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Pacha HM, Al-Khadra Y, Darmoch F, Soud M, Kwok CS, Mamas MA, Ashraf S, Sattar Y, Ullah W, Banerjee S, Arain SA, Feldman DN, Abu-Fadel M, Aronow HD, Shishehbor MH, Alraies MC. In-Hospital Outcomes and Trends of Endovascular Intervention vs Surgical Revascularization in Octogenarians With Peripheral Artery Disease. Am J Cardiol 2021; 145:143-150. [PMID: 33460607 DOI: 10.1016/j.amjcard.2020.12.091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/26/2020] [Accepted: 12/31/2020] [Indexed: 01/22/2023]
Abstract
It is unknown whether endovascular intervention (EVI) is associated with superior outcomes when compared with surgical revascularization in octogenarian. National Inpatient Sample (NIS) database was used to compare the outcomes of limb revascularization in octogenarians who had surgical revascularization versus EVI. The NIS database's information on PAD patients ≥80-year-old who underwent limb revascularization between 2002 and 2014 included 394,504 octogenarian patients, of which 184,926 underwent surgical revascularization (46.9%) and 209,578 underwent EVI (53.1%). Multivariate analysis was performed to examine in-hospital outcomes. Trend over time in limb revascularization utilization was examined using Cochrane-Armitage test. EVI group had lower odds of in-hospital mortality (adjusted odds ratio [aOR]: 0.61 [95% CI: 0.58 to 0.63], myocardial infarction (aOR: 0.84 [95% CI: 0.81 to 0.87]), stroke (aOR: 0.93 [95% CI: 0.89 to 0.96]), acute kidney injury (aOR: 0.79 [95% CI: 0.77 to 0.81]), and limb amputation (aOR: 0.77 [95% CI: 0.74 to 0.79]) compared with surgical group (p < 0.001 for all). EVI group had higher risk of bleeding (aOR: 1.20 [95% CI: 1.18 to 1.23]) and vascular complications (3.2% vs 2.7%, aOR: 1.25 [95% CI: 1.19 to 1.30]) compared with surgical group (p < 0.001 for all). Within study period, EVI utilization increased in octogenarian patients from 2.6% to 8.9% (ptrend < 0.001); whereas use of surgical revascularization decreased from 11.6% to 5.2% (ptrend < 0.001). In conclusion, the utilization of EVI in octogenarians is increasing, and associated with lower risk of in-hospital mortality and adverse cardiovascular and limb outcomes as compared with surgical revascularization.
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Affiliation(s)
- Homam Moussa Pacha
- University of Texas Health Science Center, McGovern Medical School, Memorial Hermann Heart & Vascular Institute, Houston, Texas
| | | | - Fahed Darmoch
- Beth Israel Deaconess Medical center/Harvard medical school, Boston, Massachusetts
| | | | - Chun Shing Kwok
- Keele Cardiovascular Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Said Ashraf
- Wayne State University, Detroit Medical Center, Detroit Heart Hospital, Detroit, Michigan
| | - Yasar Sattar
- Icahn school of medicine at Mount Sinai Elmhurst Hospital New York
| | - Waqas Ullah
- Abington Jefferson Health, Abington, Pennsylvania
| | | | - Salman A Arain
- University of Texas Health Science Center, McGovern Medical School, Memorial Hermann Heart & Vascular Institute, Houston, Texas
| | - Dmitriy N Feldman
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | | | - Herbert D Aronow
- Alpert Medical School at Brown University/Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - Mehdi H Shishehbor
- University Hospital Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - M Chadi Alraies
- Wayne State University, Detroit Medical Center, Detroit Heart Hospital, Detroit, Michigan.
