Multilevel Arterial Disease Research Articles

The Comorbidity-Polypharmacy Score as a Predictive Tool of Survival and Limb Salvage in Patients Undergoing Lower Limb Revascularization Procedures for Chronic Limb-Threatening Ischemia

ObjectiveThe comorbidity-polypharmacy score (CPPS) was created to evaluate the clinical burden of comorbidities in geriatric patients. It represents an objective tool to stratify patients’ risk in different settings. The study aimed to evaluate CPPS in predicting mortality and amputation in patients undergoing elective revascularization procedures in CLTI patients. MethodsThis is 2 years retrospective single-centre study. We included all patients undergoing elective lower-limb revascularization procedures admitted with CLTI diagnosis. Four CPPS groups were defined: mild, moderate, severe and morbid. The primary early and long-term outcomes were 30-day overall mortality, 30-day amputation rate and overall survival and limb salvage respectively. ResultsA total of 442 patients were enrolled in the study. Mean age was 76.5±9.9 years and 61.5% (272/442) were male. CPPS was calculated: 22.6% (100/442) have mild CPPS, 54.3% (240/442) moderate, 21.9% (97/442) severe and 1.2% (5/442) morbid.Kaplan-Meier curves for overall survival stratified for CPPS grade highlighted a strong statistically significant difference (p<0.0001) among the four CPPS classes.Mild CPPS has significantly higher limb salvage rate among moderate, severe and morbid CPPS groups (p<0.0001). Limb salvage for mild and severe CPPS, at 36 months was 95% vs. 85.1% respectively.Stepwise multivariable Cox-analysis revealed that mortality was independently associated with dialysis, Rutherford Classification V, age and CPPS. Male sex, multilevel arterial disease, and hybrid surgical repair were independently associated with amputations. ConclusionCPPS is a straightforward tool to evaluate the patient’s complexity and could be used as an adjuvant tool to stratify early- and long-term outcomes in CLTI patients undergoing elective revascularization procedures.

The Role of Hybrid Revascularization Procedures for Symptomatic Chronic Peripheral Arterial Disease

Abstract Background Peripheral arterial disease (PAD) is a chronic vascular disease characterized by impaired circulation to the lower extremities. While early stages of PAD may be asymptomatic, the hallmarks of its most severe stage, known as chronic limb threatening ischemia (CLTI). It is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration &amp;gt;2 weeks duration. Aim of the Work The aim of this study is to assess the clinical and hemodynamic outcome of CLTI treated by hybrid revascularization procedures and the possible risk of postoperative amputation. Patients and Methods The following electronic databases were searched up to 2022: PubMed, Google Scholar search engine, Cochrane database of systematic reviews, EMBASE, Science Direct, Wiley Online Library, ELSEVIER, Scopus and the European journal of vascular society searching keywords and terms listed below: “Critical limb threatening ischemia, management of peripheral arterial disease, multi-level occlusive arterial disease, hybrid revascularization, outcome of hybrid procedures”. Results In our meta-analysis, risk factors of PAD included gender, smoking, HTN, DM, coronary artery disease, CVS, CKD, Hyperlipidemia and COPD. Success rate of hybrid revascularization technique showed a significant effect than other techniques. Conclusion The results of this meta-analysis showed that Diabetes Mellitus and hypertension are two major risk factors that worsen the outcome of hybrid procedures. Hybrid procedures have added to the armamentarium for treatment of patients with multilevel arterial disease and offer a less risky option for elderly patients with multiple comorbid conditions. Hybrid procedures are effective to treat patients with either CLI or claudication.

Retrograde distal access versus femoral access for below the knee angioplasty.

