=0.28 [95% CI=0.15-0.51], p<0.001). CONCLUSIONS Ischemia-guided coronary revascularization of CLTI patients with asymptomatic (silent) coronary ischemia following lower-extremity revascularization resulted in more than 2-fold reduction in all-cause death, cardiac death, MI, and MACE with improved 5 year survival compared with patients with standard cardiac evaluation and care (76% vs 53%, p<0.001). CLINICAL IMPACT Silent coronary ischemia in patients with chronic limb-threatening ischemia (CLTI) is common even in the absence of cardiac history or symptoms. FFRCT is a convenient tool to diagnose silent coronary ischemia perioperatively. Our data suggest that post-surgery elective FFRCT-guided coronary revascularization reduces adverse cardiac events and improves long-term survival in this very-high risk patient group. Randomized study is warranted to finally test this concept.
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Affiliation(s)
- Gustavs Latkovskis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Dainis Krievins
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Edgars Zellans
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Indulis Kumsars
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | | | | | - Sanda Jegere
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Andrejs Erglis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Aigars Lacis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- Riga Stradins University, Riga, Latvia
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Wainwright BS, Chihade DB, Costanza MJ, Feghali AC, Shaw PM. Paradigm Shift of Interventional Strategies and Outcomes for Acute Limb Ischemia Post-Pandemic. J Endovasc Ther 2024:15266028241246162. [PMID: 38606923 DOI: 10.1177/15266028241246162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
PURPOSE We performed a large-scale comparison of patients treated for acute limb ischemia (ALI) in the pre-COVID (2017-2019) and COVID (2020-2022) eras to evaluate changes in interventional strategies and compare factors associated with adverse outcomes. We sought to characterize patient outcomes in an evolving ALI treatment algorithm in response to pandemic-associated presentation delays and rapid technological advancements in mechanical thrombectomy (MT). METHODS Using the TriNetX global research network, we conducted a multicenter query across 80 health care organizations (HCOs) spanning 4 countries for patients treated for ALI. Propensity score matching was performed to account for comorbidities. Risk of adverse outcomes within 30 days was calculated for each era, including re-intervention (RI30), major/minor amputation, and death. Patients were then stratified by initial intervention: open revascularization (OR), MT, or catheter-directed thrombolysis and adjunctive endovascular procedures alone (CDT/EP). Risk of adverse outcomes was compared between treatment groups of the same era. RESULTS After propensity score matching, the pre-COVID era and COVID era cohorts included 7344 patients each. COVID era patients experienced a statistically significant higher risk of 30-day mortality (RR=1.211, p=0.027). Mechanical thrombectomy interventions were performed more frequently in the COVID era (RR=1.314, p<0.0001). Comparing outcomes between treatment groups, MT patients required RI30 more than OR patients (pre-COVID: RR=2.074, p=0.006; COVID: RR=1.600, p=0.025). Open revascularization patients had higher 30-day mortality (pre-COVID: RR=2.368, p<0.0001; COVID: RR=2.013, p<0.0001) and major amputations (pre-COVID: RR=2.432, p<0.0001; COVID: RR=2.176, p<0.0001) than CDT/EP. Pre-COVID CDT/EP patients were at higher risk for RI30 (RR=1.449, p=0.005) and minor amputations (RR=1.500, p=0.010) than OR. The MT group had higher major amputation rates than CDT/EP (pre-COVID: RR=2.043, p=0.019; COVID: RR=1.914, p=0.007). COVID-era MT patients had greater 30-day mortality (RR=1.706, p=0.031) and RI30 (RR=1.544, p=0.029) than CDT/EP. CONCLUSION Significant shifts toward an MT-based approach have been observed in the last 3 years. Although MT required more RI30 than OR, there was no associated consequence of mortality and limb salvage. The increased mortality seen among COVID-era patients could be explained by delayed presentation, as well as poorly understood pro-thrombogenic or pro-inflammatory mechanisms related to the first waves of COVID. More research is necessary to determine an optimal treatment algorithm. CLINICAL IMPACT Comorbid risk factors and severity of ischemia must be carefully considered before selecting an interventional strategy to prevent adverse outcomes and maximize limb salvage. Open revascularization strategies are associated with increased mortality and limb loss compared to less-invasive thrombolytic therapy alone. Mechanical thrombectomy (MT)-based approaches have been increasingly used in the last 3 years. Patients receiving MT are more likely to require reintervention within 30 days.
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Affiliation(s)
- Brandon S Wainwright
- Norton College of Medicine, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Deena B Chihade
- Division of Vascular Surgery & Endovascular Services, Department of Surgery, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Michael J Costanza
- Division of Vascular Surgery & Endovascular Services, Department of Surgery, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Anthony C Feghali
- Division of Vascular Surgery & Endovascular Services, Department of Surgery, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Palma M Shaw
- Division of Vascular Surgery & Endovascular Services, Department of Surgery, State University of New York Upstate Medical University, Syracuse, NY, USA
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Wolf H, Singh N. Using Multidisciplinary Teams to Improve Outcomes for Treating Chronic-Limb Threatening Ischemia. Ann Vasc Surg 2024:S0890-5096(24)00141-9. [PMID: 38604501 DOI: 10.1016/j.avsg.2023.11.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/23/2023] [Indexed: 04/13/2024]
Abstract
Multidisciplinary teams are necessary to treat complex patients with chronic limb-threatening ischemia (CLTI). The need for adequate wound care and control of comorbid conditions cannot be accomplished by the vascular specialist alone. Numerous specialties have a role in this group to include surgical podiatrists, orthopedic surgery, plastic and reconstructive surgery endocrinology, and wound care. However, the vascular specialist must drive this team as the patients are usually referred to them and numerous studies have shown a direct correlation between major amputations and the lack of vascular involvement. Creating these teams is unique in each community and must consider practice patterns that are relevant in the local region. CLTI is a challenging disease to manage, and multidisciplinary teams have demonstrated an ability to improve outcomes and deliver superior care to this patient population.
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Affiliation(s)
- Hannah Wolf
- University of Washington School of Medicine, Seattle, WA
| | - Niten Singh
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA.
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Nakhaei P, Hamouda M, Malas MB. The Double Burden: Deciphering Chronic Limb-Threatening Ischemia in End-Stage Renal Disease. Ann Vasc Surg 2024:S0890-5096(24)00151-1. [PMID: 38599491 DOI: 10.1016/j.avsg.2023.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 04/12/2024]
Abstract
BACKGROUND Chronic limb-threatening ischemia (CLTI) in patients with end-stage renal disease (ESRD) poses significant challenges in clinical management due to its unique pathology and poor treatment outcomes. This review calls for a tailored classification and risk assessment for these patients to guide better revascularization choices with early minor amputation as a first-line strategy in advanced stages. METHODS This review consolidates key findings from recent literature on CLTI in ESRD, focusing on disease mechanisms, treatment options, and patient outcomes. It evaluates the literature to clarify the decision-making process for managing CLTI in ESRD. RESULTS CLTI in ESRD patients often results in worse clinical outcomes, such as nonhealing wounds, increased limb loss, and higher mortality rates. While the literature reveals ongoing debates regarding the optimal revascularization method, recent retrospective studies and meta-analyses suggest potential benefits of endovascular treatment (EVT) over open bypass surgery (OB) in reducing mortality and wound complications, with comparable amputation-free survival rates. CONCLUSIONS The selection of revascularization methods in ESRD patients with CLTI is complex, necessitating individualized strategies. The importance of early detection and timely intervention is critical to decelerate disease progression and improve revascularization outcomes. There is a shift in these treatment strategies toward less invasive endovascular procedures, acknowledging the limitations these patients face with open revascularization surgeries. Considering early minor amputations after revascularization could prevent worse consequences, reflecting a shift in the approach to managing CLTI in ESRD patients.
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Affiliation(s)
- Pooria Nakhaei
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA
| | - Mohammed Hamouda
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA.
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D'Angelo O, Menard MT, Farber A. Common Criticisms and Rebuttals of the Best Endovascular Versus Best Surgical Therapy in Patients with Chronic Limb-Threatening Ischemia (BEST-CLI) Trial. Ann Vasc Surg 2024:S0890-5096(24)00149-3. [PMID: 38599479 DOI: 10.1016/j.avsg.2023.12.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 04/12/2024]
Abstract
The Best Endovascular Versus Best Surgical Therapy in Patients With Chronic Limb-Threatening Ischemia trial was a landmark trial which provides high-quality data for the decision-making regarding the treatment of chronic-limb threatening ischemia. Overall, the trial suggests that in patients with adequate greater saphenous vein conduit, bypass surgery should be offered as a first line treatment given superior outcomes. In this article, we outline the common critiques of the trial, followed by responses to provide a deeper understanding of the strengths and limitations of this important trial.