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Kim TI, Aboian E, Fischer U, Zhang Y, Guzman RJ, Ochoa Chaar CI. Lower Extremity Revascularization for Chronic Limb-Threatening Ischemia among Patients at the Extremes of Age. Ann Vasc Surg 2020; 72:517-528. [PMID: 32927042 DOI: 10.1016/j.avsg.2020.08.135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/16/2020] [Accepted: 08/17/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with chronic limb-threatening ischemia (CLTI) at the extremes of age are thought to have distinct risk factor profiles and poor outcomes after lower extremity revascularization (LER). The aim of this study is to examine the relationships among age, risk factor profiles, and outcomes of LER in patients with CLTI in a large database focusing on the extreme age groups. METHODS Patients undergoing LER for CLTI in the Vascular Quality Initiative suprainguinal bypass, infrainguinal bypass, and peripheral vascular intervention files were reviewed through 2019. Patients were stratified into 3 groups: premature peripheral artery disease (PAD) (≤50 years old), 51-84 years old, and elderly (≥85 years old). Trends in major amputation and mortality by age group were analyzed. RESULTS There were 156,513 patients who underwent LER for CLTI. Of these, 9,063 (5.79%) patients had premature PAD, 131,694 (84.14%) patients were 51-84 years old, and 15,756 (10.07%) were elderly. Patients with premature PAD were more likely to have insulin-dependent diabetes, be dialysis-dependent, and be active smokers compared to patients 51-84 years old and the elderly. Elderly patients were more likely to undergo an endovascular procedure for tissue loss compared to younger groups. Perioperative and 1-year major amputation rates were highest among patients with premature PAD and decreased with increasing age (P < 0.001), while perioperative and 1-year mortality increased with age (P < 0.001). On multivariable analysis, premature PAD was associated with an increased risk of major amputation (odds ratio, OR = 1.41 [1.22-1.62]), while elderly age was associated with decreased odds of major amputation compared to patients 51-84 years old (OR = 0.61 [0.51-0.73]). CONCLUSIONS Patients at the extremes of age have significantly different outcomes after LER for CLTI. Although mortality increases with age, the risk of major amputation decreases. Patients with premature PAD constitute a group of patients with a high risk of perioperative and 1-year major amputation.
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Affiliation(s)
- Tanner I Kim
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Edouard Aboian
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Uwe Fischer
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Yawei Zhang
- Department of Surgery, Yale School of Medicine, New Haven, CT; Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT
| | - Raul J Guzman
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
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Tong Y, Febrer G, Mao J, Wawryko P, Mao Y, Le-Bel G, How D, Philippe E, Zhou T, Zhang Z, Wang L, Germain L, Guidoin R. Limb salvage after aneurysmal degeneration of a cryopreserved vein allograft: Searching the autologous veins of the arm is worth the effort. Morphologie 2020; 104:202-213. [PMID: 32518049 DOI: 10.1016/j.morpho.2020.05.001] [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: 09/23/2019] [Revised: 04/29/2020] [Accepted: 05/14/2020] [Indexed: 06/11/2023]
Abstract
CLINICAL DATA We hereby report a case of limb salvage involving a 64-year-old man who was hospitalized with ischemic foot ulcers for two months. Endarterectomy with patching and stenting of the left iliofemoral artery failed. A composite bypass of two segments of the endarterectomized superficial femoral artery and a cryopreserved saphenous vein graft was implanted one week later. On day 4 postoperatively, an infection (Staphylococcus epidermidis and Pseudomonas aeruginosa) was treated empirically with antibiotics. Four months later, the femoro-tibial bypass thrombosed and the patency was restored by thrombolysis. The aneurysmal cryopreserved vein was excised. Iterative complications followed and final success was attained after implantation of autologous cephalic and basilic veins. Four years later, this femoro-tibial is still patent. PATHOLOGICAL ANALYSES After a gross observation, the explant was dissected and the most significant sections were processed for histology, followed by analyses in scanning electron microscopy, light microscopy and transmission electron microscopy. RESULTS The explanted specimen showed a smooth flow surface proximally but a severe distortion distally, with an accumulation of poorly organized mural thrombi. The wall of the arterialized vein was accompanied with an important inflammatory reaction. The degradation of the collagen structure was evidenced in TEM. The fibrils of collagen were still individualized but were fragmented and did not display parallelly. The regular banding was preserved. The presence of Pseudomonas aeruginosa was shown inside the wall of the homologous vein. COMMENTS In case of sepsis, the most aggressive antibiotic treatments cannot fully eliminate the bacteremic colonizations within the wall of an alternative conduit. The cephalic and basilic autologous veins are proved to be preferable in absence of the autologous saphenous vein. The amputation was prevented and four years later the bypass is still patent. This is an outstanding result based upon the comorbidities of the patient. The most aggressive harvesting shall be recommended. This patient represented a considerable challenge and the clinical result is highly gratifying: the search for the autologous cephalic and basilic veins proved to be worth the effort.
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Affiliation(s)
- Yiwei Tong
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada; Comprehensive Breast Health Center, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, 200025 Shanghai, China
| | - Guillaume Febrer
- Service de chirurgie vasculaire, Département de chirurgie, Hôpital du Sacré-Cœur, Université de Montréal, Montréal (QC), Canada
| | - Jifu Mao
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada; Key Laboratory of Textile Science & Technology, Ministry of Education and College of Textiles, Donghua University, Shanghai, China
| | - Paul Wawryko
- Department of Pathology, University of Manitoba, Winnipeg (MB), Canada
| | - Ying Mao
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada; Key Laboratory of Textile Science & Technology, Ministry of Education and College of Textiles, Donghua University, Shanghai, China
| | - Gaëtan Le-Bel
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada
| | - Daniel How
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Eric Philippe
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada
| | - Tianyi Zhou
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada
| | - Ze Zhang
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada
| | - Lu Wang
- Key Laboratory of Textile Science & Technology, Ministry of Education and College of Textiles, Donghua University, Shanghai, China
| | - Lucie Germain
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada
| | - Robert Guidoin
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada.
