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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. Cardiovasc Revasc Med 2024:S1553-8389(24)00019-8. [PMID: 38350775 DOI: 10.1016/j.carrev.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [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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Discalzi A, Maglia C, Nardelli F, Mancini A, Rossato D, Muratore P, Gibello L, Gobbi F, Calandri M. Endovascular revascularization of critical limb ischemia: the role of ultrasound-guided popliteal sciatic nerve block for the procedural pain management. Eur Radiol 2024; 34:287-293. [PMID: 37515633 DOI: 10.1007/s00330-023-09988-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/07/2023] [Accepted: 06/06/2023] [Indexed: 07/31/2023]
Abstract
OBJECTIVES To evaluate the impact of the ultrasound-guided popliteal sciatic nerve block (PSNB) for pain management during endovascular treatment of chronic limb-threatening ischemia (CLTI). MATERIAL AND METHODS From November 2020 to January 2022, 111 CLTI patients that underwent endovascular procedures were prospectively enrolled in this prospective single-arm interventional study. Ultrasound-guided PSNB was used for procedural pain control. Pain intensity was evaluated throughout the procedure (baseline, 10 min after the block, pain peak, and at the end of the procedure) with the visual analog scale (VAS). RESULTS Forty-six patients underwent above-the-knee revascularization (ATK), 20/111 below-the-knee (BTK) revascularization, 20/111 to both ATK and BTK revascularization. In 25 cases, no endovascular option was feasible at diagnostic angiography. The PSNB was effective in 96% of patients, with no need for further pain management with a statistically significant reduction (p < 0.0001) in the mean value of the VAS from 7.86 ± 1.81 (pre-procedural) to 2.04 ± 2.20 after 10 min from the block and up to 0.74 ± 1.43 at the end of the procedure (mean time 43 min). Only 1 complication related to the popliteal sciatic nerve block was registered (a temporary foot drop, completely resolved within 48 h). The time necessary to perform the block ranged between 4 and 10 min. CONCLUSION Ultrasound-guided PSNB is a feasible and effective method to manage patients with rest pain and increase comfort and compliance during endovascular procedures. CLINICAL RELEVANCE STATEMENT An ultrasound-guided popliteal sciatic nerve block is a safe, feasible, and effective technique to manage pain during endovascular treatment of chronic limb-threatening ischemia, especially in frail patients with multiple comorbidities who are poor candidates for deep sedoanalgesia or general anesthesia. KEY POINTS Endovascular treatment of CTLI may require long revascularization sessions in patients with high levels of pain at rest, which could be exacerbated during the revascularization procedure. The PSNB is routinely used for anesthesia and analgesia during foot and ankle surgery, but the experience with lower limb revascularization procedures is very limited and not included in any international guideline. Ultrasound-guided PSNB is a feasible and effective regional anesthesia technique to relieve procedural and resting pain. Because of its safety and availability, every interventional radiologist should know how to perform this type of loco-regional anesthesia.
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Affiliation(s)
- Andrea Discalzi
- Department of Surgical Sciences, Radiology Unit, University of Torino, Via Genova 3, 10126, Turin, Italy
| | - Claudio Maglia
- Department of Surgical Sciences, Radiology Unit, University of Torino, Via Genova 3, 10126, Turin, Italy
| | - Floriana Nardelli
- Department of Surgical Sciences, Radiology Unit, University of Torino, Via Genova 3, 10126, Turin, Italy.
| | - Andrea Mancini
- Department of Surgical Sciences, Radiology Unit, University of Torino, Via Genova 3, 10126, Turin, Italy
| | - Denis Rossato
- Department of Surgical Sciences, Radiology Unit, University of Torino, Via Genova 3, 10126, Turin, Italy
| | - Pierluigi Muratore
- Department of Surgical Sciences, Radiology Unit, University of Torino, Via Genova 3, 10126, Turin, Italy
| | - Lorenzo Gibello
- Department of Surgical Sciences, Division of Vascular Surgery, University of Torino, Turin, Italy
| | - Fabio Gobbi
- Department of Anesthesiology, Ospedale Humanitas Gradenigo, Turin, Italy
| | - Marco Calandri
- Department of Surgical Sciences, Radiology Unit, University of Torino, Via Genova 3, 10126, Turin, Italy
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer. J Vasc Surg 2023; 78:1101-1131. [PMID: 37724985 DOI: 10.1016/j.jvs.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot Ulcer. Eur J Vasc Endovasc Surg 2023:S1078-5884(23)00586-5. [PMID: 37724984 DOI: 10.1016/j.ejvs.2023.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
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Ba K, Sow MA, Magne J, Salle L, Lacroix P, Chastaingt L, Aboyans V. Risk of amputation under diuretics in patients with or at risk of lower extremity arterial disease: A systematic review and meta-analysis. Arch Cardiovasc Dis 2023; 116:357-363. [PMID: 37150644 DOI: 10.1016/j.acvd.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/02/2023] [Accepted: 04/04/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Recently, increased risk of amputation under sodium glucose cotransporter-2 inhibitors has been debated. Similar concerns have been raised with other "traditional" diuretics, more particularly in patients with or at risk of lower extremity arterial disease (LEAD). AIM To collect all available data on any potential risk of amputation associated with diuretics in patients with or at risk of LEAD. Additionally, we looked for other limb-related events in these patients. METHODS We searched in PubMed, Embase and Scopus databases up to February 2021 for references, using peripheral or lower extremity arterial disease, diuretics and amputation keywords, excluding case reports, experimental animal studies and non-English reports. RESULTS Among the 1376 hits identified in the databases, six studies were finally included in this review, including one cross-sectional and five longitudinal studies (total of 47,612 participants). One study was limited to thiazide diuretics, one focused on loop diuretics and the remainder mixed all diuretics. All studies reported a significant association between diuretic use and amputation risk in patients with or at high risk of LEAD. Despite some limitations in several studies, the meta-analysis showed an increased risk of amputation associated with diuretics (odds ratio: 1.75, 95% confidence interval: 1.53-1.99; P<0.001). Beyond amputation, patients with or at risk of LEAD under diuretics appeared to be at increased risk of other lower limb events, mostly in the presence of other comorbidities, including diabetes. CONCLUSIONS Although the amount of data in the literature is scarce, this first systematic review and meta-analysis favours an increased risk of amputation in patients with or at risk of LEAD under diuretics. Further prospective studies must be conducted to provide a better understanding of the mechanisms. Meanwhile, the use of diuretics in these patients should be parsimonious, considering alternatives whenever possible.
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Affiliation(s)
- Khadija Ba
- EpiMaCT, Inserm 1094, IRD, Limoges University Hospital, 87025 Limoges, France
| | - Mamadou Adama Sow
- EpiMaCT, Inserm 1094, IRD, Limoges University Hospital, 87025 Limoges, France
| | - Julien Magne
- EpiMaCT, Inserm 1094, IRD, Limoges University Hospital, 87025 Limoges, France; Department of Cardiology, Dupuytren University Hospital, 87025 Limoges, France
| | - Laurence Salle
- EpiMaCT, Inserm 1094, IRD, Limoges University Hospital, 87025 Limoges, France; Department of Endocrinology, Diabetology and Metabolism, Dupuytren University Hospital, 87025 Limoges, France
| | - Philippe Lacroix
- EpiMaCT, Inserm 1094, IRD, Limoges University Hospital, 87025 Limoges, France; Department of Vascular Surgery and Medicine, Dupuytren University Hospital, 87025 Limoges, France
| | - Lucie Chastaingt
- EpiMaCT, Inserm 1094, IRD, Limoges University Hospital, 87025 Limoges, France; Department of Vascular Surgery and Medicine, Dupuytren University Hospital, 87025 Limoges, France
| | - Victor Aboyans
- EpiMaCT, Inserm 1094, IRD, Limoges University Hospital, 87025 Limoges, France; Department of Cardiology, Dupuytren University Hospital, 87025 Limoges, France.
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Gandini R, Semeraro V, Salimei F. Foot Dorsal and Plantar Flexion to Enhance Crossing of Tortuous Highly-Calcific Ankle Vessels During Lower Limb Revascularization Procedures: A Technical Note. Cardiovasc Intervent Radiol 2023:10.1007/s00270-023-03436-8. [PMID: 37039865 DOI: 10.1007/s00270-023-03436-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/28/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE To describe a crossing technique of stenotic/occluded and tortuous highly calcific ankle vessels during complex percutaneous limb salvage intervention in diabetic patients with ischaemic foot ulcers (Rutherford 5 and 6). TECHNIQUE We propose a simple technique to achieve "straightening" of the tortuous vessel and allow safe devices passage into the foot arteries, Patients were asked to hold their foot in plantar or dorsal flexion, accordingly to the treated artery. If unable to do so, an equipe member executed the manoeuvre on their behalf. RESULTS The technique was applied in 148 cases, with a success rate of 81% (120/148). No complications related to the manoeuvre were observed. CONCLUSION Crossing of tortuous distal crural vessels can be challenging in diabetic patients; in our experience, this technique can be a useful tool to obtain a successful recanalization in complex procedures with high risk of failure.
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Affiliation(s)
- Roberto Gandini
- Department of Interventional Radiology, University Hospital "Tor Vergata", Viale Oxford, 81, 00133, Rome, Italy
| | - Vittorio Semeraro
- Department of Interventional Radiology, Santissima Annunziata Hospital, Taranto, Italy
| | - Fabio Salimei
- Department of Interventional Radiology, University Hospital "Tor Vergata", Viale Oxford, 81, 00133, Rome, Italy.
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Shan LL, Yang LS, Tew M, Westcott MJ, Spelman TD, Choong PF, Davies AH. Quality of Life in Chronic Limb Threatening Ischaemia: Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2022; 64:666-683. [PMID: 35952907 DOI: 10.1016/j.ejvs.2022.07.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 07/12/2022] [Accepted: 07/22/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To assess the comparative effectiveness and temporal changes in quality of life (QoL) outcomes after revascularisation, major lower extremity amputation (MLEA), and conservative management (CM) in chronic limb threatening ischaemia (CLTI). DATA SOURCES MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science. REVIEW METHODS A systematic review and meta-analysis were performed on QoL measured by any QoL instrument in adult patients with CLTI after open surgery (OS), endovascular intervention (EVI), MLEA, or CM. Randomised controlled trials and prospective observational studies published in any language between 1 January 1990 and 21 May 2021 were included. There was a pre-specified measurement time point of six months. Random effects meta-analysis was conducted on total scores for each QoL instrument. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach (PROSPERO registration: CRD42021253953). RESULTS Fifty-five studies with 8 909 patients were included. There was significant heterogeneity in the methods used to measure QoL, and the study characteristics. In particular, 14 different QoL instruments were used with various combinations of disease specific and generic instruments within each study. A narrative summary is therefore presented. Comparative effectiveness data showed there was reasonable certainty that QoL was similar between OS and EVI at six months. Temporal outcomes suggested small to moderate improvements in QOL six months after OS and EVI compared with baseline. Limited data indicated that QoL can be maintained or slightly improved after MLEA or CM. Treatment effects were overestimated owing to small study effects, selective non-reporting, attrition, and survivorship bias. CONCLUSION QoL after OS and EVI appears to be similar. Revascularisation may provide modest QoL benefits, while MLEA or CM can maintain QoL. However, certainty of evidence is generally low or very low, and interpretation is hampered by significant heterogeneity. There is a need for a CLTI specific QoL instrument and methodological standardisation in QoL studies.