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Affiliation(s)
- Olivia D'Angelo
- Division of Vascular & Endovascular Surgery, Boston University School of Medicine, Boston, MA.
| | - Matthew T Menard
- Division of Vascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Alik Farber
- Division of Vascular & Endovascular Surgery, Boston University School of Medicine, Boston, MA
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31
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Creeden T, Jones DW. "Evolution of Drug-Coated Devices for the Treatment of Chronic Limb Threatening Ischemia". Ann Vasc Surg 2024:S0890-5096(24)00147-X. [PMID: 38582201 DOI: 10.1016/j.avsg.2023.11.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 11/24/2023] [Indexed: 04/08/2024]
Abstract
For patients with Chronic Limb Threatening Ischemia (CLTI), endovascular approaches to revascularization are often employed as a component of multimodality care aimed at limb preservation. However, patients with CLTI are also prone to treatment failure, particularly following balloon angioplasty alone. Drug-coated devices utilizing Paclitaxel were developed to decrease restenosis but have been primarily studied in patients presenting with claudication. In recent years, data have emerged which describe the efficacy of drug-coated devices in the treatment of patients with CLTI. Concurrently, there has been major controversy surrounding the use of drug-coated devices in peripheral arterial disease. A historical narrative of the development and use of drug-coated devices for peripheral arterial disease is presented, along with discussion of major trials. Evidence argues that paclitaxel-based therapies for peripheral arterial disease (PAD) do not increase mortality risk compared to nondrug-coated devices. In CLTI patients, paclitaxel-based balloons and stents provide superior patency and freedom reintervention compared to nondrug-coated devices when treating femoropopliteal disease. However, the use of Paclitaxel-based therapies for below-the-knee (BTK) interventions has not been shown to provide clinically meaningful outcomes compared to nondrug-based therapies. Newer generation antiproliferative agents (Sirolimus, Everolimus) and delivery systems (bioabsorbable scaffolds) hold promise for BTK interventions with early data suggesting decreased rates of major amputation or major adverse limb events.
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Affiliation(s)
- Thomas Creeden
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, UMass Medical Center, Worcester, MA
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, UMass Medical Center, Worcester, MA.
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32
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Popplewell MA, Bradbury AW. Responses to the Main Critiques of the Bypass Versus Angioplasty in Severe Ischemia of the Leg (BASIL)-2 Trial. Ann Vasc Surg 2024:S0890-5096(24)00142-0. [PMID: 38582217 DOI: 10.1016/j.avsg.2023.11.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 11/22/2023] [Indexed: 04/08/2024]
Affiliation(s)
| | - Andrew W Bradbury
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Koelemay M, Vega de Ceniga M. Drug-Eluting Resorbable Scaffold for Infrapopliteal Artery Disease. N Engl J Med 2024; 390:1243-1244. [PMID: 38598585 DOI: 10.1056/nejmc2401419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Mark Koelemay
- Amsterdam University Medical Center, Amsterdam, the Netherlands
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34
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Ciaramella M, LoGerfo F, Liang P. Lower Extremity Bypass for Occlusive Disease: A Brief History. Ann Vasc Surg 2024:S0890-5096(24)00139-0. [PMID: 38582212 DOI: 10.1016/j.avsg.2023.11.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/10/2023] [Indexed: 04/08/2024]
Abstract
BACKGROUND This is a narrative review that aims to highlight key advancements that led to the current state of lower extremity bypass surgery. It focuses on key contributors during the last century who have driven the standardization of surgical treatment of peripheral arterial occlusive disease. METHODS A narrative review was conducted utilizing available resources in the scientific and historical literature to track landmark achievements in the development of modern lower extremity bypass surgery for occlusive disease, focusing primarily on the last century of advancement. RESULTS Several critical conceptual, technological, and technical landmarks were identified as critical components of modern lower extremity bypass surgery. This includes fundamental developments in the techniques of vascular anastomosis led by Carrel and others, a developing understanding of vascular occlusive disease as a localized and segmental process with broad implementation of the techniques of arteriography, and the development of safe thromboendarterectomy aided by the development and utilization of heparin for anticoagulation. These factors led to the first femoral-to-popliteal artery bypass by Jean Kunlin in 1948. From here, advances in vascular prosthetic material pioneered by Voorhees and others, alternative vascular conduits, increasing acceptance of tibial revascularization, and dispelling the myth of diabetic "small vessel" disease broadened revascularization options for patients with complex patterns of occlusive disease and those who have limited conduit availability. CONCLUSIONS Modern lower extremity bypass surgery for occlusive disease arose steadily over a course of a century, driven by complex problem-solving in the pathophysiological understanding of atherosclerosis, technical developments in vascular anastomosis and arteriography, and evolution of conduit materials and pharmacologic therapy. Future advancements in bypass surgery are targeted at solving the complex problems of anastomotic intimal hyperplasia, expanding technology for alternative vascular conduits, ongoing optimization of risk factors, and scrutinizing of outcomes to make patient-centered, evidence-based decisions regarding revascularization strategy.
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Affiliation(s)
- Michael Ciaramella
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Frank LoGerfo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Montelione N, Catanese V, Nenna A, Gabellini T, Ferrisi C, Paolini J, Ciolli A, Barillà D, Loreni F, Chello M, Spinelli F, Stilo F. External Scaffold for Venous Graft to Treat Chronic Limb-Threatening Ischemia: Results of the FRAME Vascular Support. J Clin Med 2024; 13:2095. [PMID: 38610860 PMCID: PMC11012784 DOI: 10.3390/jcm13072095] [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: 02/14/2024] [Revised: 03/22/2024] [Accepted: 03/30/2024] [Indexed: 04/14/2024] Open
Abstract
Background: The surgical treatment of chronic limb-threatening ischemia and optimal conduit choice are extensively debated. The presence of suboptimal autologous material, such as varicosities or venous aneurysms, might impair long-term outcomes. Therefore, kink-resistant external supports have been advocated in the recent literature to improve the conduit quality and outcomes. This study analyzes the FRAME external support in venous ectasic grafts in patients with chronic limb-threatening ischemia. Methods: From September 2017 to September 2023, a total of sixteen patients underwent CLTI surgery with FRAME external support for venous grafts. The inclusion criteria for FRAME applications were varicose or ectasic autologous material with a diameter ≥ 4.5 and ≤ 8 mm in an isolated segment or in the entire vein and a higher risk of bypass extrinsic compression (e.g., extra-anatomical venous bypass course). Results: Technical success and intraoperative patency were achieved in all cases. At 30 days, the limb salvage and survival rates were 100%. The primary bypass patency was 93.7% due to an early graft occlusion. No graft infection was registered. In one case, dehiscence of the surgical wound was treated by surgical debridement and antibiotic therapy. Minor amputation was required in four patients. Over a median follow-up of 32 months, two occlusions were observed; one was treated with reoperation and the other with major amputation. The primary patency was 68.7% and the assisted primary patency was 75%. Limb salvage rates observed during the entire follow-up period were 87.5%. No graft infections or dilatation of the reinforced veins were registered. Conclusions: For patients with CLTI undergoing infrainguinal bypass, satisfactory results in terms of patency and limb salvage rates were achieved using the autologous venous material, even if ectasic or varicose, with the vascular external support FRAME.
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Affiliation(s)
- Nunzio Montelione
- Vascular Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (N.M.); (V.C.); (T.G.); (J.P.); (A.C.); (F.S.); (F.S.)
| | - Vincenzo Catanese
- Vascular Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (N.M.); (V.C.); (T.G.); (J.P.); (A.C.); (F.S.); (F.S.)
| | - Antonio Nenna
- Cardiac Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (C.F.); (F.L.)
| | - Teresa Gabellini
- Vascular Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (N.M.); (V.C.); (T.G.); (J.P.); (A.C.); (F.S.); (F.S.)
- Vascular Surgery Residency Program, University of Ferrara, 44124 Ferrara, Italy
| | - Chiara Ferrisi
- Cardiac Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (C.F.); (F.L.)
- Cardiac Surgery Residency Program, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Julia Paolini
- Vascular Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (N.M.); (V.C.); (T.G.); (J.P.); (A.C.); (F.S.); (F.S.)
- Vascular Surgery Residency Program, Università Cattolica del Sacro Cuore, 00128 Rome, Italy
| | - Alessandro Ciolli
- Vascular Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (N.M.); (V.C.); (T.G.); (J.P.); (A.C.); (F.S.); (F.S.)
- Vascular Surgery Residency Program, Università Cattolica del Sacro Cuore, 00128 Rome, Italy
| | - David Barillà
- Vascular Surgery, Humanitas Clinical and Research Center—IRCCS, Rozzano, 20148 Milan, Italy
| | - Francesco Loreni
- Cardiac Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (C.F.); (F.L.)
