Outcomes Of Lower Extremity Revascularization Research Articles

Anticoagulation in Patients with Premature Peripheral Artery Disease Undergoing Lower Extremity Revascularization

ObjectivesPremature peripheral artery disease (PAD), defined by lower extremity revascularization (LER) at age ≤ 50 years, is associated with poor major adverse limb events. The early onset of disease is thought to be influenced by genetic factors that regulate homeostasis of the vascular wall and coagulation. The aim of this study is to investigate the effect of anticoagulation as an adjunct to antiplatelet therapy on the outcomes of LER in patients with premature PAD. MethodsThere were 8,804 patients with premature PAD on pre- and post-operative antiplatelet therapy only and 1,236 patients on pre- and post-operative anticoagulation plus antiplatelet therapy in the Vascular Quality Initiative (VQI) peripheral vascular intervention, infra-, and suprainguinal files. Propensity score matching (2:1) was performed between patients with premature PAD who were on antiplatelet therapy and those on anticoagulation plus antiplatelet therapy. Perioperative and one-year outcomes were analyzed including reintervention, major amputation, and mortality. ResultsPatients on anticoagulation were more likely to have coronary artery disease (48.7% vs 41.2%, P<.001), congestive heart failure (20.2% vs 13.1%, P<.001), and have undergone prior LER (73.9% vs 49.2%, P<.001) compared to patients on antiplatelet therapy only. They were also less likely to be independently ambulatory (74.2% vs 81.8%, P<.001) and be on a statin medication (66.8% vs 74.3%, P<.001) compared to patients on antiplatelet therapy only. Patients on anticoagulation were also less likely to be treated for claudication (38.1% vs 48.6%, P<.001), and less likely to be treated with an endovascular procedure (64.8% vs 73.8%, P<.001). After matching for baseline characteristics, there were 1,256 patients on antiplatelet therapy only and 628 patients on anticoagulation. Patients on anticoagulation were more likely to require a return to the operating room (3.7% vs 1.6%, P<.001) and had higher perioperatively mortality (1.1% vs 0.3%, P=.032), but major amputation was not significantly different (1.8% vs 1.6%, P=.798) compared to patients on antiplatelet therapy alone. At one-year, amputation-free survival was higher in patients on antiplatelets only compared to patients on anticoagulation and antiplatelet medications (87.5% vs 80.9%, log-rank P=.001). ConclusionAnticoagulation in addition to antiplatelet therapy in patients with premature PAD undergoing lower extremity revascularization is associated with increased reintervention and mortality at one year.

Perioperative myocardial injury in patients with coronary artery disease during elective lower limb surgery

Aim. To assess the prevalence of ischemic myocardial injury and the cardioprotective effect of nicorandil by assessing high-sensitivity cardiac troponin (hs-cTn) in patients with stable coronary artery disease (CAD) during elective lower limb surgery, as well as to identify predictors of adverse cardiac events.Material and methods. The study included 70 patients with stable coronary artery disease hospitalized for elective autogenous femoropopliteal bypass (FPB) surgery. After randomization, all patients were divided into two following groups: control group — 35 patients; main group — 35 patients, who, in addition to standard therapy, were prescribed nicorandil (Cordinic, PIQ-PHARMA) in a single dose of 20 mg 2 hours before surgery. In the postoperative period, the incidence of myocardial injury was assessed by hs-cTn increase. The obtained primary data were subjected to mathematical processing using the R-Studio software package (R language).Results. At baseline, patients in both groups were comparable in clinical characteristics, therapy, and duration of vascular surgery. In the main group of patients receiving nicorandil, a significant decrease in the incidence of perioperative myocardial injury was noted. In 5 patients of the control group, hs-cTn level 24 hours after surgery exceeded the threshold value, which indicated myocardial injury in the early postoperative period. In the nicorandil group, there was no hs-cTn increase (14% vs 0%, p=0,027). Regression analysis identified a predictor of perioperative myocardial injury — left ventricular ejection fraction (LVEF) &lt;50%. LVEF &lt;50% increases the risk of myocardial injury in the early postoperative period by 7,36 times (p=0,04) and 9,15 times (p=0,048) according to univariate and multivariate regression analysis, respectively.Conclusion. Perioperative myocardial injury is a common complication in patients with CAD undergoing lower extremity revascularization. The use of nicorandil (Cordinic, PIQ-PHARMA) before elective revascularization surgery helps reduce the incidence of ischemic myocardial injury in the early postoperative period and is not accompanied by adverse reactions, which rationales this approach to improve the clinical outcomes of lower extremity revascularization in patients with stable CAD. A predictor of myocardial injury, determined by hs-cTn, is a LVEF &lt;50%.