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Affiliation(s)
- Leonard L Shan
- Department of Surgery, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia.
| | - Linda S Yang
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Michelle Tew
- Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Mark J Westcott
- Department of Surgery, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Tim D Spelman
- Department of Surgery, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Peter F Choong
- Department of Surgery, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Alun H Davies
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
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Liu P, Zheng LH, He XQ, Yang Y, Zhang LK, Zhang L, Zhang F. Mid-Term Outcomes of Endovascular Therapy for TASC II D Femoropopliteal Lesions with Critical Limb Ischaemia: A Retrospective Analysis. Ann Vasc Surg 2022; 88:182-190. [PMID: 36007776 DOI: 10.1016/j.avsg.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/17/2022] [Accepted: 08/07/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study evaluated the mid-term results of endovascular therapy (EVT) for Trans-Atlantic Inter-Society (TASC) II D femoropopliteal lesions in patients with critical limb ischaemia (CLI). METHODS Fifty-seven limbs of 54 patients with CLI due to TASC II D femoropopliteal lesions who underwent EVT at the First Hospital of Hebei Medical University were retrospectively analysed in single-centre, observational study. The patient characteristics, endovascular procedural details, freedom from target lesion revascularisation (TLR), patency rates, ulcer healing rate, and limb salvage rate were accessed. RESULTS The patients' mean age was 68.2 ± 8.2 years. All patients were treated by EVT. The final technical success rate was 98.2% (56/57). There were 23 cases of pain at rest, 18 cases of ulcer, and 15 cases of gangrene. The median length of the treated segment was 286 ± 42 mm (56/56) and the mean number of stents placed per patient was 2.0 ± 0.8 (49/56). The postoperative ankle-brachial index (ABI) was significantly higher than that of the preoperative ABI (P < 0.05). The perioperative complication rate was 10.7% (6/56). The re-stenosis or occlusion rate was 44.6% (25/56). The estimated rates of freedom from TLR at 1 year, 2 years, and 3 years were 86.8%, 67.0%, and 62.5%, respectively. Univariate analysis showed that predictors of freedom from TLR were the number of runoff vessels, length of the lesion, and complexity of the lesion, while predictors for re-stenosis or occlusion were the length and the complexity of the lesion. The ulcer healing rate was 93.8%. The limb salvage rates were 76.4%, 74.4%, and 70.9% at 1, 2, and 3 years after treatment, respectively. CONCLUSIONS The mid-term outcomes of EVT for TASC II D femoropopliteal lesions in patients with CLI indicated that this treatment approach is safe and effective, and is clinically applicable.
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Affiliation(s)
- Peng Liu
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Li-Hua Zheng
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Xin-Qi He
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Yan Yang
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Li-Ke Zhang
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Lei Zhang
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Feng Zhang
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China.
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Mantilla Ibañez ML, Sánchez Bardales F, Zavaleta Corvera C, Caballero Alvarado J, Pozzuoli G, Muente Alva LS. ERICVA Risk Scale simplified as a predictor of amputation in critical limb ischemia. J Med Vasc 2022; 47:116-124. [PMID: 36055680 DOI: 10.1016/j.jdmv.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/17/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Demonstrate that simplified ERICVA (Valladolid Critical Limb Ischaemia Risk Scale) is useful in predicting amputation in chronic limb-threatening ischemia (CLI) after one year of revascularization. METHODS A retrospective cohort study was performed. We analyzed the medical records of 93 patients over the age of 35 with the diagnosis of CLI who were treated in the Department of Internal Medicine, Orthopedics or in the Cardiovascular Surgery Unit of the Víctor Lazarte Echegaray Hospital and the High Complexity Virgen de La Puerta Hospital during the period 2015-2018. The simplified ERICVA score was determined in patients before surgical and endovascular revascularization. We included 31 patients who scored 2 or more points in the exposed group and 62 patients who scored less than 2 points in the group not exposed to amputation risk. The collected data was analyzed with the statistical program SPSS where the Relative Risk and significance was obtained with Pearson's Chi-square. The multivariate analysis was also carried out in order to obtain the adjusted relative risk. RESULTS It was identified that the simplified ERICVA score greater than or equal to 2 points was more frequent in those who underwent amputation (90.3%) compared to patients who did not undergo amputation (4.8%), increasing the risk of amputation in those patients with CLI who underwent revascularization (RR: 18.67, P<0.001). It was also possible to identify that within the group of patients that showed a high risk of amputation according to the ERICVA scale, they had a higher risk of major amputation (RR: 9.32, P<0.001) as opposed to the risk of minor amputation (RR: 1, 89, P=0.193). Among the items of the simplified ERICVA scale, the preoperative neutrophil-lymphocyte ratio and hematocrit were significantly higher in the group of amputated patients (P<0.001). In addition, it was possible to identify that the score greater than or equal to 2 was independently associated with the risk of amputation in patients revascularized with CLI (RR: 13.5, P<0.001). CONCLUSION In our patient population, the simplified ERICVA scale is useful in predicting major and minor amputation in critical limb ischemia after revascularization. The present data showed that the patients who had a simplified ERICVA score greater than or equal to 2 had a higher risk of major amputation compared to the risk of minor amputation. However, it is important to highlight that the impact on the prediction of minor amputation is greater because in some circumstances major amputation can appear as a complication of CLI.
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Affiliation(s)
| | - Fernando Sánchez Bardales
- School of Medicine, Antenor Orrego Private University, Trujillo 13007, Peru; Surgery Department, Alta Complejidad Virgen de la Puerta Hospital, Essalud, Trujillo 13007, Peru
| | | | | | - Gabriela Pozzuoli
- La Libertad Healthcare Assistance Network, Essalud, Trujillo 13007, Peru
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Math N, Hegazi S, Richards T, Kommu S, Senaratne J. A novel innovative technique in the management of bilateral critical limb ischaemia: delayed saphenous vein autologous graft. Ann R Coll Surg Engl 2022; 104:e177-e179. [PMID: 35138964 PMCID: PMC9158042 DOI: 10.1308/rcsann.2021.0248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A 31-year-old man with primary oxalosis and resultant polyneuropathy presented with worsening leg pain. He was found to have bilateral superficial femoral artery dissections with a non-viable left leg and critically ischaemic right leg. He underwent emergency left above-knee amputation with harvesting of the full-length ipsilateral great saphenous vein (GSV). In a novel technique, the vein was stored for 10 days before being used as conduit in a femoral-popliteal bypass in the contralateral leg. The success of the delayed GSV autograft means the salvage of clinically viable veins in non-viable limbs should be considered when patients present with bilateral acute or critically ischaemic limbs.
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Affiliation(s)
- N Math
- East Kent Hospitals University NHS Foundation Trust, UK
| | - S Hegazi
- East Kent Hospitals University NHS Foundation Trust, UK
| | - T Richards
- East Kent Hospitals University NHS Foundation Trust, UK
| | - S Kommu
- East Kent Hospitals University NHS Foundation Trust, UK
| | - J Senaratne
- East Kent Hospitals University NHS Foundation Trust, UK
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11
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Liu H, Liu Y, Pan T, Fang Y, Fang G, Jiang X, Chen B, Wei Z, Gu S, Liu P, Fu W, Dong Z. Return to work after cell transplantation in patients with angiitis-induced critical limb ischaemia and factors related: a single-centre retrospective cohort study. Stem Cell Res Ther 2022; 13:139. [PMID: 35365238 PMCID: PMC8972707 DOI: 10.1186/s13287-022-02807-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background Angiitis-induced critical limb ischaemia (AICLI) patients, who are usually young and have a high amputation rate, always lose their ability to return to the labour force. Return to work (RTW) not only indicates patients’ physical health, showing that they could undertake the work, but also demonstrates their psychological well-being. While cell transplantation showed satisfactory efficacy in limb salvage, few studies of AICLI patients’ RTW after transplantation have been reported. Methods From May 2009 to May 2021, AICLI patients who underwent cell transplantation and completed no less than 12 months of follow-up were retrospectively enrolled. The primary endpoint was RTW. Patient demographics and characteristics of the ischaemic limbs were reviewed to analyse independent risk factors for RTW. Results A total of 171 AICLI patients (170 males) were enrolled with a mean age of 41.9 ± 9.6 years (range: 20–57 years). The 12-month and 24-month RTW cumulative rates were 69.4% (95% confidence interval [CI] 61.6–75.6%) and 70.1% (95% CI 62.3–76.2%), respectively. Age < 40 years (odds ratio [OR] 2.659, 95% CI 1.138–6.719) and preoperative occupation as a mental worker (OR 8.930, 95% CI 2.665–42.847) were identified as independent protective factors for RTW. Perioperative limb infection with ulcer or gangrene (OR 0.250, 95% CI 0.075–0.779) was identified as an independent risk factor. Conclusion AICLI patients who underwent cell transplantation usually had a satisfactory midterm RTW cumulative rate. AICLI patients < 40 years old with preoperative occupation as mental workers were more likely to return to work. Prevention of limb infection during the perioperative period is of great significance to RTW.
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Affiliation(s)
- Hao Liu
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Yifan Liu
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Tianyue Pan
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Yuan Fang
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Gang Fang
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Xiaolang Jiang
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Bin Chen
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Zheng Wei
- Department of Hematology of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China
| | - Shiyang Gu
- Department of Hematology of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China
| | - Peng Liu
- Department of Hematology of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Zhihui Dong
- Department of Vascular Surgery of Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
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Lin DS, Lo HY, Yu AL, Lee JK, Yang WS, Hwang JJ. A Dose Response Association Between Body Mass Index and Mortality in Patients with Peripheral Artery Disease: A Meta-analysis Including 5 729 272 Individuals. Eur J Vasc Endovasc Surg 2022:S1078-5884(21)00903-5. [PMID: 35027277 DOI: 10.1016/j.ejvs.2021.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 11/01/2021] [Accepted: 11/14/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Obesity is a significant risk factor for atherosclerotic cardiovascular disease; however, the "obesity paradox", in which obese patients enjoy superior survival, has been observed in various cardiovascular conditions. Whether this phenomenon exists for peripheral artery disease (PAD) remains uncertain. The goal of this study was to evaluate the relationship between body mass index (BMI) and mortality in patients with PAD. METHODS A comprehensive literature search identified seven eligible cohort studies that reported the association between BMI and all cause mortality in patients with PAD. A dose response meta-analysis was done for all cause mortality, short term (30 day or in hospital) mortality and long term mortality. The dose response association between BMI and mortality was also assessed in patients who received endovascular therapy (EVT). RESULTS The non-linear dose response analysis showed that higher BMI values were associated with a lower mortality risk from the range between 15 kg/m2 to approximately 33 - 34 kg/m2. The risk of mortality increased slightly thereafter. This relationship was consistent with that of long term mortality but was not apparent in short term mortality. A U shaped relationship was also observed between BMI and mortality in patients who received EVT with the lowest mortality observed at around 30 kg/m2. CONCLUSION The obesity paradox was evident in the analysis of long term survival among patients with PAD, with the lowest mortality rates observed in obese patients. However, this association was not observed for short term or in hospital mortality.
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Gunnarsson T, Lindgren H, Gottsäter A, Pärsson H. Intraprocedural Transcutaneous Oxygen Pressure and Systolic Toe Pressure Measurements During and After Endovascular Intervention in Patients with Chronic Limb Threatening Ischaemia. Eur J Vasc Endovasc Surg 2021; 62:583-589. [PMID: 34334314 DOI: 10.1016/j.ejvs.2021.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/27/2021] [Accepted: 06/06/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate changes in transcutaneous oxygen pressure (tcpO2) and systolic toe pressure (TP) during endovascular intervention. METHODS This was a single centre prospective, non-randomised, observational feasibility study. Patients with chronic limb threatening ischaemia (CLTI) due to infrainguinal disease scheduled for endovascular treatment were included between March 2018 and December 2019. TcpO2 was measured continuously bilaterally at foot level throughout the procedure and at follow up. Specific time points during the intervention were chosen for comparison to baseline (before arterial puncture): average tcpO2 level five minutes prior to percutaneous transluminal angioplasty (PTA); 10 minutes after PTA; and at completion. Bilateral TP was recorded using laser Doppler flowmetry before arterial puncture, at completion, and at clinical follow up. Angiograms were analysed for successful revascularisation and vascular lesions classified according to the Global Limb Anatomical Scoring System (GLASS). Rutherford and WIfI (Wound, Ischaemia, and foot Infection) classifications were registered, as well as clinical outcome. RESULTS Twenty-one patients completed the study. Completion angiograms showed inline flow to the foot in all but two patients. Median time to follow up was 10 weeks (range 8 - 13 weeks) and all patients except one improved clinically. TcpO2 decreased during the initial stage of the intervention, from before arterial puncture to five minute average before PTA (p < .001) and did not recover to above baseline values at the end of intervention. TcpO2 increased significantly at follow up (p < .001). TP increased statistically significantly during intervention (p < .001) and at follow up (p < .001) compared with baseline. CONCLUSION TcpO2 and TP measurements are safe and feasible non-invasive techniques for haemodynamic monitoring during endovascular revascularisation. TP increased significantly immediately after completion of the successful intervention, whereas tcpO2 did not. Both TP and tcpO2 demonstrated a significant increase at the 10 week follow up.