- Cardiac Surgery Residency Program, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Massimo Chello
- Cardiac Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (C.F.); (F.L.)
| | - Francesco Spinelli
- Vascular Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (N.M.); (V.C.); (T.G.); (J.P.); (A.C.); (F.S.); (F.S.)
| | - Francesco Stilo
- Vascular Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (N.M.); (V.C.); (T.G.); (J.P.); (A.C.); (F.S.); (F.S.)
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Low M, Gray BH. Refining Vascular Care Through Science Without Losing the Art. Ann Vasc Surg 2024; 101:11-14. [PMID: 38110077 DOI: 10.1016/j.avsg.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 12/07/2023] [Indexed: 12/20/2023]
Abstract
The science of medicine involves the incorporation of data from evidence-based medicine (collecting, analyzing, conducting clinical trials), medical knowledge (learned patterns of health and disease), diagnostic testing (objective evidence), treatment protocols (guidelines based on scientific evidence and/or expert consensus), and pharmacology (prescribing safely and effectively). The art of medicine involves clinical judgment (learn to interpret clinical signs, symptoms, and histories often relying on intuition and gut feelings), bedside manner (understanding patient needs), customization of care (artistic touch to meet each person's unique circumstances including values, preferences, and social determinants of health), complex decision-making (decision-making based on experience or expertise when confronted with limited or conflicting data), and managing uncertainty (making decisions keeping "doors open" when faced with limited objective confirmation). The delivery of healthcare is not "either science or art" but rather "both science and art" proposition. So, how do we wrestle with this potential paradox?
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Affiliation(s)
- Matthew Low
- Department of Vascular Surgery, Kootenai Health, Coeur d'Alene, ID.
| | - Bruce H Gray
- Department of Surgery/Vascular Medicine, University of South Carolina School of Medicine/Greenville, Greenville, SC
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Hale AL, Gray WS, Gray BH. The Importance of Team Alignment and Retention in Vascular Center Development: A Clinician's Perspective. Ann Vasc Surg 2024; 101:1-5. [PMID: 38110078 DOI: 10.1016/j.avsg.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 12/07/2023] [Indexed: 12/20/2023]
Abstract
The healthcare landscape is in a state of constant evolution, presenting both challenges and opportunities. Recent trends, including the departure or retirement of medical professionals, the rise in travel and per diem positions, and the expansive growth of healthcare networks, have resulted in a palpable divide within the field. This divide often manifests as a shift from prioritizing patient care and staff well-being toward financial security and operational efficiency and productivity. Amid these ongoing changes, vascular centers possess the potential for a positive distinction that extends beyond their specialization to encompass their approaches to patient care and team dynamics. This article presents a 3-phase strategy for vascular clinicians and centers to consider as they seek to attract and retain top-tier staff, provide exceptional patient care, and attain sustainable growth and financial success.
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Affiliation(s)
| | | | - Bruce H Gray
- Department of Surgery/Vascular Medicine, University of South Carolina School of Medicine, Greenville, SC.
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38
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Cleman J, Romain G, Callegari S, Scierka L, Jacque F, Smolderen KG, Mena-Hurtado C. Evaluation of short-term mortality in patients with Medicare undergoing endovascular interventions for chronic limb-threatening ischemia. Vasc Med 2024; 29:172-181. [PMID: 38334045 DOI: 10.1177/1358863x231224335] [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] [Indexed: 02/10/2024]
Abstract
INTRODUCTION Patients with chronic limb-threatening ischemia (CLTI) have high mortality rates after revascularization. Risk stratification for short-term outcomes is challenging. We aimed to develop machine-learning models to rank predictive variables for 30-day and 90-day all-cause mortality after peripheral vascular intervention (PVI). METHODS Patients undergoing PVI for CLTI in the Medicare-linked Vascular Quality Initiative were included. Sixty-six preprocedural variables were included. Random survival forest (RSF) models were constructed for 30-day and 90-day all-cause mortality in the training sample and evaluated in the testing sample. Predictive variables were ranked based on the frequency that they caused branch splitting nearest the root node by importance-weighted relative importance plots. Model performance was assessed by the Brier score, continuous ranked probability score, out-of-bag error rate, and Harrell's C-index. RESULTS A total of 10,114 patients were included. The crude mortality rate was 4.4% at 30 days and 10.6% at 90 days. RSF models commonly identified stage 5 chronic kidney disease (CKD), dementia, congestive heart failure (CHF), age, urgent procedures, and need for assisted care as the most predictive variables. For both models, eight of the top 10 variables were either medical comorbidities or functional status variables. Models showed good discrimination (C-statistic 0.72 and 0.73) and calibration (Brier score 0.03 and 0.10). CONCLUSION RSF models for 30-day and 90-day all-cause mortality commonly identified CKD, dementia, CHF, need for assisted care at home, urgent procedures, and age as the most predictive variables as critical factors in CLTI. Results may help guide individualized risk-benefit treatment conversations regarding PVI.
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Affiliation(s)
- Jacob Cleman
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Santiago Callegari
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Lindsey Scierka
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Francky Jacque
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
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Kumar A, Gajanana D, Sharma N, Nanjundappa A, Kalra A. Surgical revascularization versus best endovascular therapy for chronic limb-threatening ischemia with infrapopliteal disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 61:111-112. [PMID: 37951759 DOI: 10.1016/j.carrev.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/01/2023] [Indexed: 11/14/2023]
Affiliation(s)
- Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH, USA
| | - Deepakraj Gajanana
- Department of Cardiology, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH, USA
| | - Navneet Sharma
- Department of Cardiology, Cleveland Clinic Fairview Hospital, Cleveland, OH, USA
| | | | - Ankur Kalra
- Department of Cardiology, Franciscan Health, 3900 St. Francis Way, Suite 200, Lafayette, IN, USA.
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Moras E, Khan MI, Song DD, Syed M, Prabhakaran SY, Gandhi KD, Lavie CJ, Alam M, Sharma R, Krittanawong C. Pharmacotherapy and revascularization strategies of peripheral artery disease. Curr Probl Cardiol 2024; 49:102430. [PMID: 38309544 DOI: 10.1016/j.cpcardiol.2024.102430] [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: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/05/2024]
Abstract
The global epidemiological transition of atherosclerotic vascular diseases is witnessing a rapid redistribution of its burden, shifting from high-income to low- and middle-income countries. With a wide clinical spectrum, spanning from intermittent claudication to more complex critical limb threatening ischemia, nonhealing ulcers, gangrene as well as acute limb ischemia, peripheral artery disease is often faced with the challenges of under-diagnosis and under-treatment despite its high prevalence. The management of peripheral arterial disease in patients with multiple comorbidities presents a formidable challenge and remains a pressing global health concern. In this review, we aim to provide an in-depth overview of the pathophysiology of peripheral artery disease and explore evidence-based management strategies encompassing pharmacological, lifestyle, interventional, and surgical approaches. By addressing these challenges, the review contributes to a better understanding of the evolving landscape of peripheral artery disease, offering insights into effective and holistic management strategies.