The prevalence of peripheral artery disease (PAD) in the general population is about 12% to 14% and it increases with age. PAD increased from 164 million people in 2000 to 202 million people in 2010. More than two-thirds of people with PAD are based in low- or middle-income countries. Critical limb ischaemia (CLI) occurs in 1% to 2% of people with intermittent claudication over five years. One third of people with CLI have isolated below the knee (BTK) lesions. CLI and isolated BTK lesions are associated with a higher incidence of limb loss when compared with people with multilevel arterial disease. Endovascular procedures such as angioplasty (with or without stenting) are widely used to treat isolated BTK lesions, aiming to improve blood flow and limb salvage. The technical success of any angioplasty procedure depends on the ability to cross the target lesion. Failed attempts are underestimated in the literature and failures in the real world appear to be higher than reported. People with isolated BTK lesions undergoing angioplasty by conventional femoral access present a high failure rate to cross these lesions. Retrograde distal access may provide some advantages that can lead to successful crossing of the target lesion. To evaluate the benefits and harms of retrograde distal access versus conventional femoral access for people undergoing below the knee angioplasty. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases, and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 September 2022. We planned to include randomised or quasi-randomised controlled trials comparing people undergoing retrograde distal access versus people undergoing conventional femoral access (ipsilateral antegrade or contralateral retrograde) for BTK angioplasty. Two review authors independently assessed identified studies for potential inclusion in the review. We used standard methodological procedures in accordance with the Cochrane Handbook for Systematic Review of Interventions. Our primary outcomes were technical success of angioplasty procedure and major procedural complications. Our secondary outcomes were mortality rate, amputation-free survival, primary patency, minor procedural complications and wound healing. We planned to use GRADE to assess the certainty of the evidence for each outcome. We identified no randomised or quasi-randomised controlled trials that met the inclusion criteria. We identified no randomised or quasi-randomised controlled trials that compared retrograde distal access versus femoral access for BTK angioplasty. High-quality studies that compare retrograde distal access versus conventional femoral access for BTK angioplasty are needed.

Midterm Results of Endovascular Management of Multilevel Arterial Disease in Lower Limb in Diabetic Patients

Midterm Results of Endovascular Management of Multilevel Arterial Disease in Lower Limb in Diabetic Patients

Outcome after Hybrid Outflow Interventions for Chronic Limb-threatening Ischemia.

Because chronic limb-threatening ischemia (CLTI) is often associated with multilevel arterial disease, it usually requires revascularization at different sites of the limb vasculature. We aim to assess the outcome of the hybrid interventions including open surgical revascularization together with outflow segment percutaneous transluminal angioplasty (PTA) in patients with chronic limb-threatening ischemia. This study included all hybrid outflow-PTA interventions (n = 80) on patients suffering from CLTI performed in Helsinki University Hospital between 2003 and 2015. Follow-up ended on 31 December 2019. Patient data were prospectively collected into our vascular registry and scrutinized retrospectively. Thirty-one patients (39%) suffered from rest pain (Rutherford category IV) and 49 patients (61%) had ischemic ulcers (Rutherford category V-VI). The most common open surgical procedure was femoral endarterectomy (n = 63, 79%) and the most common endovascular procedure was superficial femoral artery percutaneous transluminal angioplasty (n = 65, 81%). Mean follow-up time was 56 months (range: 4 days-183 months). Limb salvage was at 30 days-92%, at 1 year-91%, and at 5 and 10 years-86%. Survival and amputation-free survival were at 30 days-93% and 86%, at 1 year-80% and 76%, at 5 years-51% and 48%, and at 10 years-21% and 21%. Wound healing at 3, 6, and 12 months was 48%, 71%, and 87%. Freedom from target lesion revascularization was at 30 days-97%, at 1 year-88%, at 5 years-72%, and at 10 years-66%. Hybrid outflow revascularization is an important tool in the vascular surgeon's armamentarium for treatment of patients with multilevel arterial disease causing chronic limb-threatening ischemia.