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Affiliation(s)
- Thordur Gunnarsson
- Faculty of Medicine, Lund University, Lund, Sweden; Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden.
| | - Hans Lindgren
- Faculty of Medicine, Lund University, Lund, Sweden; Department of Surgery, Helsingborg Hospital, Helsingborg, Sweden
| | - Anders Gottsäter
- Faculty of Medicine, Lund University, Lund, Sweden; Department of Vascular Diseases, Skåne University Hospital, Malmö, Sweden
| | - Håkan Pärsson
- Department of Biomedical and Clinical Sciences, Medical Faculty, Linköping University, Linköping, Sweden
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14
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Giusca S, Lichtenberg M, Eisenbach C, Korosoglou G. Clinical safety of low-dose anticoagulation with fondaparinux in patients undergoing peripheral endovascular treatment due to critical limb-threatening ischaemia - a pilot study. Acta Cardiol 2021; 76:365-372. [PMID: 32167029 DOI: 10.1080/00015385.2020.1737782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AIMS To evaluate the safety and effectiveness of fondaparinux in addition to dual antiplatelet therapy (DAPT) in patients with critical limb-threatening ischaemia (CLTI). METHODS Fondaparinux (2.5 mg/d) was administered for 1-4 weeks after endovascular procedures together with DAPT (fondaparinux arm). Patients who received standard DAPT were retrospectively matched and generated the control arm. Demographic, angiographic and follow-up data, including (i) clinically relevant bleeding and (ii) target vessel revascularisation or major amputation after 12 months was analysed. RESULTS Twenty-four patients (78.7 ± 6.9 years, 14 [58%] female, 4 TASC B, 10 TASC C and 10 TASC D lesions, total lesion length = 210 ± 98 mm, mean Rutherford class = 4.7 ± 0.6) received fondaparinux (over a period of 22 ± 9 d, range 7-28 d) and DAPT versus 24 control patients who received standard DAPT (78.3 ± 8.4 years, 14 [58%] female, 4 TASC B, 8 TASC C and 12 TASC D lesions, total lesion length = 204 ± 73 mm, mean Rutherford class = 4.6 ± 0.6). During follow-up, 3(13%) patients in the fondaparinux arm exhibited significant bleeding versus 5 (21%) in the control arm (p = ns). Four (17%) patients of the fondaparinux arm underwent target vessel revascularisation or major amputation versus 6 (25%) in the control group (p = ns). CONCLUSIONS Adding fondaparinux to DAPT does not seem to result in excess of clinically relevant bleeding. Our preliminary data suggest that prospective studies are now warranted in larger patient cohorts. GERMAN CLINICAL TRIALS REGISTER DRKS00015856.
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Affiliation(s)
- Sorin Giusca
- Department of Cardiology, Vascular Medicine, Pneumology, Gastroenterology and Diabetology, GRN Hospital Weinheim, Weinheim, Germany
| | | | - Christoph Eisenbach
- Department of Cardiology, Vascular Medicine, Pneumology, Gastroenterology and Diabetology, GRN Hospital Weinheim, Weinheim, Germany
| | - Grigorios Korosoglou
- Department of Cardiology, Vascular Medicine, Pneumology, Gastroenterology and Diabetology, GRN Hospital Weinheim, Weinheim, Germany
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Houghton JS, Nickinson AT, Helm JR, Dimitrova J, Dubkova S, Rayt HS, Gray LJ, Haunton VJ, Davies RS, Sayers RD. Associations of Clinical Frailty with Severity of Limb Threat and Outcomes in Chronic Limb-threatening Ischaemia. Ann Vasc Surg 2021; 76:406-416. [PMID: 33951523 DOI: 10.1016/j.avsg.2021.04.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/25/2021] [Accepted: 04/03/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Investigate the relationship of frailty and severity of chronic limb-threatening ischaemia (CLTI), and their comparative associations with one-year outcomes, in patients presenting to a vascular limb salvage (VaLS) clinic. METHODS This retrospective cohort study utilised data collected from a prospectively maintained VaLS clinic database. Patients aged ≥50 presenting to the VaLS clinic with CLTI between February 2018 and April 2019 were included. Frailty was measured using the Clinical Frailty Scale (CFS) and limb threat severity by the Wound, Ischaemia, and foot Infection (WIfI) score. Excessive polypharmacy was defined as ≥10 medications. Anticholinergic burden (ACB) score and Charlson comorbidity index (CCI) were calculated for all patients. The primary outcome measure was a composite endpoint of death or amputation at one-year. Associations with outcome were assessed using Cox regression and reported as hazards ratios (HR) with 95% confidence intervals (CI). RESULTS A total of 198 patients were included, with CFS scores available for 190 patients. 98 patients (52%) were frail (CFS ≥5). 127 patients (67%) initially underwent endovascular revascularisation. Excessive polypharmacy was common (55 patients; 28%). Frailty was associated with increased WIfI stage (P = 0.025) as well as age, female sex, CCI score, number of medications, excessive polypharmacy but not ACB score. Frail patients were more frequently managed non-operatively (P = 0.017). Frailty (HR 1.91; 95% CI 1.09, 3.34; P = 0.024) and WIfI stage 4 (HR 3.29; 95%CI 1.23, 8.80; P = 0.018) were associated with death or amputation on univariable analysis. WIfI stage 4 (HR 2.80; 95%CI 1.04, 7.57; P = 0.042) and CCI score (HR 1.21; 95%CI 1.03, 1.41; P = 0.015), but not frailty (HR 1.25; 95%CI 0.67, 2.33; P = 0.474), were independently associated with death or amputation on multivariable analysis. CONCLUSIONS Frailty is highly prevalent among CLTI patients and related to severity of limb threat. The CFS may be a useful adjunct to patient risk assessment in CLTI.
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Affiliation(s)
- John Sm Houghton
- Department of Cardiovascular Sciences, University of Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK; National Institute for Health Research Leicester Biomedical Research Centre - The Glenfield Hospital, Leicester, UK.
| | - Andrew To Nickinson
- Department of Cardiovascular Sciences, University of Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK; National Institute for Health Research Leicester Biomedical Research Centre - The Glenfield Hospital, Leicester, UK
| | - Jessica R Helm
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK
| | - Jivka Dimitrova
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK
| | - Svetlana Dubkova
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK
| | - Harjeet S Rayt
- Department of Cardiovascular Sciences, University of Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK
| | - Laura J Gray
- Department of Health Sciences, University of Leicester, UK
| | | | - Robert Sm Davies
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK
| | - Rob D Sayers
- Department of Cardiovascular Sciences, University of Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, UK; National Institute for Health Research Leicester Biomedical Research Centre - The Glenfield Hospital, Leicester, UK
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16
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Miller R, Ambler GK, Ramirez J, Rees J, Hinchliffe R, Twine C, Rudd S, Blazeby J, Avery K. Patient Reported Outcome Measures for Major Lower Limb Amputation Caused by Peripheral Artery Disease or Diabetes: A Systematic Review. Eur J Vasc Endovasc Surg 2020; 61:491-501. [PMID: 33388237 DOI: 10.1016/j.ejvs.2020.11.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/06/2020] [Accepted: 11/24/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Most major lower limb amputations are related to peripheral artery disease (PAD) or diabetes. Just 40% of patients who undergo major lower limb amputation will use a prosthesis yet measures of surgical success commonly focus on prosthesis use. Patient reported outcome measures (PROMs) are valuable to comprehensively evaluate health related quality of life (HRQL) after surgery. This systematic review aimed to identify and describe PROMs available to assess HRQL in patients after amputation for PAD or diabetes. METHODS A search was conducted based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) for systematic reviews of PROMs. Ovid MEDLINE, Ovid EMBASE, PsycINFO, CINAHL, and Cochrane CENTRAL were also searched from inception until August 2019. Included were articles describing the development, measurement properties, or evaluation of HRQL via a PROM in adult patients after amputation for PAD or diabetes. Studies of amputation exclusively for trauma or malignancy were excluded. Data were collected on study characteristics, PROM characteristics (generic/disease specific), and properties of amputation specific PROMs. RESULTS Of 3 317 abstracts screened, 111 full text articles were assessed for eligibility and 64 included. Fifty-six studies evaluated HRQL, with 23 (46%) of these using an amputation specific PROM to do so. Eleven different amputation specific PROMs were identified, 10 (91%) of which were developed only for prosthesis users. One measure was suitable for use in all patients after amputation. This "Amputee single item mobility measure" includes a single item evaluating mobility. Nine studies reported some psychometric testing of an amputation specific PROM. CONCLUSION A well tested, multidimensional PROM applicable to wheelchair and prosthetic users after amputation is lacking and urgently needed for studies in this field. Future work to develop an appropriate measure is required.
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Affiliation(s)
- Rachael Miller
- Centre for Surgical Research, University of Bristol, UK; North Bristol NHS Trust, Bristol, UK.
| | - Graeme K Ambler
- Centre for Surgical Research, University of Bristol, UK; North Bristol NHS Trust, Bristol, UK
| | - Jozel Ramirez
- Centre for Surgical Research, University of Bristol, UK; University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jonathan Rees
- Centre for Surgical Research, University of Bristol, UK; University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Robert Hinchliffe
- Centre for Surgical Research, University of Bristol, UK; North Bristol NHS Trust, Bristol, UK
| | | | | | - Jane Blazeby
- Centre for Surgical Research, University of Bristol, UK; University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Kerry Avery
- Centre for Surgical Research, University of Bristol, UK
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Giannopoulos S, Palena LM, Armstrong EJ. Technical Success and Complication Rates of Retrograde Arterial Access for Endovascular Therapy for Critical Limb Ischaemia: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2020; 61:270-279. [PMID: 33358346 DOI: 10.1016/j.ejvs.2020.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/26/2020] [Accepted: 11/12/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Antegrade crossing techniques via transfemoral access are often challenging and may be associated with technical and clinical failure when treating patients with critical limb ischaemia (CLI). The objective of this study was to summarise all available literature regarding retrograde endovascular treatment of patients with CLI and to investigate the technical success and complication rate of retrograde access. METHODS A systematic literature search was performed in PubMed, Scopus, and Cochrane Central until May 2020. A meta-analysis of 31 observational studies (29 retrospective and two prospective; 26 and five studies with low and moderate risk of bias, respectively) was conducted with random effects modelling. The incidence of adverse events peri-procedurally and during follow up were calculated. RESULTS The 31 studies enrolled 1 910 patients who were treated endovascularly for femoropopliteal and/or infrapopliteal lesions causing CLI. Most of the patients had diabetes while more than half of the overall population had coronary artery disease and dyslipidaemia. All lesions were located in the infra-inguinal segment and most were chronic total occlusions (96%; 95% CI 85%-100%). Seven studies reported moderate or severe calcification in approximately half of the cases (45%; 95% CI 30%-60%). The overall technical success of the retrograde approach was 96% (18 studies; 95% CI 92%-100%). Perforation, flow limiting dissection, distal embolisation, and local haematoma at the retrograde access site were infrequent and observed in 2.1%, 0.6%, 0.1%, and 1.3% of the patients, respectively. The six month primary patency rate was 78% (five studies; 95% CI 46%-99%), the six month limb salvage rate was 77% (four studies; 95% CI 70%-84%). CONCLUSION The results indicated that the retrograde or bidirectional antegrade/retrograde approach is safe and effective and facilitates angioplasty when antegrade treatment fails. However, prospective studies with standardised wound care and surveillance protocols are needed to investigate retrograde techniques in patients with CLI who failed antegrade revascularisation, to improve long term limb salvage and survival.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Centre, University of Colorado, Denver, CO, USA
| | - Luis M Palena
- Endovascular Surgery Unit, Endovascular Interventions & Research, Foot & Ankle Clinic, Maria Cecilia Hospital, Cotignola, Italy
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Centre, University of Colorado, Denver, CO, USA.