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Affiliation(s)
- Errol Moras
- Department of Medicine, Mount Sinai Morningside- West, Mount Sinai Health System, New York, USA
| | - Mohammad Ishrak Khan
- Department of Medicine, Mount Sinai Morningside- West, Mount Sinai Health System, New York, USA
| | - David D Song
- Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, The Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at the Mount Sinai Hospital, Mount Sinai Heart, New York, NY, USA
| | - Moinuddin Syed
- Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, The Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at the Mount Sinai Hospital, Mount Sinai Heart, New York, NY, USA
| | | | - Kruti D Gandhi
- Department of Medicine, Mount Sinai Morningside- West, Mount Sinai Health System, New York, USA
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Mahboob Alam
- The Texas Heart Institute, Baylor College of Medicine, Houston, TX
| | - Raman Sharma
- Department of Medicine/Cardiology, Icahn School of Medicine at Mount Sinai, The Zena and Michael A. Wiener Cardiovascular Institute and the Marie-Josée Henry R. Kravis Cardiovascular Health Center, Icahn School of Medicine at the Mount Sinai Hospital, Mount Sinai Heart, New York, NY, USA
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Patrone L, Pasqui E, Conte MS, Farber A, Ferraresi R, Menard M, Mills JL, Rundback J, Schneider P, Ysa A, Abhishek K, Adams GL, Ahmad N, Ahmed I, Alexandrescu VA, Amor M, Alper D, Andrassy M, Attinger C, Baadh A, Barakat H, Biasi L, Bisdas T, Bhatti Z, Blessing E, Bonaca MP, Bonvini S, Bosiers M, Bradbury AW, Beasley R, Behrendt CA, Brodmann M, Cabral G, Cancellieri R, Casini A, Chandra V, Chisci E, Chohan O, Choke ETC, Chong PFS, Clerici G, Coscas R, Costantino M, Dalla Paola L, Dand S, Davies RSM, D'Oria M, Diamantopoulos A, Debus S, Deloose K, Del Giudice C, Donato GD, Rubertis BD, Paul De Vries J, Dias NV, Diaz-Sandoval L, Dick F, Donas K, Dua A, Fanelli F, Fazzini S, Foteh M, Gandini R, Gargiulo M, Garriboli L, Genovese EA, Gifford E, Goueffic Y, Goverde P, Chand Gupta P, Hinchliffe R, Holden A, Houlind KC, Howard DP, Huasen B, Isernia G, Katsanos K, Katzen B, Kolh P, Koncar I, Korosoglou G, Krishnan P, Kroencke T, Krokidis M, Kumarasamy A, Hayes P, Iida O, Alejandre Lafont E, Langhoff R, Lecis A, Lessne M, Lichaa H, Lichtenberg M, Lobato M, Lopes A, Loreni G, Lucatelli P, Madassery S, Maene L, Manzi M, Maresch M, Santhosh Mathews J, McCaslin J, Micari A, Michelagnoli S, Migliara B, Morgan R, Morelli L, Morosetti D, Mouawad N, Moxey P, Müller-Hülsbeck S, Mustapha J, Nakama T, Nasr B, N'dandu Z, Neville R, Noory E, Nordanstig J, Noronen K, Mariano Palena L, Parlani G, Patel AS, Patel P, Patel R, Patel S, Pena C, Perkov D, Portou M, Pratesi G, Rammos C, Reekers J, Riambau V, Roy T, Rosenfield K, Antonella Ruffino M, Saab F, Saratzis A, Sbarzaglia P, Schmidt A, Secemsky E, Siah M, Sillesen H, Simonte G, Sirvent M, Sommerset J, Steiner S, Sakr A, Scheinert D, Shishebor M, Spiliopoulos S, Spinelli A, Stravoulakis K, Taneva G, Teso D, Tessarek J, Theivacumar S, Thomas A, Thomas S, Thulasidasan N, Torsello G, Tripathi R, Troisi N, Tummala S, Tummala V, Twine C, Uberoi R, Ucci A, Valenti D, van den Berg J, van den Heuvel D, Van Herzeele I, Varcoe R, Vega de Ceniga M, Veith FJ, Venermo M, Vijaynagar B, Virdee S, Von Stempel C, Voûte MT, Khee Yeung K, Zeller T, Zayed H, Montero Baker M. The "Woundosome" Concept and Its Impact on Procedural Outcomes in Patients With Chronic Limb-Threatening Ischemia. J Endovasc Ther 2024:15266028241231745. [PMID: 38523459 DOI: 10.1177/15266028241231745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Affiliation(s)
- Lorenzo Patrone
- West London Vascular and Interventional Center, London North West University Healthcare NHS Trust, London, UK
| | - Edoardo Pasqui
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA
| | - Alik Farber
- Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Roberto Ferraresi
- Diabetic Foot Unit, Clinica San Carlo, Paderno Dugnano, Milan, Italy
| | - Matthew Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Joseph L Mills
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, Texas, USA
| | - John Rundback
- Advanced Interventional and Vascular Services, LLP, Teaneck, New Jersey
| | - Peter Schneider
- Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, CA, USA
| | - August Ysa
- Department of Vascular Surgery, Hospital Universitario Cruces, Barakaldo, Spain
| | - Kumar Abhishek
- Department of Radiology, University Hospital, Newark, NJ
| | | | - Naseer Ahmad
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Irfan Ahmed
- Department of Interventional Radiology, Guys' and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Vlad A Alexandrescu
- Department of Thoracic and Vascular Surgery, Princess Paola Hospital, MarcheenFamenne, Belgium
| | - Max Amor
- Department of Interventional Cardiology, U.C.C.I. Polyclinique d'Essey, Nancy, France
| | | | | | - Christopher Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, United States
| | - Andy Baadh
- Regions Hospital, Saint Paul, Minnesota, USA
| | - Hashem Barakat
- University Hospitals Plymouth NHS Trust; Plymouth; United Kingdom
| | - Lukla Biasi
- Cardiovascular Division, Academic Department of Surgery, Guy's and St Thomas' Hospital NHS Trust, London, United Kingdom
| | - Theodosios Bisdas
- Department of Vascular Surgery, Athens Medical Center, Athens, Greece
| | | | | | - Marc P Bonaca
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Stefano Bonvini
- Department of Vascular Surgery, Santa Chiara Hospital, Trento, Italy
| | - Michel Bosiers
- Department of Vascular Surgery, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | | | - Christian-Alexander Behrendt
- Center for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center HamburgEppendorf, Hamburg, Germany
| | | | | | | | - Andrea Casini
- Diabetic Foot Unit, Clinica San Carlo, Paderno Dugnano, Milan, Italy
| | - Venita Chandra
- Stanford Health Care, Division of Vascular & Endovascular Surgery, Stanford, CA, United States
| | - Emiliano Chisci
- Vascular and Endovascular Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
| | - Omar Chohan
- Great Lakes Medical Imaging, Buffalo, NY, United States
| | - Edward T C Choke
- Department of Vascular Surgery, Seng Kang General Hospital, Singapore
| | | | | | - Raphael Coscas
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance PubliqueHôpitaux de Paris, BoulogneBillancourt, France
| | | | | | - Sabeen Dand
- Los Angeles Imaging and Interventional Consultants, PIH Health, Whittier, CA
| | - Robert S M Davies
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, CardioThoracoVascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Athanasios Diamantopoulos
- Department of Interventional Radiology, Guys' and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery-Angiology-Endovascular Therapy, University Heart & Vascular Center, University of HamburgEppendorf, Hamburg, Germany
| | - Koen Deloose
- Department of Vascular Surgery, AZ Sint Blasius, Dendermonde, Belgium
| | - Costantino Del Giudice
- Department of Radiology, Interventional Radiology, Institut Mutualiste Montsouris, Paris, France
| | - Gianmarco de Donato
- Vascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Brian De Rubertis
- New York Presbyterian Weill Cornell Medical Center, Mount Sinai Hospital, Columbia University Irving Medical Center and Columbia Vagelos College of Physicians and Surgeons, New York, United States
| | - Jean Paul De Vries
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Nuno V Dias
- Department of Thoracic Surgery and Vascular Diseases, Vascular Center, Skåne University Hospital, Malmö, Sweden
| | | | - Florian Dick
- Kantonsspital St. Gallen, St. Gallen, and University of Bern, Bern, Switzerland
| | - Konstantinos Donas
- Department of Vascular Surgery, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany
| | - Anahita Dua
- Division of Vascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Fabrizio Fanelli
- Interventional Radiology Unit, Azienda OspedalieroUniversitaria Careggi, Florence, Italy
| | - Stefano Fazzini
- Division of Vascular Surgery, Tor Vergata University of Rome, Rome, Italy
| | - Mazin Foteh
- Baylor Scott & White Heart Hospital, Plano, TX, United States
| | - Roberto Gandini
- UOSD Radiologia Interventistica, University Hospital Policlinico Tor Vergata, Roma, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'OrsolaMalpighi Hospital, Bologna, Italy
| | - Luca Garriboli
- Vascular Surgery Divisoin, IRCCS Sacro Cuore Don Calabria" Negrar, Verona, Italy
| | - Elizabeth A Genovese
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, PA, United States
| | - Edward Gifford
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT, United States
| | - Yann Goueffic
- Vascular Center, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Peter Goverde
- Department of Vascular Surgery, ZNA Stuivenberg, Antwerp, Belgium
| | - Prem Chand Gupta
- Department of Vascular and Endovascular Surgery, Care Hospitals, Banjara Hills, Hyderabad, India
| | - Robert Hinchliffe
- Department of Vascular Surgery, North Bristol NHS Trust, Bristol, United Kingdom
| | - Andrew Holden
- Auckland City Hospital, School of Medicine, University of Auckland, Auckland, New Zealand
| | - Kim C Houlind
- Department of Vascular Surgery, Hospital Lillebaelt, University of Southern Denmark, Odense, Denmark
| | - Dominic Pj Howard
- Nuffield Department of Clinical Neurosciences, Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | - Bella Huasen
- Department of Interventional Radiology, Lancashire University Teaching Hospitals, Lancashire Care NHS Foundation Trust, Preston, United Kingdom
| | - Giacomo Isernia
- Vascular and Endovascular Surgery Unit, S. Maria Della Misericordia University Hospital, Perugia, Italy
| | | | - Barry Katzen
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, FL, United States
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University of Liège, Liège, Belgium
| | - Igor Koncar
- Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Grigorios Korosoglou
- Departments of Cardiology, Vascular Medicine and Pneumology, GRN Academic Teaching Hospital Weinheim, Weinheim, Germany
| | - Prakash Krishnan
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Thomas Kroencke
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Miltiadis Krokidis
- National and Kapodistrian University of Athens, Areteion Hospital, Athens, Greece
| | - Arun Kumarasamy
- European Vascular Centre AachenMaastricht, Department of Vascular Surgery, Medical Faculty, University Hospital RWTH Aachen, Aachen, Germany
| | - Paul Hayes
- St John's Innovation Centre, Cambridge, United Kingdom