Endovascular Therapy Provides Similar Results of Bypass Graft Surgery in the Treatment of Infrainguinal Multilevel Arterial Disease in Patients with Chronic Limb-Threatening Ischemia in All GLASS Stages

Extensive infrainguinal arterial disease still pose a challenge for technical and clinical success of percutaneous angioplasty. The purpose of this study was to compare the results of concomitant femoropopliteal and infrapopliteal percutaneous angioplasty/stenting (PTA/S) with distal bypass graft surgery (BGS) in patients with chronic limb-threatening ischemia (CLTI). In a single-center retrospective investigation between 2011 and 2017, 668 revascularization procedures for CLTI were reviewed. Concomitant femoropopliteal and infrapopliteal disease was identified in 153 CLTI patients, treated with BGS (48) using autogenous veins as substitute or PTA/S in a single procedure (105). A subgroup of patients with complex, extensive arterial lesions (GLASS stage III) received additional analysis. Primary outcomes were limb salvage and survival. The mean follow-up time was 21.4months. Patients treated with PTA/S were significantly older and with predominance of females, diabetes and chronic kidney disease. Smoking was more common in patients treated with BGS. The BGS group showed a 36-month survival rate of 73.4%, whereas the PTA/S group presented a survival of 61.3% in the same interval (P=0.25). The 36-month cumulative limb salvage rate was 53.3 and 59.7% for BGS and PTA/S, respectively (P=0.24). For GLASS stage III patients, 36-month limb salvage rates were 54.4% for the PTA/S group and 50.2% for the BGS group (P=0.29). Multivariate analysis pointed poor runoff status (all endovascular patients) and diabetes (GLASS III endovascular patients) as risk factors for limb loss. PTA/S and BGS presented similar results of limb salvage and survival in the treatment of concomitant femoropopliteal and infrapopliteal arterial disease in patients with CLTI, even for patients with extensive and complex arterial disease.

The Effect of Iliac Angioplasty – As A Single Level Correction in Patients With Multi-level Arterial Disease – On Improving the Patient's Condition

The Effect of Iliac Angioplasty – As A Single Level Correction in Patients With Multi-level Arterial Disease – On Improving the Patient's Condition

Hybrid Surgery in Lower Limb Revascularization: A Real-World Experience from a Single Center

Through the association of endovascular and open procedures, hybrid surgery for lower limb revascularization allows the treatment of multilevel occlusive disease with a lower risk when compared to extensive open interventions. The aim of this study is to evaluate the immediate and midterm clinical outcomes of hybrid techniques for lower limb revascularization in a cohort of patients with multilevel arterial disease. Data from elective procedures between 2012 and 2017 were retrospectively collected regarding hybrid lower limb revascularization procedures. The outcomes of the study were categorical clinical improvement, patency rates, major amputation rates, and mortality. A total of 81 patients, 89 limbs, with a median age of 69years (interquartile range [IQR] 61-73) were submitted to hybrid lower limb revascularization, with a median follow-up of 10.7months (IQR 2.5-25.1). Treatment indications were chronic limb-threatening ischemia in 80.9% of the cases (rest pain in 18.0% and tissue loss in 62.9%). One-year primary, primary-assisted, and secondary patency rates were 78.28% (95% confidence interval [CI] 65.20-86.92), 85.12% (95% CI 72.96-92.09), and 90.19% (95% CI 79.13-95.54), respectively. Overall categorical clinical improvement was observed in 56.2%. Major amputation and mortality rates were 14.6% and 16.0%, respectively. Multilevel Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) C or D and stage IV Leriche-Fontaine classification were strongly associated with decreased categorical clinical improvement (adjusted odds ratio [aOR] 0.08, P<0.0001 and aOR 0.25, P=0.013, respectively). Multilevel TASC C or D was also related to higher amputation rates, contrary to clinical presentation (adjusted hazard ratio [aHR] 11.37, P=0.002 and aHR 4.70, P=0.091, respectively). Primary-assisted and secondary patency rates were associated with higher categorical clinical improvement (aOR 4.30, P=0.036 and aOR 7.36, P=0.021, respectively) and decreased major amputation rates (aHR 0.11, P=0.003 and aHR 0.09, P=0.001, respectively) but were not related to multilevel TASC and Leriche-Fontaine classifications. The present study reports a real-world experience with a large proportion of patients with chronic limb-threatening ischemia. Hybrid interventions for lower limb revascularization revealed to be a potential approach for patients with complex arterial disease that would beneficiate from less invasive procedures.