Outcomes of lower extremity revascularization in octogenarians and nonagenarians for intermittent claudication

ObjectiveRevascularization for intermittent claudication (IC) due to infrainguinal peripheral arterial disease (PAD) is dependent on durability and expected benefit. We aimed to assess outcomes for IC interventions in octogenarians and nonagenarians (age ≥80 years) and those younger than 80 years (age <80 years). MethodsThe Vascular Quality Initiative was queried (2010-2020) for peripheral vascular interventions (PVIs) and infrainguinal bypasses (IIBs) performed to treat IC. Baseline characteristics, procedural details, and outcomes were analyzed (comparing age ≥80 years and age <80 years). ResultsThere were 84,210 PVIs (12.1% age ≥80 years and 87.9% age <80 years) and 10,980 IIBs (7.4% age ≥80 years and 92.6% age <80 years) for IC. For PVI, patients aged ≥80 years more often underwent femoropopliteal (70.7% vs 58.1%) and infrapopliteal (19% vs 9.3%) interventions, and less often iliac interventions (32.1% vs 48%) (P < .001 for all). Patients aged ≥80 years had more perioperative hematomas (3.5% vs 2.4%) and 30-day mortality (0.9% vs 0.4%) (P < .001). At 1-year post-intervention, the age ≥80 years cohort had fewer independently ambulatory patients (80% vs 91.5%; P < .001). Kaplan-Meier analysis showed patients aged ≥80 years had lower reintervention/amputation-free survival (81.4% vs 86.8%), amputation-free survival (87.1% vs 94.1%), and survival (92.3% vs 96.8%) (P < .001) at 1-year after PVI. Risk adjusted analysis showed that age ≥80 years was associated with higher reintervention/amputation/death (hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.1-1.35), amputation/death (HR, 1.85; 95% CI, 1.61-2.13), and mortality (HR, 1.92; 95% CI, 1.66-2.23) (P < .001 for all) for PVI. For IIB, patients aged ≥80 years more often had an infrapopliteal target (28.4% vs 19.4%) and had higher 30-day mortality (1.3% vs 0.5%), renal failure (4.1% vs 2.2%), and cardiac complications (5.4% vs 3.1%) (P < .001). At 1 year, the age ≥80 years group had fewer independently ambulatory patients (81.7% vs 88.8%; P = .02). Kaplan-Meier analysis showed that the age ≥80 years cohort had lower reintervention/amputation-free survival (75.7% vs 81.5%), amputation-free survival (86.9% vs 93.9%), and survival (90.4% vs 96.5%) (P < .001 for all). Risk-adjusted analysis showed age ≥80 years was associated with higher amputation/death (HR, 1.68; 95% CI, 1.1-2.54; P = .015) and mortality (HR, 1.85; 95% CI, 1.16-2.93; P = .009), but not reintervention/amputation/death (HR, 1.1; 95% CI, 0.85-1.44; P = .47) after IIB. ConclusionsOctogenarians and nonagenarians have greater perioperative morbidity and long-term ambulatory impairment, limb loss, and mortality after PVI and IIB for claudication. Risks of intervention on elderly patients with claudication should be carefully weighed against the perceived benefits of revascularization. Medical and exercise therapy efforts should be maximized in this population.