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Kodama A, Meecham L, Popplewell M, Bate G, Conte MS, Bradbury AW. Editor's Choice - Relationship Between Global Limb Anatomic Staging System (GLASS) and Clinical Outcomes Following Revascularisation for Chronic Limb Threatening Ischaemia in the Bypass Versus Angioplasty in Severe Ischaemia of the Leg (BASIL)-1 Trial. Eur J Vasc Endovasc Surg 2020; 60:687-95. [PMID: 32778491 DOI: 10.1016/j.ejvs.2020.06.042] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 05/29/2020] [Accepted: 06/26/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The Global Vascular Guideline on chronic limb threatening ischaemia (CLTI) has introduced the Global Limb Anatomic Staging System (GLASS) as a new angiographic scoring system. However, the relationship between GLASS and outcomes following revascularisation has not previously been studied. METHODS Using pre-intervention angiograms the relationship between GLASS and immediate technical failure (ITF), amputation free survival (AFS), limb salvage (LS), overall survival (OS), and freedom from major adverse limb events (FF-MALE) was examined in 377 patients undergoing endovascular therapy (EVT, n = 213) or bypass surgery (BS, n = 164) in the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL)-1 trial (randomised 1999-2004). RESULTS There was no significant difference in GLASS between cohorts. There was a significant relationship between ITF and GLASS in EVT (I 14%, II 15%, III 28%, p = .049). GLASS was significantly related to AFS (hazard ratio [HR], 1.37; 95% CI 1.01-1.85; p = .042), LS (HR 1.96; 95 % CI 1.12-3.43; p = .018), and FF-MALE (HR 1.49; 95% CI 1.04-1.87; p = .028) in the EVT cohort. In BS patients, there was no relationship between GLASS and these outcomes. FF-MALE was significantly worse after EVT than BS in GLASS II (p = .038) and III (p = .001). Among the subgroup of patients with femoropopliteal (FP) disease (BS, n = 109 or EVT, n = 159), FF-MALE was significantly higher after BS than EVT (p < .001). The superiority of BS over EVT with increasing GLASS FP grade was greater in the analysis of patients using vein grafts. CONCLUSION In the BASIL-1 cohort, GLASS is associated with outcomes following EVT but not BS. Although further validation in contemporary CLTI cohorts is required, GLASS seems likely be useful in shared decision making and for stratifying patients in future trials.
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Khan A, Hughes M, Ting M, Riding G, Simpson J, Egun A, Banihani M. A 'hot clinic' for cold limbs: the benefit of urgent clinics for patients with critical limb ischaemia. Ann R Coll Surg Engl 2020; 102:412-417. [PMID: 32306742 DOI: 10.1308/rcsann.2020.0068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The national reconfiguration of vascular surgery means that arterial centres serve larger populations with increased demand on resources. Emergency general surgery ambulatory clinics facilitate timely review and intervention, avoiding admission; a critical limb ischaemia (CLI) 'hot clinic' (HC) was implemented to achieve similar for vascular patients. The aim of the study was to determine HC efficacy. METHODS This was a prospective cohort study comparing HC patients with emergency admission (EA) patients between 1 May and 1 December 2017. Age, sex, comorbidities, CLI severity and smoking status were noted. HC patients were provided with satisfaction surveys. Primary outcome measures were freedom from reintervention and major amputation. Secondary outcome measures included time to procedure, length of stay, returns to theatre and 30-day readmission. RESULTS A total of 147 patients (72 HC, 75 EA) were enrolled in the study. No statistical difference was found in age, sex, smoking status, severity of CLI or prevalence of comorbidities between the groups except that diabetes was more prevalent in EA patients (p=0.028). The median length of stay for the HC cohort was shorter (3 days vs 17 days, p<0.001), with no difference between time to procedure, return to theatre or 30-day readmission. HC patients were nearly 6 times more likely to experience freedom from reintervention (odds ratio: 5.824, p<0.001) and 2.5 times less likely to undergo amputation (odds ratio: 2.616, p=0.043). HC utilisation saved a total of 441 bed days. Over 90% of attendees responded with 100% positive feedback. CONCLUSIONS A vascular HC facilitates urgent review and revascularisation. It provides comparable in-hospital outcomes and better long-term outcomes, with greater efficiency than hospital admission, demonstrating its value in treating CLI.
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Affiliation(s)
- A Khan
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
| | - M Hughes
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
| | - M Ting
- University of Manchester, UK
| | - G Riding
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
| | - J Simpson
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
| | - A Egun
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
| | - M Banihani
- Lancashire Teaching Hospitals NHS Foundation Trust, UK
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Jung HW, Ko YG, Hong SJ, Ahn CM, Kim JS, Kim BK, Choi D, Hong MK, Jang Y. Editor's Choice - Impact of Endovascular Pedal Artery Revascularisation on Wound Healing in Patients With Critical Limb Ischaemia. Eur J Vasc Endovasc Surg 2019; 58:854-863. [PMID: 31653609 DOI: 10.1016/j.ejvs.2019.07.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 06/23/2019] [Accepted: 07/05/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The present study investigated the impact of endovascular pedal artery revascularisation (PAR) on the clinical outcomes of patients with critical limb ischaemia (CLI). METHODS This retrospective analysis of a single centre cohort included 239 patients who underwent endovascular revascularisation of infrapopliteal arteries for a chronic ischaemic wound. PAR was attempted in 141 patients during the procedure. After propensity score matching, there were 87 pairs of patients with and without PAR. RESULTS After the matching, the two groups showed balanced baseline clinical and lesion characteristics. PAR was achieved in 60.9% of the PAR group. Direct angiosome flow was more frequently obtained in the PAR group than in the non-PAR group (81.6% vs. 34.5%; p < .001). Subintimal angioplasty (47.1% vs. 29.9%; p = .019) and pedal-plantar loop technique (18.4% vs. 0%; p < .001) were more frequent in the PAR group. At the one year follow up, the PAR group showed greater freedom from major amputation (96.3% vs. 84.2%; p = .009). The wound healing rate, overall survival, major adverse limb event, and freedom from re-intervention did not differ significantly between the two groups. However, the patient subgroup with successful PAR showed a higher wound healing rate than the non-PAR group (76.0% vs. 67.0%; p = .031). In a multivariable Cox proportional hazards regression model, successful PAR (hazard ratio [HR] 1.564, 95% confidence interval [CI] 1.068-2.290; p = .022) was identified as an independent factor associated with improved wound healing, whereas gangrene (HR 0.659, 95% confidence interval [CI] 0.471-0.923; p = .015), C reactive protein >3 mg/dL (HR 0.591, 95% CI 0.386-0.904; p = .015), and pre-procedural absence of pedal arch (HR 0.628, 95% CI 0.431-0.916; p = .016) were associated with impaired wound healing. CONCLUSION Successful PAR significantly improved wound healing in patients with CLI. Thus, efforts should be made to revascularise the pedal arteries, especially when the pedal arch is completely absent.
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Affiliation(s)
- Hae Won Jung
- Department of Cardiology, Daegu Catholic University Medical Centre, Daegu, Republic of Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Sung-Jin Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yangsoo Jang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Cardiovascular Institute, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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Hata Y, Iida O, Okamoto S, Ishihara T, Nanto K, Tsujumura T, Takahara M, Mano T. Additional Risk Stratification Using Local and Systemic Factors for Patients with Critical Limb Ischaemia Undergoing Endovascular Therapy in the WIfI Era. Eur J Vasc Endovasc Surg 2019; 58:548-55. [PMID: 31409542 DOI: 10.1016/j.ejvs.2019.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 05/29/2019] [Accepted: 06/11/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVES While current guidelines describe the importance of assessing limb characteristics for predicting limb prognosis in patients with critical limb ischaemia (CLI), several reports have also suggested that systemic factors are associated with limb prognosis. The aim of this study was to evaluate whether systemic factors have the same impact on wound healing as limb characteristics in CLI patients undergoing endovascular therapy. METHODS A total of 735 patients who were treated for the first time for CLI with tissue loss between April 2010 and December 2015 were extracted from a prospective registry and data for the Wound, Ischaemia, and foot Infection (WIfI) classification were searched retrospectively. The predictors of wound healing were explored with Cox proportional hazards regression. RESULTS The one year wound healing rate was 60.2% in WIfI stage 1-3 patients and 53.6% in WIfI stage 4 (p = .01). In WIfI stage 1-3, no systemic factors were significantly associated with wound healing, whereas, in WIfI stage 4 patients, non-ambulatory status [hazard ratio (HR) 1.98; 95% confidence interval (CI) 1.37-2.84], haemodialysis (HR 1.90; 95% CI 1.33-2.72) and an albumin level under 3.0 g/dL (HR 1.53; 95% CI 1.02-2.31), were identified as independent risk factors for failure to achieve wound healing. If none or one of these risk factors were present, wound healing was comparable with WIfI 4 and WIfI 1-3 patients (67.7% vs. 63.6%, p = .89), whereas in patients with two or more risk factors wound healing was worse in WIfI 4 than in WIfI 1-3 patients (35.7% vs. 49.5%, p = .01). CONCLUSION Non-ambulatory status, haemodialysis, and a low albumin level were additional systemic risk factors for impaired wound healing in patients with WIfI stage 4. The wound healing rate in WIfI stage 4 patients with one or fewer of these risk factors was comparable to that in WIfI stage 1-3.
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Teichgräber U, Lehmann T, Thieme M, Wahl KU, Stelzner C, Bormann A, Götz L, Kroeßner T, Boden H, Maiwald L, Aschenbach R. Drug-Coated Balloon Angioplasty of Infrapopliteal Lesions in Patients with Critical Limb Ischaemia: 1-Year Results of the APOLLO Trial. Cardiovasc Intervent Radiol 2019; 42:1380-90. [PMID: 31286197 DOI: 10.1007/s00270-019-02279-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 06/26/2019] [Indexed: 01/18/2023]
Abstract
PURPOSE This study intended to assess effectiveness and safety of the drug-coated balloon (DCB) angioplasty of infrapopliteal atherosclerotic lesions in patients with critical limb ischaemia (CLI) in a real-world setting. METHODS Consecutive patients with critical limb ischaemia who underwent infrapopliteal drug-coated balloon angioplasty with the ELUTAX SV DCB were enrolled into the prospective, multicentre, single-arm observational registry. Primary outcome was clinical improvement at 6 and 12 months. Secondary outcomes were change in quality of life, primary patency, freedom from repeat revascularisation, and amputation-free survival at 6 and 12 months. RESULTS A total of 164 patients (74.7 ± 9.2 years) with CLI were included at nine German sites between November 2015 and September 2017. The majority (79.9%) of patients had diabetes mellitus, 57.3% had renal insufficiency, and 35.3% had coronary artery disease. Mean lesion length was 71.2 ± 76.5 mm. The Rutherford category improved by 3.0 ± 2.0 (p < 0.0001) within 12 months, resulting in a clinical improvement by at least one Rutherford category in 80.2% of the patients. Walking impairment questionnaire score, European Quality of Life index, and patient-reported pain improved significantly from baseline to 6 and 12 months. Primary patency was 68.5%, freedom from target lesion revascularisation 90.6%, and amputation-free survival 83.5% at 12 months. CONCLUSION Infrapopliteal drug-coated balloon angioplasty with the ELUTAX SV DCB in patients with critical limb ischaemia was efficacious and safe over the medium term. The study is registered with Clinical.Trials.gov (Identifier: NCT02539940).
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Masmejan S, Deslarzes-Dubuis C, Petitprez S, Longchamp A, Haller C, Saucy F, Corpataux JM, Déglise S. Ten Year Experience of Using Cryopreserved Arterial Allografts for Distal Bypass in Critical Limb Ischaemia. Eur J Vasc Endovasc Surg 2019; 57:823-831. [PMID: 31130420 DOI: 10.1016/j.ejvs.2018.11.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 11/27/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE/BACKGROUND In critical limb ischaemia (CLI), current guidelines recommend revascularisation whenever possible, preferentially through endovascular means. However, in the case of long occlusions or failed endovascular attempts, distal bypasses still have a place. Single segment great saphenous vein (GSV), which provides the best conduit, is often not available and currently there is no consensus about the best alternative graft. METHODS From January 2006 to December 2015, 42 cryopreserved arterial allografts were used for a distal bypass. Autologous GSVs or alternative autologous conduits were unavailable for all patients. The patients were observed for survival, limb salvage, and allograft patency. The results were analysed with Kaplan-Meier graphs. RESULTS Estimates of secondary patency at one, two and five years were 81%, 73%, and 57%, respectively. Estimates of primary patency rates at one, two and five years were 60%, 56%, and 26%, respectively. Estimates of limb salvage rates at one, two and five years were 89%, 89%, and 82%, respectively. Estimates of survival rates at one, two and five years were 92%, 76% and 34%, respectively. At 30 days, major amputations and major adverse cardiac events were one and zero, respectively. Six major amputations occurred during the long-term follow up. CONCLUSION Despite a low primary patency rate at two years, the secondary patency of arterial allografts is acceptable for distal bypasses. This suggests that cryopreserved arterial allografts are a suitable alternative for limb saving distal bypasses in the absence of venous conduits, improving limb salvage rates and, possibly, quality of life.