Comparison of the results of hybrid and open surgical treatment of multilevel arterial disease of lower extremities

Comparison of the results of hybrid and open surgical treatment of multilevel arterial disease of lower extremities

Clinical outcomes of bypass-first versus endovascular-first strategy in patients with chronic limb-threatening ischemia due to infrageniculate arterial disease

BackgroundChronic limb-threatening ischemia (CLTI), defined as ischemic rest pain or tissue loss secondary to arterial insufficiency, is caused by multilevel arterial disease with frequent, severe infrageniculate disease. The rise in CLTI is in part the result of increasing worldwide prevalence of diabetes, renal insufficiency, and advanced aging of the population. The aim of this study was to compare a bypass-first with an endovascular-first revascularization strategy in patients with CLTI due to infrageniculate arterial disease. MethodsWe reviewed the American College of Surgeons National Surgical Quality Improvement Program targeted lower extremity revascularization database from 2012 to 2015 to identify patients with CLTI and isolated infrageniculate arterial disease who underwent primary infrageniculate bypass or endovascular intervention. We excluded patients with a history of ipsilateral revascularization and proximal interventions. The end points were major adverse limb event (MALE), major adverse cardiovascular event (MACE), amputation at 30 days, reintervention, patency, and mortality. Multivariable logistic regression was used to determine the association of a bypass-first or an endovascular-first intervention with outcomes. ResultsThere were 1355 CLTI patients undergoing first-time revascularization to the infrageniculate arteries (821 endovascular-first revascularizations and 534 bypass-first revascularizations) identified. There was no significant difference in adjusted rate of 30-day MALE in the bypass-first vs endovascular-first revascularization cohort (9% vs 11.2%; odds ratio [OR], 0.73; 95% confidence interval [CI], 0.50-1.08). However, the incidence of transtibial or proximal amputation was lower in the bypass-first cohort (4.3% vs 7.4%; OR, 0.60; CI, 0.36-0.98). Patients with bypass-first revascularization had higher wound complication rates (9.7% vs 3.7%; OR, 2.75; CI, 1.71-4.42) compared with patients in the endovascular-first cohort. Compared with the endovascular-first cohort, the incidence of 30-day MACE was significantly higher in bypass-first patients (6.9% vs 2.6%; adjusted OR, 3.88; CI, 2.18-6.88), and 30-day mortality rates were 3.23% vs 1.8% (adjusted OR, 2.77; CI, 1.26-6.11). There was no difference in 30-day untreated loss of patency, reintervention of treated arterial segment, readmissions, and reoperations between the two cohorts. In subgroup analysis after exclusion of dialysis patients, there was also no significant difference in MALE or amputation between the bypass-first and endovascular-first cohorts. ConclusionsCLTI patients with isolated infrageniculate arterial disease treated by a bypass-first approach have a significantly lower 30-day amputation. However, this benefit was not observed when dialysis patients were excluded. The bypass-first cohort had a higher incidence of MACE compared with an endovascular-first strategy. These results reaffirm the need for randomized controlled trials, such as the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL-2) trial and Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI), to provide level 1 evidence for the role of endovascular-first vs bypass-first revascularization strategies in the treatment of this population of challenging patients.