The Impact of Ejection Fraction on Major Adverse Limb Events after Lower Extremity Revascularization

Peripheral arterial disease (PAD) is commonly associated with coronary artery disease, and echocardiography is frequently performed before lower extremity revascularization (LER). However, the incidence of various echocardiographic findings in patients with PAD and their impact on the outcomes of LER has not been well studied. Reduced ejection fraction (EF)≤40% is associated with increased major adverse limb events (MALE) after LER. The electronic medical records of patients undergoing LER in a single center were reviewed. Patients were divided based on the presence or absence of reduced EF. Patient, transthoracic echocardiogram, procedural characteristics, and outcomes were compared between the 2 groups. A total of 1,114 patients (N=131, 11.8% with reduced EF) underwent LER between 2013 and 2019. Patients with reduced EF were more likely to be male and have a history of coronary artery disease and heart failure. Furthermore, they were more likely to have diastolic dysfunction with moderate to severe mitral and tricuspid valve regurgitation. Patients with reduced EF were more likely to undergo LER for chronic limb-threatening ischemia, and to be treated with endovascular procedures. Perioperatively, patients with reduced EF were more likely to develop myocardial infarction. Lastly, the 2 groups had no difference in overall MALE or major amputation. However, on Kaplan-Meier curves, MALE-free survival was significantly lower for patients with reduced EF. Regression analysis demonstrated that indication and not EF was associated with MALE and MALE-free survival. Reduced EF is associated with decreased MALE-free survival for patients with PAD undergoing LER.

Abstract 12311: The Impact of Ejection Fraction on Major Adverse Limb Events After Lower Extremity Revascularization

Objective: Peripheral arterial disease (PAD) is commonly associated with cardiac disease and echocardiography is frequently performed prior to lower extremity revascularization (LER). However, the incidence of various echocardiographic findings and their impact on the outcomes of LER have not been well studied. Hypothesis: Low ejection fraction (EF) ≤ 40% is associated with increased major adverse limb events (MALE) after LER. Methods: The electronic records of patients undergoing LER in a single center were reviewed. Patients were divided based on the presence or absence of reduced EF ≤ 40%. Patient, echocardiographic, and procedural characteristics were compared as well as outcomes. Results: A total of 1,034 patients (N=130, 12.5% with EF≤ 40%) underwent LER. Patients with reduced EF were more likely to be males, with coronary artery disease and heart failure. On echocardiography, patients with reduced EF had significantly higher mean right ventricular pressure and were more likely to have diastolic dysfunction. Moderate to severe regurgitation affecting the mitral and tricuspid valves were significantly higher in patients with reduced EF. There was no difference in indication but patients with reduced EF were more likely to be treated with endovascular procedures. Perioperatively, patients with reduced EF were more likely to develop myocardial infarction. (Table) There was no difference in MALE or major amputation between the 2 groups but MALE-free survival was significantly lower for patients with EF≤ 40%. (Figure). Conclusion: Reduced EF is associated with decreased survival of patients with PAD after LER but does not seem to significantly impact MALE.

Escalation of Antithrombotic Therapy in Patients With Premature Peripheral Artery Disease Undergoing Lower Extremity Revascularization

Premature peripheral artery disease (PAD), defined by lower extremity revascularization (LER) at age 50 years or younger is associated with poor major adverse limb events. The early onset of disease is largely influenced by genetic factors that regulate homeostasis of the vascular wall and coagulation. The aim of this study is to investigate the effect of anticoagulation as an adjunct to antiplatelet therapy on the outcomes of LER in patients with premature PAD.

Diabetes mellitus and outcomes of lower extremity revascularization for peripheral artery disease.

The impact of diabetes mellitus (DM) on outcomes of lower extremity revascularization (LER) for peripheral artery disease (PAD) is uncertain. We characterized associations between DM and post-procedural outcomes in PAD patients undergoing LER. Adults undergoing surgical or endovascular LER were identified from the 2014 Nationwide Readmissions Database. DM was defined by ICD-9 diagnosis codes and sub-classified based on the presence or absence of complications (poor glycaemic control or end-organ damage). Major adverse cardiovascular and limb events (MACLEs) were defined as the composite of death, myocardial infarction, ischaemic stroke, or major limb amputation during the index hospitalization for LER. For survivors, all-cause 6-month hospital readmission was determined. Among 39441 patients with PAD hospitalized for LER, 50.8% had DM. The composite of MACLE after LER was not different in patients with and without DM after covariate adjustment, but patients with DM were more likely to require major limb amputation [5.5% vs. 3.2%, P < 0.001; adjusted odds ratio (aOR) 1.22, 95% confidence interval (CI) 1.03-1.44] and hospital readmission (59.2% vs. 41.3%, P < 0.001; aOR 1.44, 95% CI 1.34-1.55). Of 20039 patients with DM hospitalized for LER, 55.7% had DM with complications. These patients were more likely to have MACLE after LER (11.1% vs. 5.2%, P < 0.001; aOR 1.56 95% CI 1.28-1.89) and require hospital readmission (61.1% vs. 47.2%, P < 0.001; aOR 1.41 95% CI 1.27-1.57) than patients with uncomplicated DM. DM is present in ≈50% of patients undergoing LER for PAD and is an independent risk factor for major limb amputation and 6-month hospital readmission.