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital, Inabaso, Hyogo, Amagasaki, Japan
| | | | - Ralf Langhoff
- Department of Angiology, St. Gertrauden Hospital, Berlin, Germany
| | | | - Mark Lessne
- Vascular and Interventional Specialists, Charlotte Radiology, Charlotte, NC, United States
| | - Hady Lichaa
- Ascension Saint Thomas Heart, Ascension Saint Thomas Rutherford, Murfreesboro, TN, United States
| | | | - Marta Lobato
- Department of Vascular Surgery, Hospital Universitario Cruces, Barakaldo, Spain
| | - Alice Lopes
- Department of Vascular Surgery, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Giorgio Loreni
- UOC Radiologia Interventistica, ASL Roma 2, Ospedale S. Pertini, Rome, Italy
| | - Pierleone Lucatelli
- Vascular and Interventional Radiology Unit, Department of Radiological, Oncological, and AnatomoPathological Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Lieven Maene
- Department of Vascular and Thoracic Surgery, OnzeLieveVrouwziekenhuis Aalst, Aalst, Belgium
| | | | - Martin Maresch
- Department of Vascular and Endovascular Surgery, BDF Hospital Royal Medical Services, Bahrain
| | - Jay Santhosh Mathews
- Bradenton Cardiology Center, Manatee Memorial Hospital, Bradenton, FL, United States
| | - James McCaslin
- The Northern Vascular Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Stefano Michelagnoli
- Vascular and Endovascular Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
| | - Bruno Migliara
- Vascular and Endovascular Surgery Unit, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Robert Morgan
- Diagnostic, Vascular & Interventional Radiology, St George's University Hospitals NHS Foundation Trust and St George's, University of London, United Kingdom
| | - Luis Morelli
- Diabetic Foot Unit and Limb Salvage, Hospital San Juan de Dios, San Jose, Costa Rica
| | | | - Nicolas Mouawad
- Department of Surgery, McLaren Health System, Grand Blanc, MI, United States
| | - Paul Moxey
- St George's Vascular Institute, St George's University Hospital, London, United Kingdom
| | | | - Jihad Mustapha
- Advanced Cardiac and Vascular Centers for Amputation Prevention, Grand Rapids, MI, United States
| | - Tatsuya Nakama
- Jikei University Hospital, Department of Surgery, Division of Vascular Surgery, Tokyo, Japan
| | - Bahaa Nasr
- CHU Cavale Blanche Brest, Vascular and Endovascular Surgery Department, Brest, France
| | | | - Richard Neville
- Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Elias Noory
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Bad Krozingen, Germany
| | - Joakim Nordanstig
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Göteborg, Sweden
| | - Katariina Noronen
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Luis Mariano Palena
- Department of Vascular and Thoracic Surgery, OnzeLieveVrouwziekenhuis Aalst, Aalst, Belgium
| | - Gianbattista Parlani
- Department of Interventional Radiology, Lancashire University Teaching Hospitals, Lancashire Care NHS Foundation Trust, Preston, United Kingdom
| | - Ashish S Patel
- Cardiovascular Division, Academic Department of Surgery, Guy's and St Thomas' Hospital NHS Trust, London, United Kingdom
| | - Parag Patel
- Department of Radiology, Vascular and Interventional Radiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Rafiuddin Patel
- Department of Interventional Radiology, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, United Kingdom
| | - Sanjay Patel
- Cardiovascular Division, Academic Department of Surgery, Guy's and St Thomas' Hospital NHS Trust, London, United Kingdom
| | | | - Drazen Perkov
- Department of Diagnostic and Interventional Radiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Mark Portou
- Royal Free Vascular, Division of Surgery and Interventional Science, Royal Free Campus, UCL, London, UK
| | - Giovanni Pratesi
- Unit of Vascular and Endovascular Surgery-IRCCS Ospedale Policlinico San Martino, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Christos Rammos
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University of DuisburgEssen, Germany
| | - Jim Reekers
- Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Vicente Riambau
- Vascular Surgery Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Trisha Roy
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, United States
| | - Kenneth Rosenfield
- Department of Cardiology, Massachusetts General Hospital, Boston, MA, United States
| | - Maria Antonella Ruffino
- Department of Interventional Radiology, Ticino Vascular Center, Institute of Imaging of Southern Switzerland, Lugano Regional Hospital, Lugano, Switzerland
| | - Fadi Saab
- ACV Centers, Grand Rapids, MI, United States
| | - Athanasios Saratzis
- University Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Paolo Sbarzaglia
- Interventional cardiology, Maria Cecilia Hospital, Ravenna, Italy
| | - Andrej Schmidt
- Department of Angiology, University Hospital Leipzig, Leipzig, Germany
| | - Eric Secemsky
- Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Michael Siah
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Henrik Sillesen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Gioele Simonte
- Department of Interventional Radiology, Lancashire University Teaching Hospitals, Lancashire Care NHS Foundation Trust, Preston, United Kingdom
| | - Marc Sirvent
- Department General, University Hospital of Granollers, CIBERCV, ISCIII, Granollers, Spain
| | | | - Sabine Steiner
- Department of Angiology, University Hospital Leipzig, Leipzig, Germany
| | - Ahmed Sakr
- Saudi German Hospital, Jeddah, Saudi Arabia
| | - Dierk Scheinert
- Department of Angiology, University Hospital Leipzig, Leipzig, Germany
| | - Mehdi Shishebor
- University Hospitals Cleveland Medical Centre and Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Stavros Spiliopoulos
- 2nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, Attikon, University General Hospital, Athens, Greece
| | | | | | - Gergana Taneva
- Kantonsspital St. Gallen, St. Gallen, and University of Bern, Bern, Switzerland
| | | | - Joerg Tessarek
- Department Vascular and Endovascular Surgery, Bonifatius Hospital, Lingen, Germany
| | - Selva Theivacumar
- West London Vascular and Interventional Center, London North West University Healthcare NHS Trust, London, UK
| | - Anish Thomas
- Mercy Clinic Heart And Vascular LLC, Saint Louis, MO
| | | | - Narayan Thulasidasan
- Department of Interventional Radiology, Guys' and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Giovanni Torsello
- University Hospital Münster, Institute for Vascular Research, Franziskus Hospital, Münster, Germany
| | | | - Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Srini Tummala
- Department of Interventional Radiology, University of Miami Health System, UM Miller School of Medicine, Miami, FL, United States
| | | | - Christopher Twine
- Bath and Weston Vascular Network, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Raman Uberoi
- John Radcliffe Hospital, Oxford University Hospitals, Oxford, United Kingdom
| | - Alessandro Ucci
- Unit of Vascular Surgery, Department of Medicine and Surgery, Azienda OspedalieroUniversitaria di Parma, Parma, Italy
| | - Domenico Valenti
- Department of Vascular Surgery, King's College Hospital, London, United Kingdom
| | - Jos van den Berg
- Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie, Inselspital, Universitätsspital Bern, Bern, Switzerland
| | | | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Ramon Varcoe
- Prince of Wales Hospital, Sydney, NSW, Australia
| | - Melina Vega de Ceniga
- Department of Angiology and Vascular Surgery, University Hospital of GaldakaoUsansolo, Bizkaia, Spain
| | - Frank J Veith
- New York University Medical Centre, New York, NY and The Cleveland Clinic, Cleveland, OH, United States
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Sanjiv Virdee
- The University of Rochester Medical Faculty Group, NY, United States
| | - Conrad Von Stempel
- Department of Radiology, University College London Hospitals, London, United Kingdom
| | - Michiel T Voûte
- Department of Surgery, Prince of Wales Hospital, Sydney, Australia
| | - Kak Khee Yeung
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Thomas Zeller
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Bad Krozingen, Germany
| | - Hany Zayed
- Cardiovascular Division, Academic Department of Surgery, Guy's and St Thomas' Hospital NHS Trust, London, United Kingdom
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Morisaki K, Matsuda D, Guntani A, Kinoshita G, Yoshino S, Inoue K, Honma K, Yamaoka T, Mii S, Yoshizumi T. Infra-inguinal bypass surgery vs endovascular revascularization for chronic limb-threatening ischemia in average- and high-risk patients. J Vasc Surg 2024:S0741-5214(24)00505-6. [PMID: 38522583 DOI: 10.1016/j.jvs.2024.03.025] [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: 02/14/2024] [Revised: 03/14/2024] [Accepted: 03/15/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVE This study aimed to evaluate treatment outcomes after bypass surgery or endovascular therapy (EVT) in average- and high-risk patients with chronic limb-threatening ischemia (CLTI). METHODS We retrospectively analyzed multicenter data of patients who underwent infra-inguinal revascularization for CLTI between 2015 and 2022. A high-risk patient was defined as one with estimated 30-day mortality rate ≥5% or 2-year survival rate ≤50%, as determined by the Surgical Reconstruction vs Peripheral Intervention in Patients With Critical Limb Ischemia (SPINACH) calculator. The amputation-free survival (AFS), limb salvage (LS), wound healing, and 30-day mortality were compared separately for the average- and high-risk patients between the bypass and EVT with propensity score matching. RESULTS We analyzed 239 and 31 propensity score-matched pairs in the average- and high-risk patients with CLTI. In the average-risk patients, the 2-year AFS and LS rates were 78.1% and 94.4% in the bypass group and 63.0% and 87.7% in the EVT group (P < .001 and P = .007), respectively. The 1-year wound healing rates were 88.6% in the bypass group and 76.8% in the EVT group, respectively (P < .001). The 30-day mortality was 0.8% in the bypass surgery and 0.8% in the EVT group (P = .996). In the high-risk patients, there was no differences in the AFS, LS, and wound healing between the groups (P = .591, P = .148, and P = .074). The 30-day mortality was 3.2% in the bypass group and 3.2% in the EVT group (P = .991). CONCLUSIONS Bypass surgery is superior to EVT with respect to the AFS, LS, and wound healing in the average-risk patients. EVT is a feasible first-line treatment strategy for high-risk patients with CLTI undergoing revascularization, based on the lack of significant differences in the 2-year AFS rate, between the bypass surgery and EVT cohorts.