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Affiliation(s)
| | | | | | | | - Claude Haller
- Department of General Surgery, Vascular Surgery Unit, Hôpital de Sion, Sion, Switzerland
| | - François Saucy
- Department of Vascular Surgery, CHUV, Lausanne, Switzerland
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Lounes Y, Ozdemir BA, Alric P, Canaud L. Trans-iliac Bypass for Critical Limb Ischaemia with Groin Necrosis: A Case Report. EJVES Short Rep 2019; 42:31-33. [PMID: 30931404 PMCID: PMC6411489 DOI: 10.1016/j.ejvssr.2019.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 12/18/2018] [Accepted: 01/06/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction Infections at the level of the groin involving native or prosthetic vessels are typically bypassed using the obturator canal. However, extensive wounds or infections, particularly those involving the medial compartment of the thigh, can preclude this approach. Report A 66 year old male with diabetes mellitus presented after several previous revascularisations of the femoral artery with extensive necrosis of the groin and critical limb ischaemia with necrotic changes in the toes. An iliopopliteal bypass through the iliac wing was planned because of the extent of the infection. Discussion The post-operative course was uneventful with complete resolution of tissue loss at one year follow up. In the presence of extensive groin, the trans-iliac approach is feasible. The trans-iliac approach is feasible and easy to perform with good outcomes. The trans-iliac bypass increase the distance from the graft to the site of infection.
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Affiliation(s)
- Youcef Lounes
- Vascular and Thoracic Surgery, CHRU of Montpellier, France
| | | | - Pierre Alric
- Vascular and Thoracic Surgery, CHRU of Montpellier, France
| | - Ludovic Canaud
- Vascular and Thoracic Surgery, CHRU of Montpellier, France
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Yamamoto Y, Inoue Y, Igari K, Toyofuku T, Kudo T, Uetake H. Assessment of the Severity of Ischaemia and the Outcomes of Revascularisation in Peripheral Arterial Disease Patients Based on the Skin Microcirculatory Response to a Thermal Load Test. EJVES Short Rep 2019; 42:21-25. [PMID: 30815594 PMCID: PMC6378628 DOI: 10.1016/j.ejvssr.2018.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 12/21/2018] [Accepted: 12/27/2018] [Indexed: 11/18/2022] Open
Abstract
Objective This study investigated the skin microcirculatory response to a thermal load test using a laser Doppler flowmetry device to evaluate the severity of limb ischaemia and the outcomes of revascularisation in patients with peripheral arterial disease (PAD). Methods A total of 34 PAD patients (39 limbs) including 17 critical limb ischaemia (CLI) patients (21 limbs) who underwent revascularisation were enrolled. The skin microcirculation of the dorsal side of the affected foot was investigated for 15 minutes after local heating. The tests were performed both before and after revascularisation, and several parameters gleaned from the microcirculatory fluctuations were analysed and compared with the ankle brachial pressure index and the transcutaneous oxygen tension (tcPO2) values. Results Among the parameters, significant differences were observed between the CLI patients and patients with claudication with regard to the increasing phase time (Tinc), the difference in the perfusion values at the onset and the peak of the transient increase in blood perfusion (PΔ), the slope of the transient increase in blood perfusion (Sin), and the slope of the decrease in blood perfusion after the peak (Sde). In CLI patients, the PΔ, Sin, and Sde values increased significantly after revascularisation. In the patients with claudication, the changes in the parameters after revascularisation were not statistically significant. The Sde showed the most statistically significant correlation with the tcPO2 value (ρ .759, p < .001). Conclusions Thermal load testing can be used to evaluate the severity of limb ischaemia in patients with PAD. New thermal load testing for evaluation of the severity of limb ischaemia is presented. Skin blood flow response to thermal load was investigated by laser Doppler flowmetry. Thermal load testing can be used to evaluate the severity of limb ischaemia.
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Affiliation(s)
- Yohei Yamamoto
- Department of Surgical Specialties, Tokyo Medical and Dental University, Tokyo, Japan
- Corresponding author. Department of Surgical Specialties, Tokyo Medical and Dental University, 1–5-45 Yushima, Bunkyo-ku, Tokyo, 113–8519, Japan.
| | | | - Kimihiro Igari
- Department of Surgical Specialties, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takahiro Toyofuku
- Department of Surgical Specialties, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshifumi Kudo
- Department of Surgical Specialties, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Uetake
- Department of Surgical Specialties, Tokyo Medical and Dental University, Tokyo, Japan
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Norgren L, Weiss N, Nikol S, Hinchliffe RJ, Lantis JC, Patel MR, Reinecke H, Ofir R, Rosen Y, Peres D, Aberman Z. PLX-PAD Cell Treatment of Critical Limb Ischaemia: Rationale and Design of the PACE Trial. Eur J Vasc Endovasc Surg 2019; 57:538-545. [PMID: 30686676 DOI: 10.1016/j.ejvs.2018.11.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/07/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Critical limb ischaemia (CLI) is a life threatening condition with a considerable risk of major amputation and death. Besides revascularisation, no treatment has been proven to reduce the risks. Therapeutic angiogenesis by gene or cell therapy has not demonstrated definitive evidence in randomised controlled trials. PLX-PAD is an "off the shelf" allogeneic placental derived, mesenchymal like cell therapy, which, in preclinical studies, has shown pro-angiogenic, anti-inflammatory, and regenerative properties. Favourable one year amputation free survival (AFS), and trends in reduction of pain scores and increase of tissue perfusion have been shown in two small, open label, phase I trials. METHODS The PACE study is a phase III randomised, double blind, multicentre, multinational placebo controlled, parallel group study to evaluate the efficacy, tolerability, and safety of intramuscular injections of PLX-PAD cells to treat patients with atherosclerotic CLI with minor tissue loss (Rutherford Category 5) up to the ankle level, who are unsuitable for revascularisation or carry an unfavourable risk benefit for that treatment. The study will enroll 246 patients, who after screening are randomised in a ratio of 2:1 to treatment with intramuscular injections of PLX-PAD 300 × 106 cells or placebo on two occasions, eight weeks apart. The primary efficacy endpoint is time to major amputation or death (amputation free survival), which will be assessed in follow up of at least 12 months and up to 36 months. CONCLUSIONS Based on favourable pre-clinical and initial clinical study results, the PACE phase III randomised controlled trial will evaluate placenta derived PLX-PAD cell treatment in patients with critical limb ischaemia, with an unfavourable risk benefit for revascularisation. Clinicaltrials.gov: NCT03006770.
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Affiliation(s)
- Lars Norgren
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Sweden.
| | - Norbert Weiss
- University Centre for Vascular Medicine and Department of Medicine - Section Angiology, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany
| | | | - Robert J Hinchliffe
- Bristol Centre for Surgical Research, Bristol NIHR Biomedical Research Centre, University of Bristol, Bristol, UK
| | | | | | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital of Muenster, Muenster, Germany
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Testi G, Ceccacci T, Cevolani M, Acquati S, Tarantino F, Turicchia GU. Substent Anchor Technique for Recanalisation of a Full Metal Jacket Femoropopliteal In-Stent Occlusion. EJVES Short Rep 2018; 41:20-3. [PMID: 30582021 DOI: 10.1016/j.ejvssr.2018.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/21/2018] [Accepted: 08/26/2018] [Indexed: 11/22/2022] Open
Abstract
Purpose To report the endovascular treatment of a full metal jacket (FMJ) femoropopliteal chronic total occlusion (CTO) using a new ancillary retrograde technique. Case report An 80 year old woman with type 2 diabetes presented to the Diabetic Foot Clinic with critical limb ischaemia with tissue loss in the right leg. Her comorbidities included coronary artery disease, morbid obesity, hypertension, dyslipidaemia, and active smoking habit. The patient had been treated at another hospital by femoropopliteal FMJ stenting six years before this presentation. The duplex ultrasound showed a full length in-stent re-occlusion. An antegrade recanalisation was attempted via contralateral femoral access, but was unsuccessful. An ultrasound guided retrograde puncture of the popliteal artery in the P2 segment was performed very close to the distal occluded stent. A 0.018 guidewire was pushed in the substent plane, functioning as an anchor to achieve a stable system. The FMJ was then retrogradely recanalised with a second guidewire. The procedure was completed by antegrade angioplasty with drug coated balloons. Conclusion The substent anchor technique can help to achieve stability even if close to the occluded stents, and spares the distal landing zone for surgical revascularisation if the endovascular approach fails. This technique could be useful in retrograde treatment of long in-stent CTO. Recanalisation of in-stent chronic total occlusion is a challenging procedure. It is very difficult to treat long in-stent occlusion by an antegrade approach. The retrograde route allows for easier access to the stent true lumen. The distal landing zone should be spared for further surgical revascularisation. The substent anchor technique offers system stability as well as being close to the CTO.
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Kumakura H, Kanai H, Hojo Y, Iwasaki T, Ichikawa S. Long-term survival and fate of the leg in de novo intermittent claudication. Eur Heart J Qual Care Clin Outcomes 2018; 3:208-215. [PMID: 28838085 DOI: 10.1093/ehjqcco/qcw057] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 11/02/2016] [Indexed: 01/05/2023]
Abstract
Aims The long-term life expectancy and fate of the leg, including progression rate to critical limb ischaemia (CLI), were analysed in de novo patients with intermittent claudication (IC). Methods and results A prospective cohort study was performed in 1107 patients with de novo IC. The endpoints were overall survival (OS), freedom from major adverse cardiovascular events (MACE), freedom from major adverse cardiovascular and limb events (MACLE), and fate of the leg. The 5-, 10-, 15-, and 20-year rates were 73.3, 47.8, 28.1, and 14.9% for OS, and 63.0, 35.6, 18.5, and 5.7% for freedom from MACE, respectively. In Cox multivariable analysis, body mass index, diabetes, haemodialysis, and C-reactive protein (CRP) level were correlated with OS (P < 0.05). Ankle brachial pressure index, diabetes, coronary artery disease, haemodialysis, and CRP level were independently correlated with freedom from MACE and MACLE. Statins improved mortality, MACE, and MACLE (P < 0.05). Revascularization did not improve mortality and MACE, and femoropopliteal revascularization increased MACLE (P < 0.05). There was no deterioration of claudication in 881 patients (79.6%). Worsening claudication was noted in 211 patients (14.8% per 5 years), and 15 patients (1.1% per 5 years) worsened to CLI. Diabetes and haemodialysis were independent predictors of CLI. A history of cerebral infarction and femoropopliteal revascularization tended to increase CLI. Conclusions Life expectancy in patients with IC was poor, but the rate of IC progression to CLI was low. Statins improved mortality and morbidity, revascularization did not improve mortality and MACE, and femoropopliteal revascularization reduced freedom from MACLE with a risk of CLI.
