Lower extremity arterial interventions in England

External validity of randomized clinical trials in vascular surgery: systematic review of demographic factors of patients recruited to randomized clinical trials with comparison to the National Vascular Registry

BACKGROUND

Evidence-based medicine relies on randomized clinical trials, which should represent the patients encountered in clinical practice. Characteristics of patients recruited to randomized clinical trials involving vascular index operations (carotid endarterectomy, abdominal aortic aneurysm repair, infrainguinal bypass and major lower limb amputations) were compared with those recorded in the National Vascular Registry across England and Wales.

METHODS

MEDLINE, Embase, Web of Science, CENTRAL, clinicaltrials.gov and World Health Organization International Trials Registry Platform (CRD42021247905) were searched for randomized clinical trials involving the index operations. Demographic (age, sex, ethnicity) and clinical (co-morbidities, medications, body mass index, smoking, alcohol, cognition) data were extracted, by operation. Characteristics of operated on patients were extracted from publicly available National Vascular Registry reports (2014-2020). All findings are reported according to PRISMA guidelines. Rayyan.AI, Excel and GraphPad Prism were used for screening and analysis.

RESULTS

A total of 307 randomized clinical trials (66 449 patients) were included and compared with National Vascular Registry data for 119 019 patients. Randomized clinical trial patients were younger across all operations; for carotid endarterectomy, bypass and major lower limb amputation randomized clinical trials, there were differences in female patient representation. Further comparisons were limited by the insufficient baseline data reporting across randomized clinical trials, though reporting improved over decades. National Vascular Registry reports lacked information on patient factors such as patient ethnicity or body mass index.

CONCLUSIONS

There are significant differences in demographic and clinical factors between patients recruited to vascular surgery randomized clinical trials and the real-world National Vascular Registry vascular surgery patient population. Minimum reporting standards for baseline data should be defined to allow future randomized clinical trials to represent real-world patient populations and ensure the external validity of their results.

Safety and procedural success of daycase-based endovascular procedures in lower extremity arteries of patients with peripheral artery disease: a systematic review and meta-analysis

Background

Timely and economic provision of revascularisation procedures is a major healthcare need. We aimed to examine the safety and efficacy of daycase-based lower extremity endovascular revascularisation procedures in patients with peripheral artery disease.

Methods

In this systematic review and meta-analysis, we searched MEDLINE and Embase for studies from Jan 01, 2000 through Apr 01, 2024 reporting complications of lower limb endovascular revascularisation procedures with same-day discharge. Eligibility-criteria, complications, and patient characteristics were extracted, methodological quality assessed (adapted Newcastle-Ottawa Scale), and meta-analyses of complications and technical success performed to provide pooled estimates. This study is registered with PROSPERO, CRD42022316466.

Findings

Thirty observational studies (17 retrospective, 13 prospective) and 1 RCT reported 2427 minor and 653 major complications after 99,600 daycase procedures (93,344 patients). Eighteen studies reported daycase eligibility-criteria including 'responsible adult companion' (78%), 'proximity to hospital', and 'telephone availability' and excluding unstable and severe co-morbidities, offset coagulation, and severe chronic kidney disease. Pooled incidences of minor (4.7% [95% CI 3.8-5.6%], I 2 = 96%) and major (0.64% [95% CI 0.48-0.79%], I 2  = 46%) complications were low and technical success high (93% [95% CI 91-96%], I 2 = 97%). Most complications were related to the puncture site. Pooled conversion-to-hospitalisation rates and re-admission after discharge were 1.6% (95% CI 1.1-2.2%, I 2 = 82%) and 0.11% (95% CI 0.095-0.23%, I 2 = 97%), respectively. Meta-regression identified that minor complications decreased since 2000. Male sex and coronary artery disease were associated with more frequent, and higher age and closure device use with less minor complications. Diabetes mellitus and chronic kidney disease were associated with less major complications. Six studies reported complication rates both in daycases and inpatients and there was no significant difference (-0.8% [95% CI -1.9 to 0.3%]).

Interpretation

After careful evaluation of eligibility, lower limb angioplasty can be performed safely with high technical success in a daycase setting. Most complications arise from the puncture site and not the procedure itself highlighting the importance of optimal access site management. The heterogeneity between studies warrants standardised monitoring of complications and outcomes.

Funding

European Partnership on Metrology, co-financed from European Union's Horizon Europe Research and Innovation Programme and UK Research and Innovation, and Medical Research Council.

Understanding variations in reported epidemiology of major lower extremity amputation in the UK: a systematic review

OBJECTIVE

Estimate the prevalence/incidence/number of major lower extremity amputations (MLEAs) in the UK; identify sources of routinely collected electronic health data used; assess time trends and regional variation; and identify reasons for variation in reported incidence/prevalence of MLEA.

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

Medline, Embase, EMcare, CINAHL, The Cochrane Library, AMED, Scopus and grey literature sources searched from 1 January 2009 to 1 August 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Reports that provided population-based statistics, used routinely collected electronic health data, gave a measure of MLEA in adults in the general population or those with diabetes in the UK or constituent countries were included.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment using the Joanna Briggs Institute Critical Appraisal Instruments were performed by two reviewers independently. Due to considerable differences in study populations and methodology, data pooling was not possible; data were tabulated and narratively synthesised, and study differences were discussed.

RESULTS

Twenty-seven reports were included. Incidence proportion for the general population ranged from 8.2 to 51.1 per 100 000 and from 70 to 291 per 100 000 for the population with diabetes. Evidence for trends over time was mixed, but there was no evidence of increasing incidence. Reports consistently found regional variation in England with incidence higher in the north. No studies reported prevalence. Differences in database use, MLEA definition, calculation methods and multiple procedure inclusion which, together with identified inaccuracies, may account for the variation in incidence.

CONCLUSIONS

UK incidence and trends in MLEA remain unclear; estimates vary widely due to differences in methodology and inaccuracies. Reasons for regional variation also remain unexplained and prevalence uninvestigated. International consensus on the definition of MLEA and medical code list is needed. Future research should recommend standards for the reporting of such outcomes and investigate further the potential to use primary care data in MLEA epidemiology.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020165592.