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Abstract
Effective revascularization of the patient with peripheral artery disease is about more than the procedure. The approach to the patient with symptom-limiting intermittent claudication or limb-threatening ischemia begins with understanding the population at risk and variation in clinical presentation. The urgency of revascularization varies significantly by presentation; from patients with intermittent claudication who should undergo structured exercise rehabilitation before revascularization (if needed) to those with acute limb ischemia, a medical emergency, who require revascularization within hours. Recent years have seen the rapid development of new tools including wires, catheters, drug-eluting technology, specialized balloons, and biomimetic stents. Open surgical bypass remains an important option for those with advanced disease. The strategy and techniques employed vary by clinical presentation, lesion location, and lesion severity. There is limited level 1 evidence to guide practice, but factors that determine technical success and anatomic durability are largely understood and incorporated into decision-making. Following revascularization, medical therapy to reduce adverse limb outcomes and a surveillance plan should be put in place. There are many hurdles to overcome to improve the efficacy of lower extremity revascularization, such as restenosis, calcification, microvascular disease, silent embolization, and tools for perfusion assessment. This review highlights the current state of revascularization in peripheral artery disease with an eye toward technologies at the cusp, which may significantly impact current practice.
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Affiliation(s)
- Joshua A Beckman
- Cardiovascular Division, Vanderbilt University Medical Center, Nashville, TN (J.A.B.)
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco (P.A.S., M.S.C.)
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco (P.A.S., M.S.C.)
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2
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Benedetto F, Spinelli D, Pipitò N, Barillà D, Stilo F, De Caridi G, Barillà C, Spinelli F. Inframalleolar bypass for chronic limb-threatening ischemia. Vasc Med 2021; 26:187-194. [PMID: 33407009 DOI: 10.1177/1358863x20978468] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aims of this study were to analyze the results of inframalleolar bypass for chronic limb-threatening ischemia (CLTI) and to identify outcome-predicting factors. All consecutive patients undergoing inframalleolar bypass for CLTI between 2015 and 2018 were included in this retrospective, single-center study. Outflow artery was the most proximal patent vessel segment in continuity with inframalleolar arteries. Bypasses originating from the popliteal artery were defined as 'short bypasses'. Sixty patients underwent inframalleolar bypass, with four patients undergoing bilateral procedures, making a total of 64 limbs included. The mean age was 73 ± 14 and 52 (81%) were male. The great saphenous vein was the preferred conduit (n = 58, 91%), in a devalvulated fashion (n = 56, 88%). Superficial femoral artery was the most common inflow artery for 'long' grafts (n = 22, 34%), while popliteal artery was the inflow artery for all 'short' grafts (n = 25, 39%). Dorsalis pedis artery was chosen as an outflow artery in 41 patients (63%). Median follow-up was 21 months. Two-year primary and secondary patency, limb salvage, amputation-free survival, and overall survival rates were 67 ± 6%, 88 ± 4%, 84 ± 4%, 72 ± 6%, and 85 ± 4%, respectively. At multivariate analysis, dialysis was an independent predictor for poor primary patency (HR, 4.6; 95% CI, 1.62-13.05; p = 0.004), whereas a short bypass was independently associated with an increased primary patency (HR, 0.3; 95% CI, 0.10-0.89; p = 0.03). In conclusion, bypass grafting to the inframalleolar arteries resulted in good patency rates, limb salvage and overall survival. Dialysis patients had lower primary patency but still had good limb salvage and survival. Short bypass was a predictor of improved primary patency.