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Affiliation(s)
- Hisao Kumakura
- Department of Vascular Medicine, Vascular Center, Cardiovascular Hospital of Central Japan (Kitakanto Cardiovascular Hospital), Shimohakoda 740 Hokkitu-machi, Shibukawa, Gunma 377-0061, Japan
| | - Hiroyoshi Kanai
- Department of Vascular Medicine, Vascular Center, Cardiovascular Hospital of Central Japan (Kitakanto Cardiovascular Hospital), Shimohakoda 740 Hokkitu-machi, Shibukawa, Gunma 377-0061, Japan
| | - Yoshiaki Hojo
- Department of Vascular Medicine, Vascular Center, Cardiovascular Hospital of Central Japan (Kitakanto Cardiovascular Hospital), Shimohakoda 740 Hokkitu-machi, Shibukawa, Gunma 377-0061, Japan
| | - Toshiya Iwasaki
- Department of Vascular Medicine, Vascular Center, Cardiovascular Hospital of Central Japan (Kitakanto Cardiovascular Hospital), Shimohakoda 740 Hokkitu-machi, Shibukawa, Gunma 377-0061, Japan
| | - Shuichi Ichikawa
- Department of Vascular Medicine, Vascular Center, Cardiovascular Hospital of Central Japan (Kitakanto Cardiovascular Hospital), Shimohakoda 740 Hokkitu-machi, Shibukawa, Gunma 377-0061, Japan
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Dong Z, Pan T, Fang Y, Wei Z, Gu S, Fang G, Liu Y, Luo Y, Liu H, Zhang T, Hu M, Guo D, Xu X, Chen B, Jiang J, Yang J, Shi Z, Zhu T, Shi Y, Liu P, Fu W. Purified CD34 + cells versus peripheral blood mononuclear cells in the treatment of angiitis-induced no-option critical limb ischaemia: 12-Month results of a prospective randomised single-blinded non-inferiority trial. EBioMedicine 2018; 35:46-57. [PMID: 30172703 PMCID: PMC6156701 DOI: 10.1016/j.ebiom.2018.08.038] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 08/15/2018] [Accepted: 08/15/2018] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Peripheral blood mononuclear cells (PBMNCs) and purified CD34+ cells (PCCs) are increasingly being used at treating no-option critical limb ischaemia (NO-CLI). We aimed to compare the efficacies and uncover the advantages associated with each treatment approach. METHODS A randomised single-blinded non-inferiority trial (Number: NCT 02089828) was performed. NO-CLI patients were 1:1 randomised to the PBMNCs and PCCs groups, and compared in relation to safety and efficacy outcomes. The primary efficacy outcomes included major amputation and total amputation over 12 months. The major amputation-free survival (MAFS) and total amputation-free survival (TAFS) rates were calculated. FINDINGS Fifty patients (25 per group, 47 with thromboangiitis obliterans and 3 with other angiitis) were enrolled, with a median follow-up period of 24.5 months (interquartile range: 17-34 months). One patient in the PCCs group was lost at 2 months and one major amputation occurred in the PBMNCs group at 3 months post-transplantation. The total amputation rates at 6 months post-transplantation were 28.0% in the PCCs group and 16.0% in the PBMNCs group (p = 0.343), and remained unchanged at 12 months. The groups did not differ regarding the MAFS and TAFS (Breslow-Wilcoxon test: p = 0.3014 and p = 0.3414). The PCCs group had a significantly higher probability of rest pain relief than the PBMNCs group (Breslow-Wilcoxon test: p = 0.0454). INTERPRETATION PCCs was not inferior to PBMNCs at limb salvage in the treatment of angiitis-induced NO-CLI and appeared to induce earlier ischaemia relief. Each cell type had specific advantages. These outcomes require verification from longer-term trials involving larger numbers of patients. FUND: Training program for outstanding academic leaders of Shanghai health and family planning system (Hundred Talent Program,Grant No. 2018BR40); China National Natural Science Funds (Grant No. 30801122); The excellent core member training programme at Zhongshan Hospital, Fudan University, China (Grant No. 2015ZSYXGG02); and Zhongshan Funds for the Institute of Vascular Surgery, Fudan University, China. CLINICAL TRIAL REGISTRATION This study is registered with ClinicalTrials.gov (NCT 02089828).
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Affiliation(s)
- Zhihui Dong
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China.
| | - Tianyue Pan
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Yuan Fang
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Zheng Wei
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shiyang Gu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Gang Fang
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Yifan Liu
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Yang Luo
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Hao Liu
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Tiejun Zhang
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China
| | - Meiyu Hu
- Core Lab of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Daqiao Guo
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Xin Xu
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Bin Chen
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Junhao Jiang
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Jue Yang
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Zhenyu Shi
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Ting Zhu
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Yun Shi
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Peng Liu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, and Institute of Vascular Surgery, Fudan University, Shanghai, China.
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Sultan S, Kavanagh EP, Hynes N. Minimising failure in critical lower limb ischaemia intervention: Adjuvant capillary bed recruitment is the missed opportunity. Vascular 2018; 26:449-454. [PMID: 29419359 DOI: 10.1177/1708538117753213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Critical limb ischaemia is the end stage of peripheral arterial disease before limb loss. Contemporary interventions to restore blood flow have high morbidity and mortality and fail to provide sustained restoration of peripheral circulation. Cell-based therapies designed to promote neovascularisation or angiogenesis have been shown in trials to be safe but clinically ineffective. Notwithstanding endless research in the area, no headway has been made in identifying a successful therapy designed specifically to target muscle disease in critical lower limb ischaemia. Thus, the quest to find an effective, lasting solution for critical lower limb ischaemia continues and requires more innovative therapeutic tactics. Our aim is to highlight the crucially interlinked role of the capillary bed, skeletal muscle mass and mitochondria in critical lower limb ischaemia patients and to identify novel therapeutic mechanisms that the vascular interventionalist can add to their armamentarium.
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Affiliation(s)
- Sherif Sultan
- 1 Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland Galway, Galway, Ireland.,2 Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Doughiska, Galway, Ireland.,3 Royal College of Surgeons in Ireland Affiliated Hospitals, National University of Ireland Galway Affiliated Hospitals, Galway, Ireland
| | - Edel Patricia Kavanagh
- 1 Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland Galway, Galway, Ireland.,2 Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Doughiska, Galway, Ireland.,3 Royal College of Surgeons in Ireland Affiliated Hospitals, National University of Ireland Galway Affiliated Hospitals, Galway, Ireland
| | - Niamh Hynes
- 1 Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland Galway, Galway, Ireland.,2 Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Doughiska, Galway, Ireland.,3 Royal College of Surgeons in Ireland Affiliated Hospitals, National University of Ireland Galway Affiliated Hospitals, Galway, Ireland
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Khor BYC, Price P. The comparative efficacy of angiosome-directed and indirect revascularisation strategies to aid healing of chronic foot wounds in patients with co-morbid diabetes mellitus and critical limb ischaemia: a literature review. J Foot Ankle Res 2017; 10:26. [PMID: 28670345 PMCID: PMC5490238 DOI: 10.1186/s13047-017-0206-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/06/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Ischaemic ulcerations have been reported to persist and/or deteriorate despite technically successful revascularisations; a higher incidence of which affects patients with diabetes and critical limb ischaemia. In the context of wound healing, it is unclear if applications of the angiosome concept in 'direct revascularisation' (DR) would be able to aid the healing of chronic foot ulcerations better than the current 'best vessel' or 'indirect revascularisation' (IR) strategy in patients with co-morbid diabetes and critical limb ischaemia. METHODS A literature search was conducted in eight electronic databases, namely AMED, CINAHL, The Cochrane Library, ProQuest Health & Medicine Complete, ProQuest Nursing & Allied Health Source, PubMed, ScienceDirect and TRIP database. Articles were initially screened against a pre-established inclusion and exclusion criteria to determine eligibility and subsequently appraised using the Newcastle-Ottawa Scale. RESULTS Five retrospective studies of varying methodological quality were eligible for inclusion in this review. Critical analysis of an aggregated population (n = 280) from methodologically stronger studies indicates better wound healing outcomes in subjects who had undergone DR as compared to IR (p < 0.001; p = 0.04). DR also appears to result in a nearly twofold increase in probability of wound healing within 12 months (hazard ratio, 1.97; 95% CI, 1.34-2.90). This suggests that achieving direct arterial perfusion to the site of ulceration may be important for the healing of chronic diabetic foot ulcerations. CONCLUSION Incorporating an angiosome-directed approach in the lower limb revascularisation strategy could be a very useful adjunct to a solely indirect approach, which could increase the likelihood of wound healing. With the limited data currently available, findings appear promising and merit from further investigation. Additional research to form a solid evidence base for this revised strategy in patients with co-morbid diabetes and critical limb ischaemia is warranted.
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Affiliation(s)
- Benedictine Y. C. Khor
- Department of Podiatry, Galloway Community Hospital, NHS Dumfries & Galloway, Stranraer, UK
| | - Pamela Price
- Department of Podiatry, Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK
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Popplewell MA, Davies HOB, Narayanswami J, Renton M, Sharp A, Bate G, Patel S, Deeks J, Bradbury AW. A Comparison of Outcomes in Patients with Infrapopliteal Disease Randomised to Vein Bypass or Plain Balloon Angioplasty in the Bypass vs. Angioplasty in Severe Ischaemia of the Leg (BASIL) Trial. Eur J Vasc Endovasc Surg 2017; 54:195-201. [PMID: 28602580 DOI: 10.1016/j.ejvs.2017.04.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 04/20/2017] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The aim was to compare outcomes in a subgroup of patients with infrapopliteal (IP) disease randomised to infrapopliteal vein bypass (VB) or plain balloon angioplasty (PBA) in the original BASIL trial. METHODS A comparison of outcomes from patients randomised to VB or PBA undergoing revascularisation for severe limb ischaemia (SLI) because of IP disease with or without femoropopliteal disease. Data were extracted from case report forms from the BASIL trial. The primary outcome was amputation free survival (AFS); secondary outcomes included overall survival (OS), 30 day mortality and morbidity, freedom from arterial re-intervention, immediate technical success, repeat and crossover interventions, length of hospital stay, and quality of revascularisation. RESULTS A total of 104 patients were identified in the BASIL study with IP disease, 56 randomised to IP VB, and 48 to IP PBA. Groups were similar at baseline except for more chronic kidney disease and non-steroidal anti-inflammatory drug use in the VB group, and more previous surgical arterial intervention and antihypertensive use in the PBA group. There were no statistically significant differences in AFS or OS; however, clinically important trends were apparent in favour of a VB first strategy. Patients allocated to VB demonstrated significantly quicker relief of rest pain when compared with PBA (p = .005), but no significant differences in improved tissue healing. Median length of index hospital admission was significantly greater in the VB than in the PBA group (18 vs. 10 days, p < .0001) but there was no difference between the two groups in median total hospital stay between randomisation and the primary endpoint (VB 43.5 vs. PBA 42 days). CONCLUSIONS Further randomised trials, like BASIL-2 and BEST-CLI, are required to determine whether patients with severe limb ischaemia who require IP revascularisation and who are suitable for VB should have bypass or endovascular intervention as their primary revascularisation procedure.
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Affiliation(s)
- M A Popplewell
- Department of Vascular Surgery, University of Birmingham, Birmingham, UK.
