Comparative Study of Venous Arterialization and Pedal Bypass in a Patient Cohort with Critical Limb Ischemia (original) (raw)
Related papers
Annals of Vascular Surgery, 2007
In our aging population, primary major amputations (AMP, below-knee or above-knee) continue to be performed despite advances in revascularization. We hypothesized that not only patient comorbidities but also the system of health-care delivery affected the treatment of patients with critical limb ischemia (CLI). A prospective analysis of patients presenting with CLI was undertaken to determine whether patient-specific factors or healthcare delivery factors (system-related) influenced treatment with primary AMP versus lower extremity revascularization (LER). The patient-specific factors age, gender, race/ethnicity, presence of coronary artery disease, cerebrovascular disease, tobacco use, diabetes mellitus (DM), dialysis dependence (endstage renal disease, ESRD), hypertension, hyperlipidemia, stage of CLI (rest pain, minor or major tissue loss), history of revascularization, and functional status (living situation and ambulatory status) were recorded. The system-related factors time from onset of CLI to vascular surgery evaluation and type of insurance (managed care/other insurance) were also noted. The influence of patient-specific and system-related factors on the primary treatment modality (AMP versus LER) was determined with univariate and multivariate analyses. A total of 224 patients presented with CLI between March 1, 2001, and March 1, 2005. Patients were treated with primary major AMP in 97 cases (43%) and revascularization in 127 cases (57%). On univariate analysis, nonwhite race/ethnicity, DM, ESRD, major tissue loss, dependent living situation, and nonambulatory status were all significant predictors of AMP versus LER (all P < 0.01). On multivariate analysis, major tissue loss, ESRD, DM, and nonambulatory status remained independent predictors of AMP versus LER (all P < 0.05). The system-related factors of time to vascular surgery evaluation (mean 8.6 weeks, 7.1 vs. 9.3 weeks AMP versus LER, P ¼ 0.60) and type of insurance (managed care, 17% vs. 24% AMP vs. LER, P ¼ 0.15) had no influence on treatment. Fifty-four percent of all primary major AMPs were performed due to extensive gangrene or infection present at initial vascular evaluation which precluded limb salvage. Major tissue loss, ESRD, DM, and nonambulatory status are all independent predictors of treatment with primary AMP as opposed to revascularization. Treatment of CLI is determined by patient-specific factors and does not appear to be adversely influenced by system-related factors. Efforts toward improving limb salvage may be best directed at aggressive treatment of medical comorbidities to prevent the late complications of CLI. Earlier recognition of tissue loss and referral to the vascular specialist may lead to improved limb salvage.
Surgical Practice, 2014
The aim of the present study was to evaluate current results of endovascular and open-bypass treatment of critical limb ischaemia subsequent to advancement in endovascular instruments and the development of endovascular technique in the past decade. Patients and Methods: A total of 160 patients with 167 limbs treated at a single centre between 2008 and 2012 were followed up for at least 2 years and reviewed retrospectively. Patients were stratified into an endovascular group and an open-bypass group based on first intervention received. The two groups demonstrated comparable demographics, clinical profile classified by Rutherford Classifications and lesion characteristics evaluated according to TransAtlantic Intersociety Consensus staging standards. One-year primary patency, 2-year primary patency, secondary patency, overall survival rate and amputation-free-survival rate were compared between the endovascular group and open-bypass group. Results: The endovascular group showed superior results to the bypass group in terms of 1-year amputation-free-survival (endovascular: 78.2 per cent, open bypass: 61.3 per cent, P = 0.023) and 2-yearamputation-free-survival (endovascular: 73.1 per cent, open bypass: 56 per cent, P = 0.027). No significant difference was found between the two groups in 1-year primary patency (endovascular: 80.3 per cent, open bypass: 67.8 per cent, P = 0.103), 2-year primary patency (endovascular: 80.3 per cent, open bypass: 64.8 per cent, P = 0.056), 1-year secondary patency (endovascular: 77.8 per cent, open bypass: 66.7 per cent, P = 0.577) and two-year secondary patency (endovascular: 77.8 per cent, open bypass: 58.3 per cent, P = 0.350). Comparable results were noted in the 1-year survival rate (endovascular: 91 per cent, open bypass: 81.3 per cent, P = 0.082) and 2-year survival rate (endovascular: 84.6 per cent, open bypass: 72 per cent, P = 0.058). Lower median blood loss (endovascular: 15 mL, open bypass: 100 mL) and shorter mean operative time (endovascular: 27.2 min, open bypass: 143.1 min) were demonstrated in the endovascular group. Conclusion: Endovascular intervention has demonstrated superior results to bypass surgery in critical limb ischaemia in terms of 1-year and 2-year amputation-free-survival, with potential benefits of lower intraoperative blood loss and a shorter operative time. Primary patency, secondary patency and overall survival in 2 years are currently comparable between the two intervention modalities.