Trends and perioperative outcomes of patients with human immunodeficiency virus (HIV) undergoing lower extremity revascularization.

The development of highly active antiretroviral therapy (HAART) has significantly improved the life expectancy of patients with human immunodeficiency virus (HIV), but has led to the rise of chronic conditions including peripheral artery disease (PAD). However, trends and outcomes among patients with HIV undergoing lower extremity revascularization are poorly characterized. The aim of this study was to investigate the trends and perioperative outcomes of lower extremity revascularization among patients with HIV and PAD in a national database. The National Inpatient Sample (NIS) was reviewed between 2003 and 2014. All hospital admissions with a diagnosis of PAD undergoing lower extremity revascularization were stratified based on HIV status. Outcomes were assessed using propensity score matching and multivariable regression. Among all patients undergoing lower extremity revascularization for PAD, there was a significant increase in the proportion of patients with HIV from 0.21% in 2003 to 0.52% in 2014 (p < 0.01). Patients with HIV were more likely to be younger, male, and have fewer comorbidities, including coronary artery disease and diabetes, at the time of intervention compared to patients without HIV. With propensity score matching and multivariable regression, HIV status was associated with increased total hospital costs, but not length of stay, major amputation, or mortality. Patients with HIV with PAD who undergo revascularization are younger with fewer comorbidities, but have increased hospital costs compared to those without HIV. Lower extremity revascularization for PAD is safe for patients with HIV without increased risk of in-hospital major amputation or mortality, and continues to increase each year.

Lower Extremity Revascularization for Chronic Limb-Threatening Ischemia among Patients at the Extremes of Age

Patients with chronic limb-threatening ischemia (CLTI) at the extremes of age are thought to have distinct risk factor profiles and poor outcomes after lower extremity revascularization (LER). The aim of this study is to examine the relationships among age, risk factor profiles, and outcomes of LER in patients with CLTI in a large database focusing on the extreme age groups. Patients undergoing LER for CLTI in the Vascular Quality Initiative suprainguinal bypass, infrainguinal bypass, and peripheral vascular intervention files were reviewed through 2019. Patients were stratified into 3 groups: premature peripheral artery disease (PAD) (≤50years old), 51-84years old, and elderly (≥85 years old). Trends in major amputation and mortality by age group were analyzed. There were 156,513 patients who underwent LER for CLTI. Of these, 9,063 (5.79%) patients had premature PAD, 131,694 (84.14%) patients were 51-84years old, and 15,756 (10.07%) were elderly. Patients with premature PAD were more likely to have insulin-dependent diabetes, be dialysis-dependent, and be active smokers compared to patients 51-84years old and the elderly. Elderly patients were more likely to undergo an endovascular procedure for tissue loss compared to younger groups. Perioperative and 1-year major amputation rates were highest among patients with premature PAD and decreased with increasing age (P<0.001), while perioperative and 1-year mortality increased with age (P<0.001). On multivariable analysis, premature PAD was associated with an increased risk of major amputation (odds ratio, OR=1.41 [1.22-1.62]), while elderly age was associated with decreased odds of major amputation compared to patients 51-84years old (OR=0.61 [0.51-0.73]). Patients at the extremes of age have significantly different outcomes after LER for CLTI. Although mortality increases with age, the risk of major amputation decreases. Patients with premature PAD constitute a group of patients with a high risk of perioperative and 1-year major amputation.