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Klaphake S, de Leur K, Thijsse W, Ho GH, de Groot HG, Veen EJ, Haans DH, van der Laan L. Reinterventions after Endovascular Revascularization in Elderly Patients with Critical Limb Ischemia: An Observational Study. Ann Vasc Surg 2018; 53:171-176. [DOI: 10.1016/j.avsg.2018.04.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/01/2018] [Accepted: 04/11/2018] [Indexed: 11/16/2022]
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Klaphake S, de Leur K, Mulder PG, Ho GH, de Groot HG, Veen EJ, van der Laan L. Life Expectancy and Outcome of Different Treatment Strategies for Critical Limb Ischemia in the Elderly Patients. Ann Vasc Surg 2018; 46:241-248. [DOI: 10.1016/j.avsg.2017.06.141] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/20/2017] [Accepted: 06/25/2017] [Indexed: 10/19/2022]
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Dinga Madou I, Slade MD, Orion KC, Sarac T, Ochoa Chaar CI. The Impact of Functional Status on the Outcomes of Endovascular Lower Extremity Revascularization for Critical Limb Ischemia in the Elderly. Ann Vasc Surg 2017. [DOI: 10.1016/j.avsg.2017.06.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Noronen K, Saarinen E, Albäck A, Venermo M. Analysis of the Elective Treatment Process for Critical Limb Ischaemia with Tissue Loss: Diabetic Patients Require Rapid Revascularisation. Eur J Vasc Endovasc Surg 2017; 53:206-213. [DOI: 10.1016/j.ejvs.2016.10.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
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Hamdi A, Al-Zubeidy B, Obirieze A, Rose D, Tran D, Cornwell E, Obisesan T, Hughes K. Lower Extremity Arterial Reconstruction in Octogenarians and Older. Ann Vasc Surg 2016; 34:171-7. [PMID: 27177700 PMCID: PMC4930703 DOI: 10.1016/j.avsg.2015.12.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 12/02/2015] [Accepted: 12/12/2015] [Indexed: 10/21/2022]
Abstract
BACKGROUND Despite previous single-institution studies showing that lower extremity arterial reconstruction (LEAR) in octogenarians and older patients may be undertaken with acceptable postoperative morbidity and mortality, there continues to be significant reluctance, in the vascular surgical community, to undertaking these complex revascularization procedures in this very elderly population. We undertook this study in an effort to determine the outcomes of LEAR in octogenarians and older patients on a national level. METHODS The American College of Surgeons' National Surgical Quality Improvement Program database was queried to identify all patients who underwent LEAR between January 1, 2005 and December 31, 2009. Patient demographics and presenting comorbidities were recorded, and multivariate analyses were performed to compare outcomes in patients 80 and older to those in younger patients. RESULTS There were 19,028 patients who underwent open infrainguinal LEAR during this time period. Patients ≥80 comprised 18% (3,486 patients), and patients <80 years comprised 82% (15,542 patients). Multivariate analysis demonstrated that patients aged ≥80 years had an increased likelihood of mortality (odds ratio [OR] 1.79; 95% confidence interval [CI] 1.42-2.26), cardiovascular (OR, 1.46; 95% CI, 1.12-1.89), respiratory (OR, 1.37; 95% CI, 1.12-1.67), and renal (OR, 1.57; 95% CI, 1.27-1.95) complications. There was, however, no significant difference in the likelihood of graft failure (OR, 1.04; 95% CI, 0.86-1.27), wound infection (OR, 0.92; 95% CI, 0.79-1.06), or major amputation (OR, 0.59; 95% CI, 0.13-2.74) between these 2 groups. CONCLUSIONS LEAR in octogenarians is associated with an increased risk of postoperative morbidity and mortality but no increased risk of wound infection, amputation, or graft failure.