Treatment of critical limb ischemia in patients with multilevel arterial lesions

The extreme manifestation of atherosclerotic lesion of the arteries of the lower extremities is the critical ischemia of the lower extremities. The number of high amputations in such patients ranges from 120 to 500 per 1 million population in the general population annually. In order to achieve the best results in the patency of the arterial bed in the near and distant periods, revascularization of the arteries of the proximal and distal blood flow is necessary. The aim of the work was to evaluate the possibilities and effectiveness of endovascular, open and hybrid arterial interventions on the lower extremities, particularly in patients with multilevel arterial disease, by conducting a retrospective analysis of treatment of critical ischemia. The results of the preoperative ultrasound duplex scan (UDS) of the arteries of 212 patients with critical ischemia of the lower limbs (CILL) shoved, that in 78 (36.8%) were multilevel arterial lesions (MLAL). Patients were divided into two groups. The first (main group) consisted of 50 patients (64%), who have been restored to the open-end and endovascular methods of MLAL, or only endovascular. The second (control) group included 28 patients (36%) — with restoration of permeability of the proximal segment without intervention on the arteries of the distal. Installed, during the period of 16 months, postoperative observation of 78 patients with MLAL, the primary frontal area of the femoral reconstruction in the main group was 92%, and limb preservation - 96%. In the control group, the permeability of the reconstruction zone was 75%, limb preservation — 82%. Thus, it has been established that the most optimal method of recovery of inflow and outflow pathways is one-time hybrid surgical interventions performed in 88% of these patients, which allow to achieve more effectively the recurrence of ischemia and maintain limb.

Endovascular revascularization of multilevel arterial disease in patients with critical limb ischemia

Background: Critical limb ischemia (CLI) occurs due to progressive obstructive nature of atherosclerosis disease. Nowadays, there is widespread use of endovascular revascularization procedures for restoration of blood flow in CLI. The aim this study is evaluation of the efficacy of endovascular intervention for multilevel arterial disease in patients with critical limb ischemia.Methods: This prospective study was included CLI patients due to multilevel arterial disease who underwent endovascular revascularization between January 2016 and January 2017 in our institution. Study end points were limb salvage and wound healing. Results: The mean age of patients was (61.7±7.47) years, with 13 (61.9%) men. Eight limbs were identified as Rutherford category 4 (38.1%), ten limbs as Rutherford category 5 (47.6%), and three limbs as Rutherford category 6 (14.3%). Limb salvage rate was (90.5%) at 1 year. Wound healing rate was 80.9%.Conclusions: This study proved that endovascular revascularization of multilevel arterial disease for patients with critical limb ischemia is effective.

New method of vertebrobasilar revascularization in multilevel arterial disease

New method of vertebrobasilar revascularization in multilevel arterial disease

Surgical and endovascular hybrid approach in peripheral arterial disease of the lower limbs

Multilevel peripheral arterial disease is frequently observed in patients with intermittent claudication or critical limb ischemia. This report evaluates the efficacy of one-stage hybrid revascularization in patients with multilevel arterial peripheral disease. A retrospective analysis of a prospective database included all consecutive patients treated by a hybrid approach for a multilevel arterial peripheral disease. The primary outcome was the patency rate at 6 months and 1 year. Secondary outcomes were early and midterm complication rate, limb salvage and mortality rate. Statistical analysis, including a Kaplan-Meier estimate and univariate and multivariate Cox regression analyses were carried out with the primary, primary assisted and secondary patency, comparing the impact of various risk factors in pre- and post-operative treatments. 64 patients were included in the study, with a mean follow-up time of 428 days (range: 4 - 1140). The technical success rate was 100 %. The primary, primary assisted and secondary patency rates at 1 year were 39 %, 66 % and 81 %, respectively. The limb-salvage rate was 94 %. The early mortality rate was 3.1 %. Early and midterm complication rates were 15.4 % and 6.4 %, respectively. The early mortality rate was 3.1 %. The hybrid approach is a major alternative in the treatment of peripheral arterial disease in multilevel disease and comorbid patients, with low complication and mortality rates and a high limb-salvage rate.