| | - H O B Davies
- Department of Vascular Surgery, University of Birmingham, Birmingham, UK
| | - J Narayanswami
- Department of Vascular Surgery, University of Birmingham, Birmingham, UK
| | - M Renton
- Heart of England Foundation Trust, Birmingham, UK
| | - A Sharp
- Heart of England Foundation Trust, Birmingham, UK
| | - G Bate
- Department of Vascular Surgery, University of Birmingham, Birmingham, UK
| | - S Patel
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - J Deeks
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - A W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, UK
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Hunt BD, Popplewell MA, Davies H, Meecham L, Jarrett H, Bate G, Grant M, Patel S, Hewitt C, Andronis L, Deeks JJ, Bradbury A. BAlloon versus Stenting in severe Ischaemia of the Leg-3 (BASIL-3): study protocol for a randomised controlled trial. Trials 2017; 18:224. [PMID: 28526046 PMCID: PMC5438558 DOI: 10.1186/s13063-017-1968-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 05/04/2017] [Indexed: 11/27/2022] Open
Abstract
Background Severe limb ischaemia (SLI) is defined as the presence of rest pain and/or tissue loss secondary to lower extremity atherosclerotic peripheral arterial disease. The superficial femoral and popliteal arteries are the most commonly diseased vessels in such patients and are being increasingly treated using endovascular revascularisation techniques. However, it is currently unknown whether drug-eluting stents and drug-coated balloons confer additional clinical benefits over more established techniques using plain balloons and bare metal stents, or whether they represent a cost-effective use of NHS resources. Methods The BASIL-3 trial is a UK National Institute for Health Research, Health Technology Assessment Programme-funded, multicentre, randomised controlled trial (RCT) comparing the clinical and cost-effectiveness of plain balloon angioplasty with or without bail-out bare metal stenting, drug-coated balloon angioplasty with or without bail-out bare metal stenting, and primary stenting with drug-eluting stents for SLI secondary to femoro-popliteal disease. Patients with ‘multilevel’ disease may receive aorto-iliac and/or infrapopliteal treatments concurrently with their randomised femoro-popliteal intervention. The primary clinical outcome is amputation-free survival defined as the time to major (above the ankle) amputation of the index limb or death from any cause. The primary outcome for the economic analysis is cost per quality-adjusted life year. Secondary outcome measures include overall survival, major adverse limb events, major adverse cardiac events, relief of ischaemic pain, healing of tissue loss, and quality of life. The required sample size has been calculated at 861 participants (287 on each arm). These patients will be recruited over 3 years and followed-up for between 2 and 5 years. Discussion BASIL-3 is a pragmatic RCT designed to reflect current UK clinical practice. The results will inform decision-making regarding the appropriateness of funding the use of drug-coated balloons and drug-eluting stents, by the NHS, for the management of SLI due to femoro-popliteal disease. Trial registration ISRCTN Registry, identifier: ISRCTN14469736. Registered on 22 October 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1968-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Benjamin D Hunt
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, Public Health Building, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Matthew A Popplewell
- Heart of England NHS Foundation Trust, Netherwood House, Solihull Hospital, University Department of Vascular Surgery, Lode Lane, Solihull, B91 2JL, UK
| | - Huw Davies
- Heart of England NHS Foundation Trust, Netherwood House, Solihull Hospital, University Department of Vascular Surgery, Lode Lane, Solihull, B91 2JL, UK
| | - Lewis Meecham
- Heart of England NHS Foundation Trust, Netherwood House, Solihull Hospital, University Department of Vascular Surgery, Lode Lane, Solihull, B91 2JL, UK
| | - Hugh Jarrett
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, Public Health Building, University of Birmingham, Birmingham, B15 2TT, UK
| | - Gareth Bate
- Heart of England NHS Foundation Trust, Netherwood House, Solihull Hospital, University Department of Vascular Surgery, Lode Lane, Solihull, B91 2JL, UK
| | - Margaret Grant
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, Public Health Building, University of Birmingham, Birmingham, B15 2TT, UK
| | - Smitaa Patel
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, Public Health Building, University of Birmingham, Birmingham, B15 2TT, UK
| | - Catherine Hewitt
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, Public Health Building, University of Birmingham, Birmingham, B15 2TT, UK
| | - Lazaros Andronis
- Health Economics Unit, Institute of Applied Health Research, Public Health Building, University of Birmingham, Birmingham, B15 2TT, UK
| | - Jonathan J Deeks
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, Public Health Building, University of Birmingham, Birmingham, B15 2TT, UK
| | - Andrew Bradbury
- Heart of England NHS Foundation Trust, Netherwood House, Solihull Hospital, University Department of Vascular Surgery, Lode Lane, Solihull, B91 2JL, UK
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Conijn AP, Santema TBK, Bipat S, Koelemay MJW, de Haan RJ. Clinimetric Evaluation of the Vascular Quality of Life Questionnaire in Patients with Lower Limb Ischaemia. Eur J Vasc Endovasc Surg 2017; 53:412-418. [PMID: 28065441 DOI: 10.1016/j.ejvs.2016.12.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 12/03/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Although commonly used to measure health related quality of life in patients with lower limb ischaemia, the measurement properties of the VascuQol and its assumed underlying health dimensions have not been studied in depth. The objective of this study was therefore to evaluate aspects of reliability and validity of the Dutch version of the VascuQol in patients with intermittent claudication (IC) and critical limb ischaemia (CLI). METHODS Two datasets containing 195 patients with IC and 150 patients with CLI were used. Face validity of the VascuQol was examined in interviews with patients and a survey among health professionals. Homogeneity and structural validity of the VascuQol were assessed using Cronbach's α coefficients and explanatory factor analysis. Furthermore, convergent validity and known group validity were assessed. RESULTS During the face validity interviews, three items were indicated as less relevant. Homogeneity analysis showed that the α coefficient of the VascuQol was .93, while the symptoms and social domains had α coefficients below the threshold of .70. The original five domains of the VascuQol could not be reproduced. Instead, factor analysis yielded a three factor solution. Moderate correlations were found for the activities, social and emotional VascuQol domains and matching health domains of other patient reported outcome measures (PROMs). Lower convergent correlations were observed for the pain domain and the sumscore of the VascuQol. The VascuQol was able to distinguish between patients' level of HRQL in relation to their disease severity (IC versus CLI patients). CONCLUSIONS There is room for improvement of the VascuQol questionnaire. Further clinimetric studies should be performed to strengthen clinically relevant findings based on this instrument.
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Affiliation(s)
- A P Conijn
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands; Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - T B K Santema
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.
| | - S Bipat
- Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - M J W Koelemay
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - R J de Haan
- Clinical Research Unit, Academic Medical Centre, Amsterdam, The Netherlands
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Schreve MA, Vos CG, Vahl AC, de Vries JPPM, Kum S, de Borst GJ, Ünlü Ç. Venous Arterialisation for Salvage of Critically Ischaemic Limbs: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2016; 53:387-402. [PMID: 28027892 DOI: 10.1016/j.ejvs.2016.11.007] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 11/07/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Critical limb ischaemia (CLI) is the end stage of peripheral artery disease (PAD) and is associated with high amputation and mortality rates and poor quality of life. For CLI patients with no revascularisation options, venous arterialisation could be a last resort for limb salvage. OBJECTIVE To review the literature on the clinical effectiveness of venous arterialisation for lower limb salvage in CLI patients with no revascularisation options. METHOD Different databases were searched for papers published between January 1966 and January 2016. The criteria for eligible articles were studies describing outcomes of venous arterialisation, published in English, human studies, and with the full text available. Additionally, studies were excluded if they did not report limb salvage, wound healing or amputation as outcome measures. The primary outcome measure was post-operative limb salvage at 12 months. Secondary outcome measures were 30 day or in-hospital mortality, survival, patency, technical success, and wound healing. RESULTS Fifteen articles met the inclusion criteria. The included studies described 768 patients. According to the MINORS score, methodological quality was moderate to poor. The estimated pooled limb salvage rate at one year was 75% (0.75, 95% CI 0.70-0.81). Thirty day or in-hospital mortality was reported in 12 studies and ranged from 0 to 10%. Overall survival was reported in 10 studies and ranged from 54% to 100% with a mean follow-up ranging from 5 to 60 months. Six studies reported on patency of the venous arterialisations performed, with a range of 59-71% at 12 months. CONCLUSION In this systematic review on venous arterialisation in patients with non-reconstructable critical limb ischaemia, the pooled proportion of limb salvage at 12 months was 75%. Venous arterialisation could be a valuable treatment option in patients facing amputation of the affected limb; however, the current evidence is of low quality.
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Affiliation(s)
- M A Schreve
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands.
| | - C G Vos
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - A C Vahl
- Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - J P P M de Vries
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - S Kum
- Department of Surgery, Changi General Hospital, Singapore
| | - G J de Borst
- Department of Surgery, UMCU, Utrecht, The Netherlands
| | - Ç Ünlü
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
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Santema TB, Stoekenbroek RM, van Loon J, Koelemay MJ, Ubbink DT. Not All Patients with Critical Limb Ischaemia Require Revascularisation. Eur J Vasc Endovasc Surg 2017; 53:371-9. [PMID: 27919605 DOI: 10.1016/j.ejvs.2016.10.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 10/22/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVES International guidelines recommend revascularisation as the preferred treatment for patients with critical limb ischaemia (CLI). Most contemporary research focuses on the outcome of invasive procedures for CLI, but little is known about the outcome of conservative management. Amputation free survival (AFS) and overall survival (OS) was investigated in patients with CLI who did or did not receive revascularisation, and characteristics associated with clinical outcomes were explored. METHODS This was a retrospective cohort study of consecutive patients with chronic CLI between 2010 and 2014 in a Dutch university hospital. CLI was defined as the presence of ischaemic rest pain or tissue loss in conjunction with an absolute systolic ankle pressure < 50 mmHg or a toe pressure < 30 mmHg. Patients were divided into invasive (revascularisation within 6 weeks), deferred invasive (revascularisation after 6 weeks), or permanently conservative treatment groups. Univariable and multivariable survival analyses were used to identify factors associated with AFS and OS. RESULTS The majority (66.7%; N = 96) of the identified 144 patients with CLI (mean age 71.2 years; median follow-up 99 weeks) underwent revascularisation within 6 weeks of diagnosis. Deferred invasive treatment was provided in 18.1% (N = 26) patients and 22 patients (15.3%) were treated permanently conservatively. AFS and OS did not differ significantly between the three groups (Breslow-Wilcoxon p = .16 for AFS and p = .09 for OS). Age, chronic obstructive pulmonary disease (COPD), and heart disease were significant independent predictors of AFS. Age, COPD, and hypertension were significant independent predictors of OS. Treatment was not a significant predictor of either AFS or OS. CONCLUSIONS Not all patients with CLI require revascularisation to achieve an AFS that is similar to patients undergoing revascularisation, although the efficacy of conservative versus invasive treatment in CLI patients is still unclear. Further prospective studies should determine subgroups of patients in whom revascularisation may be omitted.
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Maufus M, Sevestre-Pietri MA, Sessa C, Pignon B, Egelhofer H, Dupas S, Nguyen P, Genty C, Pernod G. Critical limb ischaemia and the response to bone marrow-derived cell therapy according to tcPO 2 measurement. VASA 2016; 46:23-28. [PMID: 27869551 DOI: 10.1024/0301-1526/a000590] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cell therapy is an emerging potential biotherapy for critical limb ischaemia (CLI) patients who are not eligible for revascularization. However, the findings on this technique's efficacy are inconsistent. Trials investigating this topic focused on the more severe CLI patients who were often beyond any therapy. Therefore, identifying those who may truly benefit from cell transplantation is now warranted. To this end, we studied the prognostic value of tcPO2 for major amputation after 1 year in patients treated with bone marrow-derived cells. PATIENTS AND METHODS CLI patients ineligible for revascularization were included in a cell-therapy pilot study. On inclusion, patients underwent tcPO2 measurement in supine and sitting positions. For a tcPO2 < 10 mmHg in the supine position, the vascular reserve was defined by tcPO2 > 30 mmHg in the sitting position. Patients were administered intramuscular injections of mononuclear cells derived from aspirated bone marrow. RESULTS In total, 25 patients (a lower limbs) were included for analysis. At inclusion, 11 lower limbs had tcPO2 at rest > 10 mmHg, and 16 lower limbs had a tcPO2 < 10 mmHg. The success probability for cell therapy was 0.79 (95 % CI 0.38-0.94) and 0.44 (95 % CI 0.18-0.67), respectively (p = 0.1). Of the 16 limbs with tcPO2 < 10 mmHg, the success rate was considerably higher in patients demonstrating a tcPO2 increase in a sitting position of over 30 mmHg (6/8, success probability 0.71, 95 % CI 0.26-0.92) compared to those without (2/8, success probability 0.15, 95 % CI 0.01-0.48, p = 0.03). CONCLUSIONS For patients with chronic CLI for whom cellular therapy is a therapeutic option, a tcPO2 < 10 mmHg at rest, without vascular reserve (i. e. < 30 mmHg when sitting), is a prognostic indicator for poor outcome.
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Affiliation(s)
- Mario Maufus
- 1 Department of Vascular Medicine, University Hospital Grenoble-Alpes, France
| | - Marie Antoinette Sevestre-Pietri
- 2 Department of Vascular Medicine, University Hospital Amiens, France.,3 Université Grenoble Alpes - CNRS, TIMC-IMAG UMR 5525/Themas, Grenoble, France
| | - Carmine Sessa
- 4 Department of Vascular Surgery, University Hospital Grenoble-Alpes, France
| | | | - Harald Egelhofer
- 6 Cell Therapy Unit, University Hospital Grenoble-Alpes, France.,7 Etablissement Français du Sang, Rhône-Alpes Grenoble, France
| | - Stephane Dupas
- 2 Department of Vascular Medicine, University Hospital Amiens, France
| | | | - Celine Genty
- 9 Centre of Clinical Research, University Hospital Grenoble-Alpes, France
| | - Gilles Pernod
- 1 Department of Vascular Medicine, University Hospital Grenoble-Alpes, France.,3 Université Grenoble Alpes - CNRS, TIMC-IMAG UMR 5525/Themas, Grenoble, France
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Stabile E, Magliulo F, Zhelev D, Chervenkoff V, Taeymans K, Goverde P, Losi MA, Giugliano G, Trimarco B, Esposito G. Interim analysis at 6months from the LEG-flow Drug Eluting Balloon for the treatment of femoropopliteal occlusions (LEG-DEB) registry. Int J Cardiol 2016; 223:654-5. [PMID: 27568985 DOI: 10.1016/j.ijcard.2016.08.146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 08/06/2016] [Indexed: 11/23/2022]
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Brizuela Sanz JA, González Fajardo JA, Taylor JH, Río Solá L, Muñoz Moreno MF, Vaquero Puerta C. Design of a New Risk Score in Critical Limb Ischaemia: The ERICVA Model. Eur J Vasc Endovasc Surg 2016; 51:90-9. [PMID: 26602223 DOI: 10.1016/j.ejvs.2015.09.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 09/28/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVES It is difficult to establish which patients suffering from critical lower limb ischaemia will benefit from revascularization. Risk scores can provide objectivity in decision making. The aim was to design a new risk score (ERICVA) and compare its predictive power with the PREVENT III and Finnvasc scores. METHODS An observational retrospective study of patients who underwent revascularization (open or endovascular) in Valladolid's University Hospital between 2005 and 2010 was designed. The sample was divided into two subgroups (development and validation subsamples). After univariate analysis followed by a multivariate Cox regression, a number of variables associated with death and/or major amputation were selected, creating a weighed score called ERICVA, and a simplified version of it. The area under the curve (AUC) of receiver operating characteristic (ROC) curve analysis was performed and the AUC of these two scores were additionally compared with the AUC of the PREVENT III and Finnvasc scales. RESULTS Six hundred and seventy two cases with an average surveillance of 778 days were included in the study. Amputation free survival (AFS) was 84.8% at 30 days and 63.1% at 1 year. Variables associated with death and/or major amputation in the Cox regression were cerebrovascular disease, prior contralateral major amputation, diabetes mellitus, dialysis, chronic obstructive pulmonary disease, cancer, haematocrit less than 30%, neutrophil/lymphocyte ratio exceeding 5, absence of arterial Doppler signal at the ankle, emergency admission, and Rutherford stage 6; these variables were used for the ERICVA and simplified ERICVA score designs. Scores were applied to both subsamples; in the development sample the AUC of ERICVA and simplified ERICVA was significantly higher than the PREVENT III (p = .008 and p = .045) and Finnvasc (p < .0001 and p = .0013) scores; in the validation sample the AUC of ERICVA and simplified ERICVA were significantly higher than Finnvasc score (p = .0323 and p = .0017). CONCLUSIONS The ERICVA model has a good predictive capacity for death and/or major amputation in the clinical setting, and is better than the PREVENT III and Finnvasc scores.