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Affiliation(s)
- Abdulrahman Hamdi
- Department of Surgery, Howard University College of Medicine and Hospital, Washington, DC
| | - Batul Al-Zubeidy
- Department of Surgery, Howard University College of Medicine and Hospital, Washington, DC
| | - Augustine Obirieze
- Department of Surgery, Howard University College of Medicine and Hospital, Washington, DC
| | - David Rose
- Department of Surgery, Howard University College of Medicine and Hospital, Washington, DC
| | - Daniel Tran
- Department of Surgery, Howard University College of Medicine and Hospital, Washington, DC
| | - Edward Cornwell
- Department of Surgery, Howard University College of Medicine and Hospital, Washington, DC
| | - Thomas Obisesan
- Department of Medicine, Howard University College of Medicine and Hospital, Washington, DC
| | - Kakra Hughes
- Department of Surgery, Howard University College of Medicine and Hospital, Washington, DC.
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Huang HL, Jimmy Juang JM, Chou HH, Hsieh CA, Jang SJ, Cheng ST, Ko YL. Immediate results and long-term cardiovascular outcomes of endovascular therapy in octogenarians and nonoctogenarians with peripheral arterial diseases. Clin Interv Aging 2016; 11:535-43. [PMID: 27217735 PMCID: PMC4862757 DOI: 10.2147/cia.s106119] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Purpose To investigate the clinical outcomes of endovascular therapy (EVT) in octogenarians and nonoctogenarians with peripheral arterial disease. Methods A retrospective analysis of 511 patients (654 affected legs) who underwent EVT between July 2005 and December 2013 was conducted in a prospectively maintained database. Immediate results and long-term vascular outcomes were analyzed and compared between octogenarians and nonoctogenarians. Results Octogenarians were more likely to be female and have atrial fibrillation (AF), whereas nonoctogenarians had higher rates of obesity, claudication, and medical comorbidities. There were no differences in the rates of EVT success, 30-day major adverse vascular events, and 6-month functional improvement between groups. Over the 10-year follow-up period, the rates of 3-year limb salvage, sustained clinical success, freedom from major cerebrovascular and cardiovascular events, and composite vascular events were similar between groups, but the survival rate was better in nonoctogenarians than in octogenarians (73% vs 63%, respectively, P=0.004). In Cox regression analysis, dependence on dialysis and AF were significant predictors of death (odds ratio [OR] 4.44 in dialyzed and 2.83 in AF patients), major cerebrovascular and cardiovascular events (OR 3.49 and 2.45), and composite vascular events (OR 3.14 and 2.25). Conclusion EVT in octogenarians was feasible, without an increased risk of periprocedural complications. The rates of limb salvage, sustained clinical success, and long-term vascular events were comparable between groups. Dialysis dependence and AF are independent predictors for poor prognosis in patients with peripheral arterial disease. However, these observations require further confirmation in larger scale studies.
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Affiliation(s)
- Hsuan-Li Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Jyh-Ming Jimmy Juang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsin-Hua Chou
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chien-An Hsieh
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Shih-Jung Jang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Shih-Tsung Cheng
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Lin Ko
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
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Uhl C, Hock C, Ayx I, Zorger N, Steinbauer M, Töpel I. Tibial and peroneal bypasses in octogenarians and nonoctogenarians with critical limb ischemia. J Vasc Surg 2016; 63:1555-62. [PMID: 26926934 DOI: 10.1016/j.jvs.2015.12.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 12/21/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Elderly patients with critical limb ischemia are increasingly treated through interventional therapy. The outcome of tibial and peroneal bypasses in octogenarians who were unsuitable for endovascular therapy remains unclear. METHODS We conducted a retrospective analysis of all patients who underwent tibial or peroneal bypass surgery in our clinic between October 2007 and April 2015. In Group 1 we included all patients 80 years and older and in group 2 all patients under 80 years. Vein was used whenever possible (diameter not less than 3 mm, not more than two segments for sufficient length). Study end points were primary and secondary patency, limb salvage and survival after 3 years. RESULTS Indications were rest pain in 32.2% and ulcer and gangrene in 67.8%. There were 92 cases in Group 1 (median age, 85 years) and 178 in group 2 (median age, 70 years). Risk factors and indications were similar in both groups except for gender, renal insufficiency and smoking. 30-day mortality was 9.7% in group 1 and 1.1% in group 2 (P = .001). There was no significant difference in 30-day graft failure and major amputation. At 3 years primary patency in group 1 was 58.9% vs 49.7% (P = .058), secondary patency was 73.0% vs 54.7% (P = .007). Limb salvage was 80.1% in group 1 vs 73.0% in group 2 (P = .446), survival was 44.0% vs 71.2% (P = .000). CONCLUSIONS Our analysis showed good results in octogenarians undergoing tibial and peroneal bypass surgery with regard to patency rates and limb salvage. However, octogenarians had a significantly higher perioperative mortality rate.