Efficacy of iliac inflow repair in patients with concomitant iliac and superficial femoral artery occlusive disease

In multilevel arterial disease, whether complete revascularization or staged runoff repair should be performed remains controversial. The aim of this study was to evaluate the efficacy of iliac inflow repair and to identify clinical conditions that are associated with the need for runoff repair in concomitant iliac and superficial femoral artery (SFA) occlusive disease. Patients undergoing inflow repair for complicated flow-limiting iliac lesions with diffuse SFA disease between 2007 and 2013 were retrospectively reviewed. Patients with poor response to inflow repair underwent infrainguinal revascularization (IIR). The 29 ischemic limbs examined in this study represent 26 different patients (22 males; mean age, 77±8years). Indications for inflow repair were Rutherford Classifications III (31%), IV (31%), V (31%), and VI (7%). Severity of the complicated SFA disease was either TASC (TransAtlantic Inter-Society Consensus) type C (14%) or type D (86%). Overall, freedom from IIR was 90% after 30days and 83% after 1year. Patients having claudication, rest pain, and shallow ischemic ulcers experienced the relief of symptoms, whereas patients with deep gangrene that needed minor amputation required IIR more frequently (p<0.01). Anatomical risk factors for poor response to inflow repair were poor quality of the deep femoral artery (p<0.01) and the flow-limiting popliteal artery (p=0.02), and poor below-knee runoff (≤ 1 vessel, p<0.01). Iliac inflow repair can reverse the symptoms in patients with multilevel arterial occlusive disease that are not associated with gangrenous toes.

Multilevel Bypass Grafting: Is it Worth it?

Traditionally, multilevel arterial disease has been treated with an inflow procedure only but simultaneous multilevel bypass graft procedures have been attempted. However, these procedures are potentially high risk. We report our single-center experience of performing multilevel bypass grafts over the last 15years. We retrospectively identified patients undergoing simultaneous aortoiliac and infrainguinal bypasses between January 1996 and January 2011 at a single district general hospital. There were 32 multilevel procedures performed. Indication for surgery was acute ischemia in 10 (31.3%), critical ischemia without tissue loss in 10 (31.3%), with tissue loss in 10 (31.3%), and claudication in 2 (6.3%). In 23 (71.9%) cases inflow was restored using a direct iliofemoral or aortofemoral reconstruction. In the remaining 9 (28.1%), an extra-anatomic bypass was constructed. Two (6.3%) patients died within 30days of surgery. Twenty-nine (90.6%) patients survived to discharge. Twenty-eight patients (87.5%) were alive 1 year after surgery. Limb salvage was 96.9%, 85.7%, and 75.9% at 30days, 1year, and 5years, respectively. Twelve (37.5%) patients required a total of 19 further ipsilateral vascular procedures. Our results demonstrate that multilevel bypass procedures can be performed with good long-term outcomes and acceptable mortality, in what is typically a high-risk group with extensive comorbidities. In patients with severe critical limb ischaemia and tissue loss, who have a combination of aortoiliac and infrainguinal disease, there are significant benefits to a primary multilevel grafting procedure.

Early and late outcomes of hybrid endovascular and open repair procedures in patients with peripheral arterial disease

Hybrid endovascular and open reconstructions are used increasingly often for multilevel revascularization for lower limb ischaemia. The aim was to evaluate outcomes after such procedures in a single-center non-randomized retrospective study. Consecutive patients with multilevel arterial disease who underwent single session hybrid procedures were analyzed depending on the type of ischaemia and the type of revascularization. 164 patients were included with a median follow up time of 14 months (range: 0 - 70). Indication was claudication (group 1, 47 %), critical limb ischaemia (group 2, 33 %) and acute limb ischaemia (group 3, 20 %). Technical success rate was 99.3 %, perioperative mortality 2 %. Primary, assisted-primary and secondary patency rates at one year were 60 %, 61 % and 64 %, respectively. Primary, primary assisted and secondary patency were lower in group 2 and 3 compared to group 1 (all p < 0.05). Results were better when endovascular repairs were performed above compared to below the open repair site (all p < 0.05). Limb salvage at 1 year in groups 1 - 3 were 98 %, 92 % and 90 %, respectively. The risk of major amputation was highest in group 3 compared to group 1 (p = 0.001) or group 2 (p < 0.04). The results depend on the type of ischaemia and the localization of endovascular procedures.