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Affiliation(s)
- Filippo Benedetto
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Domenico Spinelli
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Narayana Pipitò
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - David Barillà
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Francesco Stilo
- Vascular Surgery Unit, Campus Bio-Medico of Rome University, Rome, Italy
| | - Giovanni De Caridi
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Chiara Barillà
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Francesco Spinelli
- Vascular Surgery Unit, Campus Bio-Medico of Rome University, Rome, Italy
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 678] [Impact Index Per Article: 135.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GUIDELINE SUMMARY Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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4
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69:3S-125S.e40. [PMID: 31159978 PMCID: PMC8365864 DOI: 10.1016/j.jvs.2019.02.016] [Citation(s) in RCA: 654] [Impact Index Per Article: 130.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minn
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5
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Lioupis C. The Role of Distal Arterial Reconstruction in Patients With Diabetic Foot Ischemia. INT J LOW EXTR WOUND 2016; 4:45-9. [PMID: 15860451 DOI: 10.1177/1534734605274915] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The diabetic foot, a common complication that affects patients with diabetes mellitus, is a therapeutic challenge. It places an increasing burden on society; the patient and caregivers as well as health care systems and clinicians are touched by this problem. The management of the diabetic foot with ischemia consequent to peripheral arterial disease is vexing, often leading to successive amputations. Surgical reconstruction of the peripheral arteries has always been a consideration, although the concept of coexistent small vessel disease has prejudiced the notion of offering reconstructive surgery to these patients. This article examines some of the literature relating to bypass surgery with a view to addressing the aforementioned notion. An appraisal of the literature suggests that vascular reconstructive surgery offers benefits to the diabetic patient, albeit these papers have weaknesses related to study design and methodology. Improved studies are indicated to address the role of bypass surgery to help the diabetic patient with foot complications; it is reasonable to hope that our understanding of the fundamental concepts of the pathogenesis of diabetic foot disease will also improve.
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Affiliation(s)
- Christos Lioupis
- Department of Vascular Surgery, The Red Cross General Hospital of Athens, Athens, Greece.
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6
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Abstract
Contexto: La primera idea que tuvieron los cirujanos (1902) para evitar amputaciones por isquemia fue la de desviar el flujo arterial al sistema venoso por intermedio de una fístula arteriovenosa entre vasos adyacentes, pero con resultados inciertos. Desde entonces se han inventado las simpatecomias, las endarteriectomias y los injertos puentes o bypass y, últimamente, otros avances médicos, quirúrgicos y endovasculares. Sin embargo, en el mundo se siguen haciendo amputaciones, sobre todo en diabéticos. La arterialización de las venas del pie, basada en la vieja idea de la circulación invertida, constituye una esperanza más para estos pacientes ya condenados a la pérdida del miembro. Objetivo: Demostrar que la arterialización de las venas del pie en diabéticos con lesiones neuroisquémicas, generalmente infectadas (pie diabético), es un método eficaz y durable, aunque el puente solo funcione temporalmente. Pacientes y método: De enero de 2000 a febrero de 2009, 59 pacientes con pie diabético fueron tratados por arterialización de las venas del pie. Un deceso precoz no ha sido contabilizado. De los 58 pacientes restantes, 44 fueron hombres y 14 mujeres, con edad promedio de 71 años: (53-91 años), 54 en estado IV de Fontaine y cuatro en estado IIIB. La arterialización fue hecha con un injerto venoso invertido anastomosado, proximalmente en una arteria con buen flujo (ilíaca externa, femorales o poplítea) distalmente en la vena marginal interna del pie, con destrucción de las válvulas de las venas del dorso. Resultados: De los 58 arterializados, 12 fueron fracasos por trombosis precoz, siendo amputados, y 46 fueron éxitos (79%): seis de corto, 12 de mediano y 28 de largo plazo. En los grupos que se ajustan a la definición de éxito (dos) hubo 38 trombosis tardías del puente (95%) y cuatro recidivas de la sintomatología isquémica. No ha habido ningún caso de sobrecarga cardíaca ni de várices. Conclusión: La arterialización en el pie diabético es posible, eficaz y durable, gracias, posiblemente, a la inducción de una neoarteriogénesis y neoangiogénesis, que mantiene los beneficios aun después de que el puente se haya ocluido (función temporal).