Discrepancy in Outcomes after Revascularization for Chronic Limb-Threatening Ischemia Warrants Separate Reporting of Rest Pain and Tissue Loss

Chronic limb-threatening ischemia (CLTI) manifests as rest pain (RP) and tissue loss (TL). Outcomes of lower extremity revascularization (LER) for CLTI have traditionally been evaluated as a single entity and compared with claudication. We hypothesize that patients presenting with TL have worse short-term outcomes after LER, compared to patients with RP. The National Inpatient Sample was reviewed between 2009 and 2013. All patients undergoing LER for TL and RP were identified. Patient characteristics, Charlson Comorbidity Index (CCI), length of stay, rates of inpatient major amputation, and mortality after LER were noted. Multivariable regression analysis was performed to identify predictors of inpatient mortality and major amputation between the 2 groups. A total of 218,628 patients underwent LER (RP=76,108, TL=142,519). Patients with TL were more likely to undergo endovascular LER (RP=31.3% vs. TL=48.7%; P<0.001). Patients with TL had higher comorbidities as suggested by increased likelihood of having CCI ≥3 (RP=22.9% vs. TL=40.3%; P<0.001). The mean costs were significantly higher in the TL group (RP=$23,795 vs. TL=$31,470; P<0.001). There was a significantly higher rate of major amputation (RP=1.3% vs. TL=6.6%; P<0.001) and inpatient mortality (RP=0.9% vs. TL=1.9%; P<0.001) after LER for TL. On multivariable analysis, TL was independently associated with increased major amputation (odds ratio [OR] 4.93, 95% confidence interval [CI] 4.18-5.81) and increased mortality (OR 1.42, 95% CI 1.16-1.74) compared to RP. There is significant discrepancy in outcomes of LER for TL and RP. TL is independently associated with major amputation and inpatient mortality. Outcomes of LER for TL and RP should be reported separately for better benchmarking.

Lower Extremity Revascularization Among Patients at the Extremes of Age With Chronic Limb-Threatening Ischemia

Patients presenting with chronic limb-threatening ischemia (CLTI) at the extremes of age are thought to have distinct risk factor profiles and poor outcomes after lower extremity revascularization (LER). The aim of this study is to examine the relationship of age with the risk factor profile and outcomes of LER in patients with CLTI in a large database focusing on the extreme age groups.

Chronic kidney disease and outcomes of lower extremity revascularization for peripheral artery disease

Background & aimsRenal disease is a risk factor for peripheral artery disease (PAD), yet its impact on outcomes after lower extremity (LE) revascularization is not well established. We aimed to characterize the association between chronic kidney disease (CKD) and/or end stage renal disease (ESRD) and post-procedural outcomes in PAD patients undergoing LE revascularization in the United States. MethodsAdults age ≥18 years undergoing surgical or endovascular LE revascularization for PAD with and without CKD or ESRD were identified from the 2014 Nationwide Readmissions Database. Major adverse cardiovascular events (MACE), defined as a composite of death, myocardial infarction or ischemic stroke, were identified for patients with and without renal disease. All-cause hospital readmissions within 6 months of discharge were determined for all survivors. ResultsAmong 39,441 patients with PAD hospitalized for LE revascularization, 10,530 had renal disease (26.7%), of whom 69% had CKD without ESRD and 31% had ESRD. Patients with renal disease were more likely to have MACE after LE revascularization (5.2% vs. 2.5%; adjusted OR [aOR] 1.74, 95% CI 1.40–2.16), require LE amputation (26.1% vs. 12.2%; aOR 1.33, 95% CI 1.19–1.50), and require hospital readmission within 6 months (61.0% vs. 43.6%; adjusted HR [aHR] 1.38, 95% CI 1.28–1.48) compared to those without renal disease. ConclusionsRenal disease is common among patients undergoing LE revascularization for PAD and was independently associated with in-hospital MACE, LE amputation, and hospital readmission within 6 months. Additional efforts to improve outcomes of patients with renal disease and PAD requiring LE revascularization are necessary.

Perioperative Outcomes of Lower Extremity Revascularization for Rest Pain and Tissue Loss