Journal of Vascular Surgery, 2012
The adoption of endovascular interventions has been reported to lower amputation rates, but patients who undergo endovascular and open revascularization are not directly comparable. We have adopted an endovascular-first approach but individualize the revascularization technique according to patient characteristics. This study compared characteristics of patients who had endovascular and open procedures and assessed the long-term outcomes. Methods: From December 2002 to September 2010, 433 patients underwent infrainguinal revascularization for critical limb ischemia (CLI; Rutherford IV-VI) of 514 limbs (endovascular: 295 patients, 363 limbs; open: 138 patients, 151 limbs). Patency rates, limb salvage (LS), and survival, as also their predictors, were calculated using Kaplan-Meier and multivariate analysis. Results: The endovascular group was older, with more diabetes, renal insufficiency, and tissue loss. More reconstructions were multilevel (72% vs 39%; P < .001) and the most distal level of intervention was infrapopliteal in the open group (64% vs 49%; P ؍ .001). The 30-day mortality was 2.8% in the endovascular and 6.0% in the open group (P ؍ .079). Mean follow-up was 28.4 ؎23.1 months (0-100). In the endovascular vs open groups, 7% needed open, and 24% needed inflow/runoff endovascular reinterventions with or without thrombolysis vs 6% and 17%. In the endovascular vs open group, 5-year LS was 78% ؎ 3% vs 78% ؎ 4% (P ؍ .992), amputation-free survival was 30% ؎ 3% vs 39% ؎ 5% (P ؍ .227), and survival was 36% ؎ 4% vs 46% ؎ 5% (P ؍ .146). Five-year primary patency (PP), assisted-primary patency (APP), and secondary patency (SP) rates were 50 ؎ 5%, 70 ؎ 5% and 73 ؎ 6% in endovascular, and 48 ؎ 6%, 59 ؎ 6% and 64 ؎ 6% in the open group, respectively (P ؍ .800 for PP, 0.037 for APP, 0.022 for SP). Multivariate analysis identified poor functional capacity (hazard ratio, 3.5 [95% confidence interval, 1.9-6.5]; P < .001), dialysis dependence (2.2 [1.3-3.8]; P ؍ .003), gangrene (2.2 [1.4-3.4]; P < .001), need for infrapopliteal intervention (2.0 [1.2-3.1]; P ؍ .004), and diabetes (1.8 [1.1-3.1]; P ؍ .031) as predictors of limb loss. Poor functional capacity (3.3 [2.4-4.6]; P < .001), coronary artery disease (1.5 [1.1-2.1]; P ؍ .006), and gangrene (1.4 [1.1-1.9]; P ؍ .007) predicted poorer survival. Statin use predicted improved survival (0.6 [0.5-0.8]; P ؍ .001). Need for infrapopliteal interventions predicted poorer PP (0.6 [0.5-0.9-2.2]; P ؍ .007), whereas use of autologous vein predicted better PP (1.8 [1.1-2.9]; P ؍ .017). Conclusions: Patients who undergo endovascular revascularization for CLI are medically higher-risk patients. Those who have bypass have more complex disease and are more likely to require multilevel reconstruction and infrapopliteal intervention. Individualizing revascularization results in optimization of early and late outcomes with acceptable LS, although survival remains low in those with poor health status.
Microvascular Pedal Bypass for Salvage of the Severely Ischemic Limb
Mayo Clinic Proceedings, 1991
Bypass to the pedal arteries was performed with use of the operating microscope and standard microsurgical technique in 37 patients with severe, chronic ischemia of a lower extremity. Twenty-one patients (57%) had three or more cardiovascular risk factors, and 22 (59%) had diabetes. Preoperative arteriography identified a pedal artery suitable for bypass in all but one patient. The greater or lesser saphenous vein was used in all patients, most frequently as a nonreversed, translocated vein graft. An arm vein was used as part of a composite graft in only one patient. No early deaths occurred, and only one patient had a perioperative myocardial infarction. Although five grafts occluded within 30 days, four were successfully revised, and 36 patients had a patent graft at the time of dismissal from thehospital. At I year, the primary graft patency rate (patency without revision) was 60.8%, and the secondary patency rate was 68.8%. One early and six late amputations were performed; the cumulative I-year limb salvage rate was 82.4%. Grafts with an intraoperative flow rate of 50 mil min or more had a better patency rate than those with a lower flow rate. The presence of diabetes did not adversely affect long-term patency. Of the 34 patients who were alive at the time ofthis report, 27 (79%) had a functional foot that allowed ambulation, had no rest pain, and had no substantial loss of tissue. Pedal bypass should be considered for critical, chronic ischemia, even ifthe patient has an increased surgical risk and advanced distal atherosclerotic disease.
European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery, 2017
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. To review the literature on the clinical effectiveness of venous arterialisation for lower limb salvage in CLI patients with no revascularisation options. 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, ...