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Affiliation(s)
- Christian Uhl
- Department of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany.
| | - Carolin Hock
- Department of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Isabelle Ayx
- Department of Radiology and Interventional Radiology, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Niels Zorger
- Department of Radiology and Interventional Radiology, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Markus Steinbauer
- Department of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Ingolf Töpel
- Department of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
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Saarinen E, Vuorisalo S, Kauhanen P, Albäck A, Venermo M. The Benefit of Revascularization in Nonagenarians with Lower Limb Ischemia is Limited by High Mortality. Eur J Vasc Endovasc Surg 2015; 49:420-5. [DOI: 10.1016/j.ejvs.2014.12.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 12/23/2014] [Indexed: 10/24/2022]
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12
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Chung JW, Nah DY, Bae JH. Percutaneous Transluminal Angioplasty of Contralateral Iliac and Superficial Femoral Arteries via Graft Vessel in a Patient with FemoroFemoral Bypass Graft. Korean Circ J 2013; 43:265-8. [PMID: 23682287 PMCID: PMC3654115 DOI: 10.4070/kcj.2013.43.4.265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 07/17/2012] [Accepted: 09/06/2012] [Indexed: 11/11/2022] Open
Abstract
Peripheral arterial disease represents a significant problem, particularly among the elderly population. There has been great progress made in the treatment of peripheral arterial disease in recent years. Percutaneous transluminal angioplasty (PTA) has been employed as a method of treatment for patients with a variety of peripheral arterial disease. We report our experience with PTA of contralateral common iliac and superficial femoral arteries via graft vessel in a patient with femorofemoral bypass due to ipsilateral iliac artery occlusion.
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Affiliation(s)
- Jin Wook Chung
- Department of Cardiology, College of Medicine, Dongguk University, Gyeongju Hospital, Gyeongju, Korea
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Kechagias A, Romsi P, YlÖNen K, Kechagias G, Juvonen T, Biancari F. Institutional Results and Meta-Analysis of Outcome after Infrainguinal Surgical Revascularization in Patients Greater than 80 Years Old. Am Surg 2011. [DOI: 10.1177/000313481107700936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Our aim was to evaluate the outcome after infrainguinal bypass revascularization in patients greater than 80 years old with lower limb ischemia treated at our institution and to perform a metaanalysis of literature data to better estimate current postoperative results. Eighty-four infrainguinal bypass procedures were performed in 76 patients of at least 80 years of age. Major outcome end points included survival, limb salvage, and amputation-free survival. Systematic review and meta-analysis of literature data on immediate and late outcome in patients older than 80 years who underwent infrainguinal surgical revascularization have been performed. At 30 days, seven patients (8.3%) died and seven major amputations (8.3%) occurred. Kaplan-Meier estimates of survival at 1, 3, and 5 -years were 73.8, 59.8, and 43.1 per cent; leg salvage 78.9, 71.4, and 67.8 per cent; and amputation-free survival 58.3, 42.7, and 28.2 per cent, respectively. The mean survival was 4.6 ± 0.4 years. Only Finnvasc score greater than 2 was predictive of poor late amputation-free survival (at 5 years: 4.5 vs 42.3%; relative risk, 2.19; 95% confidence interval, 1.27 to 3.76). Eleven studies were additionally available for analysis. Pooled estimates of survival at 30 days, 1 year, and 5 years were 94.8, 86.0, and 47.6 per cent, respectively, and of leg salvage were 95.5, 84.7, and 84.1 per cent, respectively. Infrainguinal bypass in patients older than 80 years carries a significant operative risk and is associated with suboptimal long-term amputation-free survival, which is particularly poor among patients with a Finnvasc score greater than 2.
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Affiliation(s)
- Aristotelis Kechagias
- Division of Cardio-thoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Pekka Romsi
- Division of Cardio-thoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Kari YlÖNen
- Division of Cardio-thoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Georgios Kechagias
- Division of Cardio-thoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Tatu Juvonen
- Division of Cardio-thoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Fausto Biancari
- Division of Cardio-thoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
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Slim H, Tiwari A, Ahmed A, Ritter J, Zayed H, Rashid H. Distal versus Ultradistal Bypass Grafts: Amputation-free Survival and Patency Rates in Patients with Critical Leg Ischaemia. Eur J Vasc Endovasc Surg 2011; 42:83-8. [DOI: 10.1016/j.ejvs.2011.03.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Accepted: 03/20/2011] [Indexed: 10/18/2022]
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Plaisance BR, Munir K, Share DA, Mansour MA, Fox JM, Bove PG, Riba AL, Chetcuti SJ, Gurm HS, Grossman PM. Safety of Contemporary Percutaneous Peripheral Arterial Interventions in the Elderly. JACC Cardiovasc Interv 2011; 4:694-701. [DOI: 10.1016/j.jcin.2011.03.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 02/23/2011] [Accepted: 03/05/2011] [Indexed: 10/18/2022]
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16
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Koskela VK, Salenius J, Suominen V. Peripheral Arterial Disease in Octogenarians and Nonagenarians: Factors Predicting Survival. Ann Vasc Surg 2011; 25:169-76. [DOI: 10.1016/j.avsg.2010.07.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 04/12/2010] [Accepted: 07/19/2010] [Indexed: 11/29/2022]
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17
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Arvela E, Venermo M, Söderström M, Korhonen M, Halmesmäki K, Albäck A, Lepäntalo M, Biancari F. Infrainguinal percutaneous transluminal angioplasty or bypass surgery in patients aged 80 years and older with critical leg ischaemia. Br J Surg 2011; 98:518-26. [DOI: 10.1002/bjs.7390] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2010] [Indexed: 01/07/2023]
Abstract
Abstract
Background
Infrainguinal revascularization for critical leg ischaemia (CLI) in patients aged 80 years and over is associated with increased operative risk. The aim was to compare the results of percutaneous transluminal angioplasty (PTA) and bypass surgery in these patients.