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Affiliation(s)
- Koichi Morisaki
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Daisuke Matsuda
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Atsushi Guntani
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan
| | - Go Kinoshita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shinichiro Yoshino
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kentaro Inoue
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenichi Honma
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Shinsuke Mii
- Department of Vascular Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Krievins DK, Zellans E, Latkovskis G, Kumsars I, Krievina AK, Jegere S, Erglis A, Lacis A, Plopa E, Stradins P, Ivanova P, Zarins CK. Diagnosis and treatment of ischemia-producing coronary stenoses improves 5-year survival of patients undergoing major vascular surgery. J Vasc Surg 2024:S0741-5214(24)00500-7. [PMID: 38518962 DOI: 10.1016/j.jvs.2024.02.043] [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: 01/26/2024] [Revised: 02/22/2024] [Accepted: 02/24/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE Patients undergoing vascular surgery procedures have poor long-term survival due to coexisting coronary artery disease (CAD), which is often asymptomatic, undiagnosed, and undertreated. We sought to determine whether preoperative diagnosis of asymptomatic (silent) coronary ischemia using coronary computed tomography (CT)-derived fractional flow reserve (FFRCT) together with postoperative ischemia-targeted coronary revascularization can reduce adverse cardiac events and improve long-term survival following major vascular surgery METHODS: In this observational cohort study of 522 patients with no known CAD undergoing elective carotid, peripheral, or aneurysm surgery we compared two groups of patients. Group I included 288 patients enrolled in a prospective Institutional Review Board-approved study of preoperative coronary CT angiography (CTA) and FFRCT testing to detect silent coronary ischemia with selective postoperative coronary revascularization in addition to best medical therapy (BMT) (FFRCT guided), and Group II included 234 matched controls with standard preoperative cardiac evaluation and postoperative BMT alone with no elective coronary revascularization (Usual Care). In the FFRCT group, lesion-specific coronary ischemia was defined as FFRCT ≤0.80 distal to a coronary stenosis, with severe ischemia defined as FFRCT ≤0.75. Results were available for patient management decisions. Endpoints included all-cause death, cardiovascular death, myocardial infarction (MI), and major adverse cardiovascular events (MACE [death, MI, or stroke]) during 5-year follow-up. RESULTS The two groups were similar in age, gender, and comorbidities. In FFRCT, 65% of patients had asymptomatic lesion-specific coronary ischemia, with severe ischemia in 52%, multivessel ischemia in 36% and left main ischemia in 8%. The status of coronary ischemia was unknown in Usual Care. Vascular surgery was performed as planned in both cohorts with no difference in 30-day mortality. In FFRCT, elective ischemia-targeted coronary revascularization was performed in 103 patients 1 to 3 months following surgery. Usual Care had no elective postoperative coronary revascularizations. At 5 years, compared with Usual Care, FFRCT guided had fewer all-cause deaths (16% vs 36%; hazard ratio [HR], 0.37; 95% confidence interval [CI], 0.22-0.60; P < .001), fewer cardiovascular deaths (4% vs 21%; HR, 0.11; 95% CI, 0.04-0.33; P < .001), fewer MIs (4% vs 24%; HR, 0.13; 95% CI, 0.05-0.33; P < .001), and fewer MACE (20% vs 47%; HR, 0.36; 95% CI, 0.23-0.56; P < .001). Five-year survival was 84% in FFRCT compared with 64% in Usual Care (P < .001). CONCLUSIONS Diagnosis of silent coronary ischemia with ischemia-targeted coronary revascularization in addition to BMT following major vascular surgery was associated with fewer adverse cardiovascular events and improved 5-year survival compared with patients treated with BMT alone as per current guidelines.
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Affiliation(s)
- Dainis K Krievins
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia.
| | - Edgars Zellans
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Gustavs Latkovskis
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Indulis Kumsars
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | | | - Sanda Jegere
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Andrejs Erglis
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Aigars Lacis
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | | | - Peteris Stradins
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Riga Stradins University, Riga, Latvia
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44
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Takei T, Kajiya T, Ohura N, Tomimura N, Kamiyama T, Ninomiya T, Takaoka J, Atsuchi N. Poor short-term outcomes for prognostic high-risk patients with chronic limb-threatening ischemia undergoing endovascular therapy. CVIR Endovasc 2024; 7:31. [PMID: 38502290 PMCID: PMC10951176 DOI: 10.1186/s42155-024-00443-9] [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: 12/10/2023] [Accepted: 03/07/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND The prognosis of chronic limb-threatening ischemia (CLTI) is poor, with an expected life expectancy of 2 or more years, which significantly influences treatment decisions. However, death may occur at the early stages of treatment for wound healing, and aggressive treatment may limit the quality of life of such patients. In patients with CLTI undergoing endovascular therapy (EVT), the Wound, Ischemia, and foot Infection (WIfI) clinical stage, male sex, older age, non-ambulatory status, low body mass index, and dialysis have been reported as predictors of mortality risk. However, most studies have not fully investigated the WIFI clinical stage as a prognostic predictor of CLTI. This study aimed to evaluate short-term prognosis and wound healing rates using the prognostic predictors (PPs) indicated above in risk-stratified patients with CLTI who underwent EVT. METHODS This retrospective single-center observational study included 61 CLTI patients undergoing EVT from April 2020 to October 2022. The patients were divided into a high-risk group (PPs ≥ 4, n = 20) and low-risk group (PPs ≤ 3, n = 41) according to the number of PPs. Survival and wound healing rates within one year were compared between these two groups. RESULTS The mean age of the patients was 74.7 ± 1.6 years, and 42 (68.9%) were male. Among these patients, the high-risk group compared with the low-risk group had a significantly worse survival rate within one year (46.4% vs. 84.7%, log-rank p < 0.001). Fifteen patients died within one year. Of these, seven deaths were cardiovascular deaths and six were deaths from infectious diseases. Cox proportional hazards analysis showed that WIfI clinical stage 4 (p = 0.043, hazard ratio [HR] = 4.85) and the male sex (p = 0.037, HR = 6.34) influenced the prognosis of this population. The high-risk group tended to have a worse wound healing rate within one year than that had by the low-risk group (55.4% vs. 83.0%, log-rank p = 0.086). CONCLUSIONS The assessment of short-term prognosis and wound healing rates using PPs may be useful. Discussing the results of short-term clinical outcome assessments with patients should be considered when determining their individualized treatment plans.