Lower Limb Multilevel Treatment With Drug-Eluting Balloons:6-Month Results From the DEBELLUM Randomized Trial

To report 6-month results of the DEBELLUM (Drug-Eluting Balloon Evaluation for Lower Limb MUltilevel TreatMent) randomized trial to evaluate the efficacy of a drug-eluting balloon (DEB) to reduce restenosis after treatment of multilevel lower limb occlusive disease vs. a conventional angioplasty balloon (AB). Between September 2010 and March 2011, 50 consecutive patients (37 men; mean age 66±4 years) with 122 lesions (96 stenoses and 26 occlusions) of the femoropopliteal (92, 75.4%) or below-the-knee (BTK) arteries (30, 24.6%) were enrolled and randomly assigned to the DEB (25 patients with 57 lesions) or AB (25 patients with 65 lesions) group. Twenty patients presented multilevel lesions. Mean lesion length was 7.5±3.5 cm. Thirty-one (62%) of the patients were Fontaine stage IIb, while 19 (38%) were stage III or IV. DEBs or ABs were used for dilation of de novo lesions or for postdilation after primary stenting (superficial femoral artery only). Patients requiring provisional stenting after angioplasty secondary to flow-limiting dissection or residual stenosis >50% were ineligible. Primary endpoint was late lumen loss at 6 months. Secondary endpoints were target lesion revascularization (TLR), amputation, and thrombosis. Late lumen loss was lower in the DEB group (0.5±1.4 vs. 1.6±1.7 mm, p<0.01). TLR was necessary in 6.1% of the DEB group vs. 23.6% of the AB group (p=0.02). Comparing the DEB to AB groups, the thrombosis rates were 3.0% vs. 5.2% (p=0.6), and the amputation rates were 3.0% vs. 7.9% (p=0.36). The binary restenosis rates were 9.1% (3/33 limbs) in the DEB group vs. 28.9% (11/38 limbs) in the control group (p=0.03). The ankle-brachial index improved to a greater degree in the DEB group: 0.87±0.22 vs. 0.70±0.13 (p<0.05). The Fontaine stage improved in both groups but more so in patients treated with DEBs (p=0.04). The DEBELLUM trial confirmed the ability of paclitaxel-eluting balloons to reduce restenosis vs. conventional balloons at 6 months after treatment of multilevel (femoropopliteal and BTK) arterial disease in patients affected by claudication and CLI. A lower TLR rate and better clinical outcomes appear to be associated with the use of DEBs regardless of stent placement.