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Reinecke H, Unrath M, Freisinger E, Bunzemeier H, Meyborg M, Lüders F, Gebauer K, Roeder N, Berger K, Malyar NM. Peripheral arterial disease and critical limb ischaemia: still poor outcomes and lack of guideline adherence. Eur Heart J 2015; 36:932-8. [PMID: 25650396 DOI: 10.1093/eurheartj/ehv006] [Citation(s) in RCA: 292] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 01/07/2015] [Indexed: 01/01/2023] Open
Abstract
AIMS Only few and historic studies reported a bad prognosis of peripheral arterial disease (PAD) and critical limb ischaemia (CLI). The contemporary state of treatment and outcomes should be assessed. METHODS AND RESULTS From the largest public health insurance in Germany, all in- and outpatient diagnosis and procedural data were retrospectively obtained from a cohort of 41 882 patients hospitalized due to PAD during 2009-2011, including a follow-up until 2013. Patients were classified in Rutherford categories 1-3 (n = 21 197), 4 (n = 5353), 5 (n = 6916), and 6 (n = 8416). The proportions of patients with classical risk factors such as hypertension, dyslipidaemia, and smoking declined with higher Rutherford categories (each P < 0.001) while diabetes, chronic kidney disease, and chronic heart failure increased (each P < 0.001). Angiographies and revascularizations were performed less often in advanced PAD (each P < 0.001). In-hospital amputations increased continuously from 0.5% in Rutherford 1-3 to 42% in Rutherford 6, as also myocardial infarctions, strokes, and deaths (each P < 0.001). Among 4298 amputated patients with CLI, 37% had not received any angiography or revascularization neither during index hospitalization nor the 24 months before. During follow-up (mean 1144 days), 7825 patients were amputated and 10 880 died. Kaplan-Meier models projected 4-year mortality risks of 18.9, 37.7, 52.2, and 63.5% in Rutherford 1-3, 4, 5, and 6, and for amputation of 4.6, 12.1, 35.3, and 67.3%, respectively. In multivariable Cox regression models, PAD categories were significant predictors of death, amputation, myocardial infarction, and stroke (each P < 0.001). Length of in-hospital stay (5.8 ± 6.7 days, 10.7 ± 11.1days, 15.2 ± 13.8 days and 22.1 ± 20.3 days; P < 0.001) and mean case costs (3662 ± 3186 €, 5316 ± 6139 €, 6021 ± 4892 €, and 8461 ± 8515 €; P < 0.001) increased continuously in Rutherford 1-3, 4, 5, and 6. While only 49% of the patients suffered from CLI, these produced 65% of in-hospital costs (141 million €), and 56% during follow-up (336 million €). CONCLUSION Regardless of recent advances in PAD treatment, current outcomes remain poor especially in CLI. Despite overwhelming evidence for reduction of limb loss by revascularization, CLI patients still received significantly less angiographies and revascularizations.
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Affiliation(s)
- Holger Reinecke
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital of Muenster, Muenster, Germany DRG Research Group, University Hospital of Muenster, Muenster, Germany
| | - Michael Unrath
- Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany Department of New Public Health, School of Human Sciences, Osnabrueck University, Osnabrueck, Germany
| | - Eva Freisinger
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital of Muenster, Muenster, Germany
| | - Holger Bunzemeier
- DRG Research Group, University Hospital of Muenster, Muenster, Germany
| | - Matthias Meyborg
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital of Muenster, Muenster, Germany
| | - Florian Lüders
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital of Muenster, Muenster, Germany
| | - Katrin Gebauer
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital of Muenster, Muenster, Germany
| | - Norbert Roeder
- DRG Research Group, University Hospital of Muenster, Muenster, Germany
| | - Klaus Berger
- Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany
| | - Nasser M Malyar
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital of Muenster, Muenster, Germany
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Velescu A, Mateos Torres E, Clará Velasco A. Predictors of medium-term patency in percutaneous endovascular therapy of femoro-popliteal lesions. Cir Esp 2014; 93:105-9. [PMID: 24931778 DOI: 10.1016/j.ciresp.2014.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 04/03/2014] [Accepted: 04/22/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND The objective is to study the medium-term results of angioplasty and stenting in the femoro-popliteal sector in patients with critical limb ischemia (CLI), and identify angiographic predictive factors of primary patency. PATIENTS AND METHODS Retrospective review of 98 patients with critical ischemia and angiographic lesions characterized as TASC A=13 (14%), B=38 (40%), C=24 (25%) or D=20 (21%). A total of 106 angioplasties and primary self-expanding stents (mean length of stent coverage of 19cm) were performed between January 2006 and January 2011. RESULTS The immediate results of patency, limb salvage and survival were 95, 96 and 96%, respectively. Primary patency at 1 and 2 years was 54 and 38%, respectively. Twenty-seven cases (25%) required endovascular iterative procedures, providing an assisted patency at 1 and 2 years of 72 and 60%, and a secondary patency of 80 and 67%. A lower primary patency was observed (log rank) when stent length was >20cm (P<.001), popliteal artery was invloved (P=.004), and in TASC C and D lesions (P=.04). In multivariate analysis (Cox), only stent length>20cm was an independent negative predictor for primary patency (HR=5.7, P<.001). The limb salvage at 1 and 2 years was 83 and 81%, respectively. CONCLUSIONS Angioplasty with stent in the femoro-popliteal sector is a safe technique, but with significantly lower permeability results in injuries that require stent coverage of more than 20cm. In these cases, vein bypass surgery should be the procedure of choice.
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Affiliation(s)
- Alina Velescu
- Servicio de Angiología y Cirugía Vascular, Hospital del Mar, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, España.
| | - Eduardo Mateos Torres
- Servicio de Angiología y Cirugía Vascular, Hospital del Mar, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, España
| | - Albert Clará Velasco
- Servicio de Angiología y Cirugía Vascular, Hospital del Mar, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, España
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Saarinen E, Laukontaus SJ, Albäck A, Venermo M. Duplex surveillance after endovascular revascularisation for critical limb ischaemia. Eur J Vasc Endovasc Surg 2014; 47:418-21. [PMID: 24560305 DOI: 10.1016/j.ejvs.2014.01.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 01/15/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Despite the popularity of endovascular therapy (EVT) for critical limb ischaemia (CLI), there are few studies investigating the efficacy of duplex ultrasound (DUS) surveillance after endovascular interventions. The aim of this study was to evaluate DUS surveillance after EVT for CLI. METHODS 146 endovascular procedures in 134 consecutive patients with CLI between 2011 and 2012 were included. Follow-up visits with ankle-brachial index (ABI), toe pressure, and target vessel DUS were performed at 1, 3, and 6 months after revascularisation. RESULTS The median age of the study population was 79 years, 58% were males, and 55% had diabetes. The target artery was at the iliac, femoro-popliteal, and infrapopliteal level in 2%, 54%, and 44% of cases, respectively. There were 282 follow-up visits. In 15 (5.3%) DUS examinations, the target vessel was not seen properly. In the remaining 267 DUS, the majority of the target arteries were patent with no or mild restenosis (n = 169, 63.3%), but in 98 (36.7%) examinations, the target artery was stenosed or occluded. When DUS was compared with the clinical presentation, there was no correlation in 30% and when DUS and toe pressure were compared, discrepancy was seen in 29%. A re-angiogram was performed for 29 patients, and the DUS finding was verified in each case. During the mean follow-up of 11 months, a new endovascular intervention was performed on 37 (25.3%) limbs, and 4 (2.7%) underwent surgical bypass. Four (3.0%) patients died and 6 (4.5%) underwent major amputation. CONCLUSION Clinical status or toe pressure alone were adequate markers of endovascular revascularisation failure in the majority of the patients, but would have missed up to one-third of the clinically significant re-stenoses or occlusions. DUS is therefore a valuable aid in surveillance after EVT for CLI, especially for patients with an ischaemic tissue lesion.
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Affiliation(s)
- E Saarinen
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland.
| | - S J Laukontaus
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - A Albäck
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - M Venermo
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland
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Malyar N, Fürstenberg T, Wellmann J, Meyborg M, Lüders F, Gebauer K, Bunzemeier H, Roeder N, Reinecke H. Recent trends in morbidity and in-hospital outcomes of in-patients with peripheral arterial disease: a nationwide population-based analysis. Eur Heart J 2013; 34:2706-14. [PMID: 23864133 DOI: 10.1093/eurheartj/eht288] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIMS The prevalence of peripheral arterial disease (PAD) and especially of critical limb ischaemia (CLI) is announced to rise dramatically worldwide, with a considerable impact on the health care and socio-economic systems. We aimed to characterize the recent trends in morbidity and in-hospital outcome of PAD among all hospitalized patients in the entire German population between 2005 and 2009. METHODS AND RESULTS Nationwide data of all hospitalizations in Germany in 2005, 2007, and 2009 were analysed regarding the prevalence of PAD, comorbidities, endovascular (EVR) and surgical revascularizations (SR), major and minor amputations, in-hospital mortality, and associated costs. From 2005 to 2009, total PAD cases increased by 20.7% (from 400 928 to 483 961), with an increase of CLI subset from 40.6 to 43.5%. Total EVR increased by 46%, while thromb-embolectomy, endarterectomy, and patch plastic increased by 67, 42, and 21%, respectively. Peripheral bypasses decreased by 2%. Major amputation decreased from 4.6 to 3.5%, while minor amputation slightly increased from 4.98 to 5.11%. The crude overall in-hospital mortality remained unchanged in claudicants (2.2%), while it decreased from 9.8 to 8.4% in CLI patients. However, mortality rate according to the Poisson model (n/1000 hospital residence days) increased significantly in claudicants (P < 0.001). Total reimbursement costs for PAD in-patient care increased by 21% with an average per case costs in 2009 of €4506 in a claudicant and €6791 in a CLI patient. CONCLUSION This population-based analysis documents the significant rise of PAD, particularly of the CLI subset, and highlights the malign prognosis associated with PAD as indicated by high amputation and in-hospital mortality rates.
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Affiliation(s)
- Nasser Malyar
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University of Muenster, Albert-Schweitzer-Campus 1, A1, 48149 Muenster, Germany
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Abstract
Critical limb ischaemia is an intractable condition associated with high levels of amputation, leading to a low quality of life and increased morbidity and mortality. It is often not treatable by standard therapeutic modalities. Neoangiogenesis has been proposed as a novel method of treatment of such patients. Vascular endothelial growth factor (VEGF) and cytokine fibroblast growth factor (FGF-1) have been shown to elicit neoangiogenesis. Stem cells are progenitor cells which can differentiate in vivo into different types of cells. Mesenchymal stem cells (MSCs) are a type of adult stem cells which have an immunomodulatory effect. Stem cell therapy has been used in animal studies to improve limb vascularity in rat and rabbit models. Several clinical studies have also validated their use for critical limb ischaemia. However many issues are still unresolved. These include the dosage, delivery and safety issues in relation to stem cell therapy. However stem cells are likely to be an important therapeutic modality to treat critical limb ischaemia in the near future.
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