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7
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Sottiurai V, White JV. Extensive Revascularization or Primary Amputation: Which Patients with Critical Limb Ischemia Should Not Be Revascularized? Semin Vasc Surg 2007; 20:68-72. [PMID: 17386366 DOI: 10.1053/j.semvascsurg.2007.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The commitment of vascular specialists to preserve the lower extremity has pushed the limits of revascularization. It is not uncommon for patients with severe distal disease to undergo extensive vascular reconstruction, bringing a bypass graft down to the ankle and beyond. Such procedures, when well-planned and well-executed, can result in a preserved and fully functional lower extremity with complete healing of all necrotic tissue. As noted in the guidelines presented by the TransAtlantic Inter-Society Consensus Working Group, there are patients who will benefit from primary amputation rather than extensive revascularization. Patients who are unable to tolerate the planned procedure or unlikely to have a functional extremity despite restoration of distal flow, should be considered for major amputation that eliminates the source of rest pain and all necrotic tissue. Although morbidity and mortality of major amputation continues to be significant, advances in prosthetic development and amputation technique can lead to preserved ambulatory ability and improved quality of life.
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Affiliation(s)
- Vikrom Sottiurai
- Center for Vein Health, Advocate Lutheran General Hospital, University School of Medicine, Park Ridge, IL 60068, USA.
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8
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Rowe VL, Hood DB, Lipham J, Terramani T, Torres G, Katz S, Kohl R, Weaver FA. Initial experience with dorsal venous arch arterialization for limb salvage. Ann Vasc Surg 2002; 16:187-92. [PMID: 11972250 DOI: 10.1007/s10016-001-0148-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Surgical reconstruction for patients with symptomatic lower extremity arterial occlusive disease is successful when a suitable distal target vessel is present. In patients with unreconstructable disease, practical surgical options are at a minimum. We report our initial experience with dorsal venous arch arterialization (DVAA) for limb salvage. Patients with a lower extremity arteriogram and tibia/plantar artery duplex scan demonstrating unreconstructable occlusive disease were evaluated for DVAA. The venous arch valve lysis technique consisted of retrograde balloon catheter, arterial dilator disruption, and direct valvulectomy. Outcome variables included patency, limb salvage rate, and toe pressure alterations. Initial results suggest that DVAA may be a viable option for end-stage limb salvage. Application of the DVAA appears to be more suitable for patients with symptoms secondary to atherosclerosis than those with Buerger's disease.
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Affiliation(s)
- Vincent L Rowe
- Department of Surgery, Division of Vascular Surgery, LAC+USC Medical Center, Keck School of Medicine at the University of Southern California, Los Angeles, CA 90033, USA.
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9
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Fusetti C, Sénéchaud C, Merlini M. [Quality of life of vascular disease patients following amputation]. ANNALES DE CHIRURGIE 2001; 126:434-9. [PMID: 11447794 DOI: 10.1016/s0003-3944(01)00541-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
STUDY AIM The purpose of this study was to assess the quality of life following lower limb amputation for vascular disease. PATIENTS AND METHODS Thirty-six vascular patients operated on for 40 major amputations were reviewed to assess demographic and clinical characteristics, possibilities of prosthesis, perception of health problems and social adaptation. These data were correlated with general satisfaction and quality of life ratings, using the Nottingham Health Profile. RESULTS The average stay in hospital was 109 days. Thirteen patients (36%) died in hospital, 23 others (64%) were discharged, but only ten patients (28%) were able to go back home. The global mortality rate at 1 year was 44%. Eighteen patients (78%) were initially fitted but only seven (30%) were fully independent. Eight patients only (35%) were satisfied at the end of treatment. Patient's satisfaction was influenced by the level of his amputation, the presence of residual pain and by his mobility, but it was independent of prosthetic equipment. CONCLUSION Quality of life of vascular amputated patients is poor and marked by persistent pain and considerable handicaps in mobility, limiting social activities and relationship. The patients' satisfaction and quality of life appear to be related to their ability to manage social relations. Amputation should be considered as the first step towards rehabilitation and not the end of the treatment. It is only through a multidisciplinary approach that the quality of life of amputated patients can be improved.
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Affiliation(s)
- C Fusetti
- Service de chirurgie générale, hôpital, CH 2300, La Chaux-de-Fonds, Suisse.