Methods
Some 584 consecutive patients aged at least 80 years treated with either PTA (277) or bypass surgery (307) for CLI between 2000 and 2007 were included in this study.
Results
After 2 years PTA achieved better results than bypass surgery (leg salvage: 85·4 versus 78·7 per cent, P = 0·039; survival: 57·7 versus 52·3 per cent, P = 0·014; amputation-free survival (AFS): 53·0 versus 44·9 per cent, P = 0·005). Cox regression analysis showed that increased age (relative risk (RR) 1·05, 95 per cent confidence interval 1·02 to 1·08), decreased estimated glomerular filtration rate (RR 0·99, 0·99 to 1·00), diabetes (RR 1·30, 1·04 to 1·62), coronary artery disease (RR 1·36, 1·05 to 1·75) and bypass surgery (RR 1·55, 1·24 to 1·93) were associated with decreased AFS. In 95 propensity score-matched pairs, leg salvage at 2 years (88 versus 75 per cent; P = 0·010) and AFS (53 versus 45 per cent; P = 0·033) were significantly better after PTA. Classification and regression tree analysis suggested that PTA was associated with better 1-year AFS, especially in patients with coronary artery disease (63·8 versus 48·9 per cent; P = 0·008).
Conclusion
When feasible, a strategy of PTA first appears to achieve better results than infrainguinal bypass surgery in patients aged 80 years and older.
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Affiliation(s)
- E Arvela
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - M Venermo
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - M Söderström
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - M Korhonen
- Department of Radiology, Helsinki University Central Hospital, Helsinki, Finland
| | - K Halmesmäki
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - A Albäck
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - M Lepäntalo
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - F Biancari
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Oulu University Central Hospital, Oulu, Finland
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Ballotta E, Gruppo M, Mazzalai F, Martella B, Terranova O, Da Giau G. Infrapopliteal arterial reconstructions for limb salvage in patients aged ≥80 years according to preoperative ambulatory function and residential status. Surgery 2010; 148:119-28. [DOI: 10.1016/j.surg.2009.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Accepted: 12/24/2009] [Indexed: 10/19/2022]
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19
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Dosluoglu HH, Lall P, Cherr GS, Harris LM, Dryjski ML. Superior limb salvage with endovascular therapy in octogenarians with critical limb ischemia. J Vasc Surg 2009; 50:305-15, 316.e1-2; discussion 315-6. [DOI: 10.1016/j.jvs.2009.01.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Revised: 12/24/2008] [Accepted: 01/04/2009] [Indexed: 10/20/2022]
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20
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Hnath J, Roddy SP, Darling RC, Paty PS, Taggert JB, Mehta M. Comparative results of open lower extremity revascularization in nonagenarians. J Vasc Surg 2009; 49:1459-63; discussion 1463-4. [DOI: 10.1016/j.jvs.2009.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Revised: 02/09/2009] [Accepted: 02/10/2009] [Indexed: 10/20/2022]
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21
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Brosi P, Dick F, Do DD, Schmidli J, Baumgartner I, Diehm N. Revascularization for chronic critical lower limb ischemia in octogenarians is worthwhile. J Vasc Surg 2007; 46:1198-207. [DOI: 10.1016/j.jvs.2007.07.047] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Revised: 07/25/2007] [Accepted: 07/25/2007] [Indexed: 10/22/2022]
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22
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Padilla L, Krötzsch E, De La Garza AS, Figueroa S, Rodriguez-Trejo J, Avila G, Schalch P, Escotto I, Glennie G, Villegas F, Di Silvio M. Bone marrow mononuclear cells stimulate angiogenesis when transplanted into surgically induced fibrocollagenous tunnels: results from a canine ischemic hindlimb model. Microsurgery 2007; 27:91-7. [PMID: 17186521 DOI: 10.1002/micr.20289] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Progenitor cell transplantation has been considered as a potential angiogenesis therapy for the ischemic hindlimb. In this work we performed an ischemic hindlimb model in dogs. We ligated the middle sacra and the external right iliac arteries. After 7 days, the femoral artery was ligated and removed, and three Silastic tubes were inserted into the gracilis muscle to create fibrocollagenous tunnels. After Silastic implantation, we administered saline or granulocyte colony stimulating factor (G-CSF) subcutaneously daily during 5 days. Fourteen days after device positioning we transplanted bone marrow mononuclear cells (BMMC) into the tunnels previously formed by Silastic tube reaction. Twenty-eight days later, contrasted angiographies were performed and angiographic scores were calculated. Also, vessels and endothelial cells and proliferating cells were identified by immunochemistry of muscle sections. Results demonstrated that BMMC transplantation enriched by G-CSF administration significantly stimulates angiogenesis in the ischemic hindlimb, and more than BMMC transplantation alone. Transplantation of progenitor cells in an appropriate extracellular matrix is a potential therapy for hindlimb ischemia.