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Affiliation(s)
- Tatsuro Takei
- Department of Cardiology, Tenyoukai Central Hospital, 6-7 Izumi-cho, Kagoshima, 892-0821, Japan.
| | - Takashi Kajiya
- Department of Cardiology, Tenyoukai Central Hospital, 6-7 Izumi-cho, Kagoshima, 892-0821, Japan
| | - Norihiko Ohura
- Department of Plastic and Reconstructive Surgery, Kyorin University School of Medicine, 6-20-2, Shinkawa Mitaka, Tokyo, Japan
| | - Natsuko Tomimura
- Department of Orthopaedic Surgery, Nanpuh Hospital, 14-3 Nagata-cho, Kagoshima, Japan
| | - Takuro Kamiyama
- Department of Radiology, Tenyoukai Central Hospital, 6-7 Izumi-cho, Kagoshima, Japan
| | - Toshiko Ninomiya
- Department of Cardiology, Tenyoukai Central Hospital, 6-7 Izumi-cho, Kagoshima, 892-0821, Japan
| | - Junichiro Takaoka
- Department of Cardiology, Tenyoukai Central Hospital, 6-7 Izumi-cho, Kagoshima, 892-0821, Japan
| | - Nobuhiko Atsuchi
- Department of Cardiology, Tenyoukai Central Hospital, 6-7 Izumi-cho, Kagoshima, 892-0821, Japan
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Soenens G, Gorden L, Doyen B, Wheatcroft M, de Mestral C, Palter V, Van Herzeele I. Development and Testing of Step, Error, and Event Frameworks to Evaluate Technical Performance in Peripheral Endovascular Interventions. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00252-1. [PMID: 38492630 DOI: 10.1016/j.ejvs.2024.03.007] [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: 08/14/2023] [Revised: 12/22/2023] [Accepted: 03/11/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE Tools for endovascular performance assessment are necessary in competency based education. This study aimed to develop and test a detailed analysis tool to assess steps, errors, and events in peripheral endovascular interventions (PVI). METHODS A modified Delphi consensus was used to identify steps, errors, and events in iliac-femoral-popliteal endovascular interventions. International experts in vascular surgery, interventional radiology, cardiology, and angiology were identified, based on their scientific track record. In an initial open ended survey round, experts volunteered a comprehensive list of steps, errors, and events. The items were then rated on a five point Likert scale until consensus was reached with a pre-defined threshold (Cronbach's alpha > 0.7) and > 70% expert agreement. An experienced endovascular surgeon applied the finalised frameworks on 10 previously videorecorded elective PVI cases. RESULTS The expert consensus panel was formed by 28 of 98 invited proceduralists, consisting of three angiologists, seven interventional radiologists, five cardiologists, and 13 vascular surgeons, with 29% from North America and 71% from Europe. The Delphi process was completed after three rounds (Cronbach's alpha; αsteps = 0.79; αerrors = 0.90; αevents = 0.90), with 15, 26, and 18 items included in the final step (73 - 100% agreement), error (73 - 100% agreement), and event (73 - 100% agreement) frameworks, respectively. The median rating time per case was 4.3 hours (interquartile range [IQR] 3.2, 5 hours). A median of 55 steps (IQR 40, 67), 27 errors (IQR 21, 49), and two events (IQR 1, 6) were identified per case. CONCLUSION An evaluation tool for the procedural steps, errors, and events in iliac-femoral-popliteal endovascular procedures was developed through a modified Delphi consensus and applied to recorded intra-operative data to identify hazardous steps, common errors, and events. Procedural mastery may be promoted by using the frameworks to provide endovascular proceduralists with detailed technical performance feedback.
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Affiliation(s)
- Gilles Soenens
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium. https://www.twitter.com/GillesSoenens
| | - Lauren Gorden
- Division of Vascular Surgery, University of Toronto, Canada; International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada; Biomedical Engineering (BME), University of Toronto, Canada
| | - Bart Doyen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Mark Wheatcroft
- Division of Vascular Surgery, University of Toronto, Canada; Department of Surgery, St. Michael's Hospital, Toronto, Canada
| | - Charles de Mestral
- Division of Vascular Surgery, University of Toronto, Canada; Department of Surgery, St. Michael's Hospital, Toronto, Canada
| | - Vanessa Palter
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium.
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Møller A, Eldrup N, Wetterslev J, Hellemann D, Nielsen HB, Rostgaard K, Hjalgrim H, Pedersen OB. Trends in Lower Extremity Artery Disease Repair Incidence, Comorbidity, and Mortality: A Danish Nationwide Cohort Study, 1996-2018. Vasc Health Risk Manag 2024; 20:125-140. [PMID: 38501043 PMCID: PMC10946405 DOI: 10.2147/vhrm.s427211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 01/23/2024] [Indexed: 03/20/2024] Open
Abstract
Background The prevalence of occlusive lower extremity artery disease (LEAD) is rising worldwide while European epidemiology data are scarce. We report incidence and mortality of LEAD repair in Denmark from 1996 through 2018, stratified on open aorto-iliac, open peripheral, and endovascular repair. Methods A nationwide cohort study of prospective data from population-based Danish registers covering 1996 to 2018. Comorbidity was assessed by Charlson's Comorbidity Index (CCI). Incidence rate (IR) ratios and mortality rate ratios (MRR) were estimated by multivariable Poisson and Cox regression, respectively. Results We identified 41,438 unique patients undergoing 46,236 incident first-time LEAD repairs by either aorto-iliac- (n=5213), peripheral surgery (n=18,665) or percutaneous transluminal angioplasty (PTA, n=22,358). From 1996 to 2018, the age- and sex-standardized IR for primary revascularization declined from 71.8 to 50.2 per 100,000 person-years (IRR, 0.70; 95% CI, 0.66-0.75). Following a 2.5-fold IR increase of PTA from 1996 to 2010, all three repair techniques showed a declining trend after 2010. The declining IR was driven by decreasing LEAD repair due to claudication, and by persons aged below 80 years, while the IR increased in persons aged above 80 years (p interaction<0.001). LEAD repair was more frequent in men (IRRfemale vs male, 0.78; 95% CI, 0.77-0.80), which was consistent over calendar time (p interaction=0.41). Crude mortality decreased following open/surgical repair, and increased following PTA, but all three techniques trended towards lower adjusted mortality comparing the start and the end of the study period (MRRaorto-iliac, 0.71; 95% CI, 0.54-0.93 vs MRRperipheral, 0.76; 95% CI, 0.69-0.83 vs MRRPTA, 0.96; 95% CI, 0.86-1.07). Increasing age and CCI, male sex, smoking, and care dependency associated with increased mortality. Conclusion The incidence rate of LEAD repair decreased in Denmark from 1996 to 2018, especially in persons younger than 80 years, and primarily due to reduced revascularization for claudication. Adjusted mortality rates decreased following open surgery, but seemed unaltered following PTA.
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Affiliation(s)
- Anders Møller
- Department of Anesthesia and Intensive Care, Næstved-Slagelse-Ringsted, Slagelse Hospital, Slagelse, Denmark
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Danish Vascular Registry, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Dorthe Hellemann
- Department of Anesthesia and Intensive Care, Næstved-Slagelse-Ringsted, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Henning Bay Nielsen
- Department of Anesthesia and Intensive Care, Zealand University Hospital Roskilde, Roskilde, Denmark
- Department of Nutrition, Exercise and Sport, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Rostgaard
- Danish Cancer Institute, Danish Cancer Society, Copenhagen, Denmark
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Henrik Hjalgrim
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Danish Cancer Institute, Danish Cancer Society, Copenhagen, Denmark
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Birger Pedersen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Immunology, Zealand University Hospital, Køge, Denmark
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Shintani T, Obara H, Matsubara K, Hayashi M, Kita H, Ono S, Watada S, Kikuchi N, Sekimoto Y, Torizaki Y, Asami A, Fujii T, Hayashi K, Harada H, Fujimura N, Hosokawa K, Nakatani E, Kitagawa Y. Impact of wound management strategies after revascularization for chronic limb-threatening ischemia. J Vasc Surg 2024; 79:632-641.e3. [PMID: 37939747 DOI: 10.1016/j.jvs.2023.11.003] [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: 08/13/2023] [Revised: 10/20/2023] [Accepted: 11/03/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE There is no established consensus or guidelines for wound management after revascularization for patients with chronic limb-threatening ischemia (CLTI) without severe infection. This study is designed to evaluate the clinical effect of the wound management strategy on toe wounds after revascularization for CLTI. METHODS This retrospective cohort study was performed at eight institutions affiliated with Keio University School of Medicine in Japan and included 261 patients who underwent revascularization for CLTI between April 2019 and July 2021. We identified 132 patients with toe wounds from the database who had restored in-line blood flow to the foot. Patients were divided into two groups by the timing of toe resection after revascularization, which dictated the wound management policy. Group A (62 patients) underwent early toe amputation for suspected osteomyelitis, whereas group B (70 patients) underwent watchful waiting. The primary outcome was wound healing after revascularization; the secondary outcome was major amputation. We compared outcomes between groups A and B after propensity score matching. RESULTS Using propensity score matching, each patient in group A (33 patients) was matched with a patient in group B (33 patients). Wound healing in matched group A was significantly better than that in matched group B (respectively: 1-year wound healing rate: 90.0% vs 68.2%, P < .001; median wound healing time: 65 days vs 258 days, P < .01). Although five major amputations were necessary in matched group B, none were required in matched group A (P = .05). The high rate of major amputations in group B was attributed to the sudden exacerbation of infection. Limb salvage rate in matched group A exceeded matched group B (100.0% vs 90.5%: 1-year limb salvage rate, P = .02). CONCLUSIONS Early toe amputation for highly suspected osteomyelitis in patients with CLTI with toe wounds may expedite wound healing compared with watchful waiting, potentially avoiding unnecessary major amputation. Considering the wound management strategy is crucial when evaluating wound healing outcomes in patients with CLTI with revascularization.