Outcomes of lower extremity bypass performed for acute limb ischemia
Objective-Acute limb ischemia remains one of the most challenging emergencies in vascular surgery. Historically, outcomes following interventions for acute limb ischemia have been associated with high rates of morbidity and mortality. The purpose of this study was to determine contemporary outcomes following lower extremity bypass performed for acute limb ischemia.
Pedal Bypass for Critical Limb Ischemia
Perspectives in Vascular Surgery, 2000
This case panel discussion addresses some of the problems and judgment decisions required in a patient with extensive forefoot gangrene, a stenosis of the superficial femoral artery (SFA), and occlusions of all three leg arteries in the mid and upper leg. With extensive foot debridement to the transmetatarsal level, balloon angioplasty of the SFA, and a vein bypass to the distal anterior tibial artery, a functional foot remnant was saved. The timing of the various procedures, technical details regarding them, and other issues are discussed.
Timing of pedal bypass failure and its impact on the need for amputation
Annals of vascular surgery, 2005
Although the utility of dorsalis pedis (DP) bypass for limb ischemia has been well established, the fate of limbs with a failed bypass to the DP artery remains unclear. Data of all patients undergoing DP bypass grafting within a 12-year period from two university hospitals' vascular registries were retrospectively reviewed. Outcomes of early (<30 days) and delayed graft failure (>30 days) were examined. The Student's t-test and chi-squared test were used for univariate analysis; patency rates and patient survival were calculated using the Kaplan-Meier product limit method. Of 1434 DP bypass grafts, 277 (19.3%) failed grafts were identified. Sixty five (4.5%) grafts failed early (within 30 days of surgery) and 212 (14.8%) failed late at a mean time of 15.3 months (range, 1.5-105 months) after initial bypass. Of the 65 limbs with early graft failure, 28 (43.1%) proceeded directly to amputation and 20 underwent additional revascularization attempts, but limb salvage was a...
Open versus Endovascular Intervention for Critical Limb Ischemia: A Population-Based Study
Journal of the American College of Surgeons, 2010
BACKGROUND: Endovascular techniques are considered by many as the first-line treatment for critical limb ischemia (CLI). The purpose of this study is to assess the impact of endovascular therapy on CLI and amputation in South Carolina during the past decade. STUDY DESIGN: This is a retrospective, comparative analysis of treatment outcomes for CLI in the preendovascular era and the endovascular era. The South Carolina Office of Research and Statistics database was reviewed using ICD-9 diagnosis and procedure codes to identify patients who underwent limb revascularization in 1996 (pre-endovascular era) and 2005 (endovascular era) for CLI and to determine those who required subsequent limb amputation and additional revascularization.
European Journal of Vascular and Endovascular Surgery
This population based observational cohort study provides mid-to long-term follow-up data on the risk of amputation and mortality in a large and unselected nationwide cohort with lower limb peripheral arterial disease who underwent revascularisation during a 5 year period. Amputations and the cumulative incidence of death or amputation are presented separately for patients with intermittent claudication (IC) and critical limb ischaemia (CLI). Pre-operative comorbidities are compared for IC versus CLI patients. Objectives: The aims of this population based study were to describe mid-to long-term amputation risk, cumulative incidence of death or amputation, and differences in pre-operative comorbidities in patients revascularised for lower limb peripheral artery disease (PAD). Methods: This was an observational cohort study. Data from the Swedish National Quality Registry for Vascular Surgery (Swedvasc) were combined with mandatory national health care registries and patient medical records. All patients who underwent revascularisation in Sweden between May 2008 and May 2013 for intermittent claudication (IC) or critical limb ischaemia (CLI), aged 50 years and older, were identified through the Swedvasc database. The mandatory national health care registries and medical records provided data on comorbidities, mortality, and major amputations. Results: A total of 16,889 patients with PAD (IC, n ¼ 6272; CLI, n ¼ 10,617) were studied. The incidence of amputations in IC patients was 0.4% (range 0.3%e0.5%) per year. Among CLI patients, the amputation rate during the first 6 months following revascularisation was 12.0% (95% CI 11.3e12.6). Thereafter, the incidence declined to approximately 2% per year. The cumulative combined incidence of death or amputation 3 years after revascularisation was 12.9% (95% CI 12.0e13.9) in IC patients and 48.8% (95% CI 47.7e49.8) in CLI patients. Among CLI patients, compared with IC patients, the prevalence of diabetes, ischaemic stroke, heart failure, and atrial fibrillation was approximately doubled and renal failure was nearly tripled, even after age standardisation. Conclusion: The risk of amputation is particularly high during the first 6 months following revascularisation for CLI. IC patients have a benign course in terms of limb loss. Mortality in both IC and CLI patients is substantial. Revascularised CLI patients have different comorbidities from IC patients.