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Affiliation(s)
- Luis Padilla
- Department of Microsurgery, Centro Médico Nacional "20 de Noviembre", I.S.S.S.T.E., Mexico City, Mexico
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23
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Atar E, Siegel Y, Avrahami R, Bartal G, Bachar GN, Belenky A. Balloon angioplasty of popliteal and crural arteries in elderly with critical chronic limb ischemia. Eur J Radiol 2005; 53:287-92. [PMID: 15664294 DOI: 10.1016/j.ejrad.2004.02.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2004] [Revised: 02/16/2004] [Accepted: 02/19/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Elderly patients with extensive infrainguinal peripheral vascular disease and critical chronic limb ischemia (CCLI) are poor surgical candidates. Our purpose was to evaluate angiographic and clinical results of popliteal, infrapopliteal, and multi-level disease percutaneous transluminal angioplasty (PTA) in such patients. DESIGN Retrospective study of angiographic and clinical files in selected group. MATERIALS AND METHODS Between 1996 and 2002, 38 elderly patients aged 80-94 years old (mean age 83.3) with critical leg ischemia were treated with PTA. All patients were at high surgical risk. 31/38 (81.5%) patients had chronic non-healing wounds, and 14/38 (37%) had multi-level disease of superficial femoral, popliteal and crural arteries. One hundred and two lesions were treated by angioplasty. Immediate angiographic and 1 year clinical results were retrospectively analyzed. RESULTS The overall procedural success rate was 32/38 (84.2%). There were three major complications (7.9%), but no deaths, and three technical failures, all were of infrapopliteal lesions. After 1 year, 27 patients could be followed, five patients died during the first year of unrelated causes. Twenty-three patients (85.2%), were clinically re-occluded within 1 year, but complete and partial wound healing was achieved in 80% (16/20) and rest pain improvement in 57% (4/7), so that overall limb salvage was 74% (20/27). CONCLUSIONS Elderly patients with multi-level CCLI have a short patency term following angioplasty of 14.8% after 1 year. Nevertheless, this temporary vascular patency enables wound healing or improvement in 74% of these patients, thus such endovascular interventions are recommended in this age group.
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Affiliation(s)
- Eli Atar
- Department of Diagnostic Radiology, Unit of Vascular Radiology, Rabin Medical Center, Golda Campus, Rachel Venachum 5, Petah Tikva 49377, Israel.
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Salas CA, Adam DJ, Papavassiliou VG, London NJM. Percutaneous transluminal angioplasty for critical limb ischaemia in octogenarians and nonagenarians. Eur J Vasc Endovasc Surg 2004; 28:142-5. [PMID: 15234694 DOI: 10.1016/j.ejvs.2004.03.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine the early and late outcome of percutaneous transluminal angioplasty (PTA) for critical limb ischaemia (CLI) in patients aged 80 years and over. METHODS Retrospective case note review of all patients aged 80 years and over who underwent attempted PTA for CLI between 1st January 1999 and 31st December 2000. Minimum follow-up was 12 months with a maximum of 42 months. RESULTS One hundred and twenty-eight PTAs were attempted in 113 severely ischaemic limbs of 98 patients (36 men and 62 women of median age 84, range 80-97, years). Seventy patients had significant co-morbidity. The indication for revascularisation was rest pain in 47 procedures, ulceration in 66 and digital gangrene in 15. The anatomical segments involved were iliac (n=19), superficial femoral (n=92), popliteal (n=91) and infrapopliteal (n=72). The technical success rate was 108 of 128 (84%) procedures. Early technical complications occurred in 24 (19%) procedures: four major, 20 minor. The 30-day operative mortality rate was six of 128 (5%). The median (range) in-hospital stay was two (1-72) days. Early or delayed surgical revascularisation was required in 11 limbs and there were six major limb amputations during the study period. The 24-month patient survival rate was 59%. The 24-month primary and secondary symptomatic patency and secondary limb salvage rates were 52, 69 and 95%, respectively. DISCUSSION PTA is safe, requires a short hospital stay, and is clinically effective in the majority of very elderly patients with CLI. Although minimally invasive, the relatively high peri-procedural mortality rate and low 24-month survival rate reflect the high co-morbidity of this group of patients.