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Affiliation(s)
- Tsunehiro Shintani
- Department of Vascular Surgery, Shizuoka Red Cross Hospital, Shizuoka, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masanori Hayashi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hidenori Kita
- Department of Vascular Surgery, Shizuoka Red Cross Hospital, Shizuoka, Japan
| | - Shigeshi Ono
- Department of Surgery, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Japan
| | - Susumu Watada
- Department of Surgery, Kawasaki Municipal Hospital, Kawasaki, Japan
| | - Naoya Kikuchi
- Department of Surgery, Kawasaki Municipal Hospital, Kawasaki, Japan
| | | | | | - Atsunori Asami
- Department of Surgery, Saitama City Hospital, Saitama, Japan
| | - Taku Fujii
- Department of Surgery, Saitama City Hospital, Saitama, Japan
| | - Keita Hayashi
- Department of Vascular Surgery, Hiratsuka City Hospital, Hiratsuka, Japan
| | - Hirohisa Harada
- Department of Vascular Surgery, Saiseikai Central Hospital, Tokyo, Japan
| | - Naoki Fujimura
- Department of Vascular Surgery, Saiseikai Central Hospital, Tokyo, Japan
| | - Kyousuke Hosokawa
- Department of Vascular Surgery, Saiseikai Central Hospital, Tokyo, Japan
| | - Eiji Nakatani
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Shizuoka, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Mufarrih SH, Khan MS, Qureshi NQ, Akbar MS, Kazimuddin M, Goldsweig AM, Goodney PP, Aronow HD. An Endovascular- Versus a Surgery-First Revascularization Strategy for Chronic Limb-Threatening Ischemia: A Meta-Analysis of Randomized Controlled Trials. Am J Cardiol 2024; 214:149-156. [PMID: 38232807 DOI: 10.1016/j.amjcard.2024.01.007] [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: 12/16/2023] [Accepted: 01/07/2024] [Indexed: 01/19/2024]
Abstract
Timely revascularization is essential for limb salvage and to reduce mortality in patients with chronic limb-threatening ischemia (CLTI). In patients who are candidates for endovascular therapy and surgical bypass, the optimal revascularization strategy remains uncertain. Recently published randomized controlled trials (RCTs) have presented conflicting results. We conducted a trial-level meta-analysis to compare the outcomes between endovascular-first and surgery-first strategies for revascularization. PubMed, Web of Science, and the Cochrane Library were searched to identify RCTs comparing the outcomes of endovascular-first versus surgery-first strategies for revascularization in patients with CLTI. Data were pooled for major outcomes and their aggregate risk ratios (RRs) with 95% confidence intervals were calculated using a random-effects model. Kaplan-Meier curves for amputation-free survival and overall survival time were plotted using the pooled aggregated data from published curves, with their corresponding hazard ratios (HRs) and 95% confidence intervals reported for up to 5 years of follow-up. A total of 3 RCTs with 2,627 patients (1,312 endovascular-first and 1,315 surgery-first) were included in the meta-analysis. Of these, 1,864 patients (70.9%) were men and 347 (13.2%) were older than 80 years. Comparing the endovascular-first and surgery-first approaches, there was no significant difference in the overall (HR 0.92 [0.83 to 1.01], p = 0.09) or amputation-free survival (HR 0.98 [0.92 to 1.03], p = 0.42), reintervention (RR 1.24 [0.74 to 2.07], p = 0.41), major amputation, (RR 1.16 [0.87 to 1.54], p = 0.31), or therapeutic crossover (RR 0.92 [0.37 to 2.26], p = 0.85). In conclusion, data from available RCTs suggest that there is no difference in clinical outcomes between endovascular-first and surgery-first revascularization strategies for CLTI. A planned patient-level meta-analysis may provide further insight.
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Affiliation(s)
| | - Mohammad Saud Khan
- Division of Cardiovascular Medicine, Department of Medicine, University of Kentucky, Bowling Green, Kentucky
| | | | - Muhammad Shoaib Akbar
- Division of Cardiovascular Medicine, Department of Medicine, University of Kentucky, Bowling Green, Kentucky
| | - Mohammed Kazimuddin
- Division of Cardiovascular Medicine, Department of Medicine, University of Kentucky, Bowling Green, Kentucky
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, Department of Medicine, Baystate Medical Center, Springfield, Massachusetts
| | - Philip P Goodney
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Herbert D Aronow
- Division of Cardiovascular Medicine, Department of Medicine, Henry Ford Health, Detroit and Michigan State University College of Human Medicine, East Lansing, Michigan.
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Messeder SJ, López-Peña G, Pepper C, Saratzis A. Biomimetic Stents for Infrainguinal Peripheral Arterial Disease: Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2024; 67:468-479. [PMID: 37931680 DOI: 10.1016/j.ejvs.2023.11.007] [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: 06/02/2023] [Revised: 09/30/2023] [Accepted: 11/03/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE Biomimetic stents are peripheral infrainguinal self expanding stents that mimic the anatomy of the vasculature and artery movement. They are indicated for use in infrainguinal arteries. This research aimed to synthesise all current evidence on the use of biomimetic stents as adjuncts for endovascular treatment of infrainguinal peripheral arterial disease (PAD), helping to guide clinical decision making. DATA SOURCES MEDLINE, Embase, CINAHL and Cochrane databases. REVIEW METHODS Random effects meta-analysis following PRISMA guidelines (PROSPERO registration CRD42022385256). Study quality was assessed using the Joanna Briggs Institute critical appraisal tools checklist, and certainty assessment through the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Endpoints included primary patency, target lesion revascularisation, stent fracture, secondary patency, and Death at one year. RESULTS In total, 37 studies were included in the meta-analysis (33 cohort studies, two case series, and two randomised controlled trials [RCTs]), representing 4 480 participants. Of these, 34 studies included data on the Supera (81.5% of participants) and three studies reported data on the BioMimics 3D (18.5% of participants) stents. The pooled primary patency rate of 33 studies at one year follow up was 81.4% (95% confidence interval [CI] 78.7 - 83.9%), and the pooled target lesion revascularisation rate of 18 studies at one year was 12.2% (95% CI 9.6 - 15.0%). The certainty of evidence outcome rating as qualified by GRADE was very low for both. Only one study reported a positive stent fracture rate at one year follow up of 0.4% with a certainty of evidence outcome of low. CONCLUSION Using biomimetic stents for infrainguinal PAD may be associated with acceptable one year primary patency and target lesion revascularisation rates, with a near negligible one year stent fracture rate. Their use should be considered in those presenting with infrainguinal PAD undergoing endovascular revascularisation. A RCT is necessary to determine their clinical and cost effectiveness.
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Affiliation(s)
- Sarah Jane Messeder
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK; British Heart Foundation, Clinical Research Training Fellow, Leicester, UK.
| | - Gabriel López-Peña
- Leicester Vascular Institute, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK
| | - Coral Pepper
- Library and Information Services, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, UK
| | - Athanasios Saratzis
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK
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50
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Orrapin S, Siribumrungwong B. Successful Revascularization, Angiosome Concept, and Multivessel Revascularization: Effects on Wound Healing: An Asian Perspective. INT J LOW EXTR WOUND 2024; 23:12-18. [PMID: 37933151 DOI: 10.1177/15347346231212330] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Endovascular treatment for revascularization in patients with chronic limb-threatening ischemia (CLTI), which is commonly found in patients with diabetes mellitus demonstrates a variable result of vessel patency, wound healing rate, and limb salvage rate. The angiosome concept has been adopted to determine the best target arterial path (TAP) for revascularization for wound healing in CLTI patients. Recent publications demonstrated the benefit of angiosome-targeted revascularization to guide the endovascular treatment in patients CLTI. The best TAP under angiosome concept by direct revascularization with at least 2 of 3 below-the-knee arteries runoff to restore in-line pulsatile blood flow to the ischemic tissue shows the best patency and high rate of wound healing. However, the clinical evidence and application of the angiosome concept in daily practice are difficult and not well established. The vascular territories, collateral vessel, wound area, and locations which associated with angiosome are varied. This article review aims to summarize the concept of angiosome-targeted revascularization and multivessel revascularization for application to the real-world practice under the evidence-based data.
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Affiliation(s)
- Saritphat Orrapin
- Vascular Surgery Division, Department of Surgery, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
- Thammasat University-Center of Excellence for Diabetic Foot care (TU-CDC), Thammasat University Hospital, Pathum Thani, Thailand
| | - Boonying Siribumrungwong
- Vascular Surgery Division, Department of Surgery, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
- Center of Excellence in Applied Epidemiology, Faculty of Medicine, Thammasat University Hospital, Thammasat University, Pathum Thani, Thailand
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