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10
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Kalra M, Gloviczki P, Bower TC, Panneton JM, Harmsen WS, Jenkins GD, Stanson AW, Toomey BJ, Canton LG. Limb salvage after successful pedal bypass grafting is associated with improved long-term survival. J Vasc Surg 2001; 33:6-16. [PMID: 11137918 DOI: 10.1067/mva.2001.112300] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Assessments of outcome after reconstruction for critical limb ischemia frequently ignore functional result and long-term morbidity and mortality. This study was undertaken to identify factors affecting long-term clinical outcome and survival after pedal bypass grafting. METHODS The clinical data of 256 consecutive patients who underwent pedal bypass grafting for critical limb ischemia over a 12-year period were retrospectively analyzed. RESULTS A total of 174 men and 82 women (median age, 70 years; range, 30-91 years) underwent 280 pedal bypass graft placements with autologous vein. Seventy-five percent of the patients were diabetic, and 20% had renal insufficiency (serum creatinine level > 2 mg/dL). The in-hospital mortality rate was 1.6% (4/256). The mean follow-up was 2.7 years (range, 0.1-10.1 years). Rates of primary and secondary patency, limb salvage, and survival at 5 years were 58%, 71%, 78%, 60%, respectively. A total of 160 limbs (57%) required additional interventions. Nineteen early graft thrombectomies/revisions and nine early amputations were performed. One hundred thirty-eight late interventions included 31 graft salvage procedures, 27 wound debridements, and 34 minor and 42 major amputations. At last follow-up or death, 219 (78%) limbs were being used for ambulation. End-stage renal disease (ESRD) and composite vein grafts predicted limb loss (P <.001, P <.001, respectively). Overall survival at 5 years was 60%. Survival after amputation was 79%, 53%, and 26% at 1, 3, and 5 years. Amputation and ESRD predicted higher mortality (P =.014, P =.0001, respectively). CONCLUSIONS Pedal bypass grafting resulted in good functional limb salvage, but at the expense of multiple interventions in more than half the cases. ESRD and composite vein graft were associated with poor long-term limb salvage. Amputation after bypass grafting was associated with significantly worse long-term survival.
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Affiliation(s)
- M Kalra
- Division of Vascular Surgery, Mayo Clinic, Rochester, MN 55905, USA
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11
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Tangelder MJ, Algra A, Lawson JA, Eikelboom BC. Risk factors for occlusion of infrainguinal bypass grafts. Eur J Vasc Endovasc Surg 2000; 20:118-24. [PMID: 10944100 DOI: 10.1053/ejvs.2000.1125] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to identify risk factors for infrainguinal bypass occlusion and quantify the predictive value of data available before and after surgery. DESIGN prospective study of 2650 patients who participated in a randomised trial of oral anticoagulants or aspirin after infrainguinal bypass surgery. MATERIALS AND METHODS risk factors were determined by univariate Cox regression analysis, and entered in multivariate analyses which distinguished two models: analysis of factors available from history and clinical examination, completed by radiological and surgical data in the second model. To compare the information content of the two models, receiver-operator characteristic (ROC) curves were computed. RESULTS in all patients female gender, critical ischaemia, femorocrural bypass grafting and non-venous graft material were independent risk factors. In patients with femoropopliteal bypasses female gender, critical ischaemia, poor run-off and non-venous graft material, the latter even in patients with supragenicular bypasses, were independent risk factors. The only significant risk factor in patients with femorocrural bypass grafts was use of a non-venous graft. The information contained in the first model was poor, whereas the second model had a higher predictive value. CONCLUSIONS the major risk factor, even in above-knee bypasses, is non-venous graft material. The venous bypass graft should be offered to patients whenever possible.
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Affiliation(s)
- M J Tangelder
- Department of Vascular Surgery, University Hospital Utrecht, Utrecht, The Netherlands
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12
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Affiliation(s)
- M Eneroth
- Department of Orthopaedics, University Hospital, Lund, Sweden
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13
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Dardik H. Graft failure and amputation. Eur J Vasc Endovasc Surg 1997; 14:417-8. [PMID: 9413391 DOI: 10.1016/s1078-5884(97)80302-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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