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Affiliation(s)
- C A Salas
- Department of Surgery, University of Leicester, Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX, UK
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Rielo-Arias F, Segura-Iglesias R, Caeiro S, Hernández-Lahoz Ortiz I, Gallegos M. Cirugía infragenicular en pacientes ancianos: el valor de la edad. ANGIOLOGIA 2004. [DOI: 10.1016/s0003-3170(04)74907-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Raffetto JD, Chen MN, LaMorte WW, Seidman CS, Eberhardt RT, Woodson J, Gibbons GW, Menzoian JO. Factors that predict site of outflow target artery anastomosis in infrainguinal revascularization. J Vasc Surg 2002; 35:1093-9. [PMID: 12042719 DOI: 10.1067/mva.2002.124375] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Lower extremity revascularization is indicated for limb salvage and incapacitating leg claudication. Many risk factors (age, hypertension, diabetes, tobacco use, dyslipidemia, etc) have been associated with atherosclerosis and the development of peripheral arterial occlusive disease. However, whether these risk factors or the surgical indication (claudication or limb salvage) influences the extent and location of infrainguinal disease and hence the target artery (distal anastomosis) is unclear. This study examines the risk factors and indication for infrainguinal revascularization with respect to the type of bypass performed. METHODS Three hundred fifty-two infrainguinal revascularizations in 282 patients were retrospectively reviewed. Patient data, including demographics, cardiovascular risk factors, indications, types of revascularization, and perioperative complications and mortality, were collected. Data were analyzed with t test, chi(2) test, Fisher exact test, and multiple logistic regression. RESULTS The indication for surgical revascularization was claudication in 70 patients and limb salvage in 282. The likelihood of a popliteal anastomosis (above or below knee) versus a tibial or pedal anastomosis was decreased with increasing age (P =.002) and diabetes (P =.0001), and smoking increased the likelihood (P =.056). However, popliteal bypass also was strongly associated with claudication as the surgical indication (odds ratio [OR], 8.7; P =.0001), and 90% of the claudicant group had undergone popliteal anastomosis. Claudication and popliteal anastomosis were both linked to smoking; 97% of subjects who underwent operation for claudication were smokers compared with 75% of subjects who underwent tibial or pedal anastomosis for limb salvage (P =.001). After adjustment for indication, the likelihood of popliteal anastomosis was still decreased with diabetes (OR, 0.46; P =.002), and age had a borderline significant effect (P =.077). When the analysis was stratified by indication for surgery, the likelihood of popliteal bypass among patients who underwent operation for claudication was not influenced by age, diabetes, or smoking. However, within the subset of patients who underwent operation for limb salvage, the likelihood of any popliteal anastomosis was diminished by diabetes (OR, 0.50; P =.007), age (OR, 0.968 per year; P =.01), and chronic renal insufficiency (OR, 0.476; P =.04). CONCLUSION Infrainguinal peripheral arterial occlusive disease is not a homogenous disease entity. Claudication and limb salvage are associated with two distinct patterns of vascular disease with different risk factors. Patients who undergo operation for claudication are seen at an earlier age, have a high prevalence of smoking, and have proximal disease and a greater likelihood of a popliteal anastomosis. In contrast, patients for limb salvage are less likely to have a popliteal bypass, favoring a more distal target outflow anastomosis that is strongly influenced by advanced age, diabetes, and chronic renal insufficiency.
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Affiliation(s)
- Joseph D Raffetto
- Department of Surgery, Section of Vascular Surgery D506, Boston University Medical Center, One Boston Medical Center Place, Boston, MA 02118-2393, USA.
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Affiliation(s)
- G Patrick Clagett
- Division of Vascular Surgery, University of Texas Southwestern Medical Center, Dallas 75390-9157, USA
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