Association of anaemia in patients with diabetic foot disease

s / International Journal of Surgery 10 (2012) S53–S109 S105 ABSTRACTS 0374: DOES SOCIO-ECONOMIC STATUS INFLUENCE AMPUTATION OUTCOMES? Risha Gohil, Rachel Barnes, Ian Chetter. Hull York Medical School, University of Hull, Hull Royal Infirmary, Hull & E Yorkshire Hospital Trust, Hull, UK Aims: To analyse the effect of socioeconomic deprivation on amputation outcome.Currently 5,000 leg amputations occur annually in England and Wales and have a 50% mortality rate at 2 years. Methods: All patients undergoing major lower limb amputation from January 2005 to December 2009 were identified from a prospectively maintained vascular database. Patient's postcodes were used to determine socioeconomic status using the ACORN classification system (1 highest group to 5 lowest). Non parametric analysis of data was performed using SPSS version 19. Results:We identified354patients (218men;65.5%),medianage68 (IQR5878) years. 47 (14.8%) patients were ACORN grade 1, 4 (1.3%) were grade 2, 65 (20.4%) were grade 3, 56(17.6%) were grade 4 and 146 (45.9%) were grade 5. Significant differences were noted for the cardiovascular risk factors; hyper-cholesterolaemia (p1⁄40.034), diabetes (p1⁄40.020), smoking status (p1⁄40.006). No significant differences were noted between classes for gender, type of admission (emergency or elective) or mortality (perioperative or 1 year death rate) or blood test (haemoglobin, white cells, urea, creatinine, sodium and potassium). Conclusions: Socio-economic status of amputees does not have an effect on mortality. However, their status does impact on their cardiovascular risk factors, therefore aggressive modification remains imperative. 0414: ASSOCIATION OF ANAEMIA IN PATIENTS WITH DIABETIC FOOT DISEASE Mustafa Khanbhai, Stavros Loukogeorgakis, Steven Hurel, Richards Toby. University College London, London, UK Aims: Anaemia and inflammation have been shown to play a role in diabetic foot disease. We aim to explore the association between anaemia and inflammation, particularly with stage of diabetic foot disease. Methods: 175 patients with diabetic foot disease were studied retrospectively. Patients were stratified in groups according to severity of diabetic foot disease according to NICE guidelines; D1 to D4, the lowest risk assigned; D1. Correlation with baseline haemoglobin, C-reactive protein (CRP) and creatinine was evaluated. Longitudinal analysis of stage of diabetic foot disease was analysed. Results: Haemoglobin was 13.2, 12.3, 11.0 and 9.3 and CRP was 6.1, 22.8, 32.4 and 39.5 in patients stratified to group D1, D2, D3 and D4 respectively (P 5.5cm) infra-renal AAA between 1st January 2008 and 31st December 2009 were included. Patients were classified into two groups; those managed non-operatively, or those offered elective repair. Survival was reported by Kaplane Meier analysis. Multivariate analysis investigated factors leading to non-operative management. Results: 251 patients with a mean (SD) age of 75(8) years were assessed. Thirty-two(13%) patients were deemed unsuitable for repair, mostly because of medical co-morbidity (16/32). 219/251(87%) patients underwent repair(25/251(10%) open repair 194/251(77%) EVAR)with 1/219(0.5%) 30-day mortality. AAA repair was associated with significantly greater survival (p<0.001,log-rank test) at 2years. In multivariate analysis Glasgow Aneurysm Score, female gender and respiratory disease were significant predictors of the decision to treat patients conservatively(p< 0.001). Conclusion:Most patients were suitable for surgical interventionwith low perioperative mortality. Data on turndown rates should be routinely reported to quantify the denominator for operative success. 0593: MULTI-LEVEL BYPASS GRAFTING – IS IT WORTH IT? Alistair Sharples, Mark Kay, Anthony Fox, Tim Sykes, Andrew Houghton. Shrewsbury and Telford NHS Trust, Shrewsbury, UK Traditionally multi-level arterial disease has been treated with an inflow procedure only but simultaneous multi-level bypass graft procedures have

Combined Retrograde–Antegrade Arterial Recanalization Through Collateral Vessels: Redefinition of the Technique for Below-the-Knee Arteries

The effectiveness of below-the-knee PTA to obtain successful revascularization in patients with critical limb ischemia (CLI) has been well established, and many centers have adopted endovascular intervention as the first-line treatment in patients with chronic lower-extremity disease. The well-known complex and multilevel arterial disease in patients with CLI have lead to interventionists to continuously implement different technologies and techniques. The aim of the present study was to standardize and redefine a technique characterized for combined retrograde-antegrade recanalization of a native leg artery through a collateral arterial branch by using a single access. This concept has been well described in coronary arteries and recently in pelvic and tibial arteries.