Critical limb ischemia (CLI) is the clinical manifestation of severe peripheral artery disease presenting as rest pain (RP) and tissue loss (TL). Most studies compare CLI as a homogenous group with claudication with limited database studies specifically studying these differences. We hypothesize that CLI should be stratified into RP and TL because of significant differences in disease severity, comorbidities, and outcomes. The American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2016 was reviewed. All patients with a postoperative diagnosis of CLI undergoing femoral to popliteal bypass (FPB) with vein or graft were identified. Patients were stratified into cohorts based on International Classification of Disease (ICD)-9 or ICD-10 codes for RP or TL (gangrene or ulcer). Univariate and multivariate analyses were performed to examine 30-day mortality, morbidity, major amputation, and readmission adjusting for demographics, comorbidities, and procedural details. There were 5,304 patients. Compared to RP, patients with TL were older (P<0.0001) and more likely to be dependent (P<0.0001). TL patients were also more likely to have diabetes (P<0.0001), congestive heart failure (P<0.0001), renal failure (P=0.004), dialysis (P<0.0001), history of wound infection (P<0.0001), and sepsis (P<0.0001). TL patients had higher American Society of Anesthesiologists class (P<0.0001), were less likely to be transferred from home (P<0.0001), and more likely to receive an FPB with vein (P=0.03). Patients with TL had worse perioperative outcomes compared with RP in terms of pneumonia (P=0.004), unplanned intubation (P=0.009), cardiac arrest requiring cardiopulmonary resuscitation (P=0.003), bleeding requiring transfusions (P<0.0001), sepsis (P<0.0001), septic shock (P=0.02), and reoperation (P<0.0001). TL was associated with significantly higher 30-day morbidity (P<0.0001), 30-day mortality (P<0.0001), major amputation (P=0.0004), and readmission rates (P=0.005). Patients with TL compared with those with RP also had longer hospital stays (P<0.0001) and days between operation to discharge (P<0.0001). TL was independently associated with increased 30-day morbidity (OR: 1.16 [1.00-1.35]) and major amputation (OR: 2.48 [1.29-4.76]) compared with RP. Patients with RP and TL have drastic differences that impact perioperative mortality and readmissions. TL is an independent predictor of 30-day morbidity and major amputation. The stratification of CLI into RP and TL can provide insight into variations in outcomes and provide a means to quantify the risks associated with the 2 manifestations of the disease.

Aggressive infrainguinal revascularization in renal transplant patients is justifiable.

While studies demonstrate poor outcomes of lower extremity revascularization in patients with end-stage renal disease, little is known about results in renal transplant patients. We analyzed 2-year primary patency and limb salvage outcomes and associated risk factors of transplant (n=202) and nontransplant patients (n=25274) in the Vascular Quality Initiative database undergoing infrainguinal bypass from 2003 to 2016. Multivariable Cox regression analysis and coarsened exact matching with many-to-one were used. Transplant patients were more likely to have critical limb ischemia and revascularization of more distal arteries and to receive vein conduits. Primary patency was similar between transplant and nontransplant patients at 1 year (80.8% vs 77.5%) and 2 years (67.9% vs 63.7%, P=.079). Amputation-free survival was higher for nontransplant patients (1 year: 82.4% vs 75.3%, 2 years: 68.8% vs 58.2%, P=.0060), although overall survival was equivalent (2 years: 84.6% vs 87.2%, 4 years: 75.9% vs 79.6%, P=.35). Risk factors for primary patency loss included being female, critical limb ischemia, prior bypass, and distal bypass. Age, diabetes, prior contralateral amputation, critical limb ischemia, prosthetic conduit, and more distal bypass were associated with limb loss. This is the largest series of infrainguinal revascularization in transplant patients. Outcomes for transplant patients are not inferior, and aggressive approaches at limb salvage are justifiable in appropriately selected patients.

Outcomes of lower extremity revascularization among the hemodialysis-dependent

Optimal patient selection for lower extremity revascularization remains a clinical challenge among the hemodialysis-dependent (HD). The purpose of this study was to examine contemporary real world open and endovascular outcomes of HD patients to better facilitate patient selection for intervention. A regional multicenter registry was queried between 2003 and 2013 for HD patients (N= 689) undergoing open surgical bypass (n= 295) or endovascular intervention (n= 394) for lower extremity revascularization. Patient demographics and comorbidities were recorded. The primary outcome was overall survival. Secondary outcomes included graft patency, freedom from major adverse limb events, and amputation-free survival (AFS). Multivariate analysis was performed to identify independent risk factors for death and amputation. Among the 689 HD patients undergoing lower extremity revascularization, 66% were male, and 83% were white. Ninety percent of revascularizations were performed for critical limb ischemia and 8% for claudication. Overall survival at 1, 2, and 5years survival remained low at 60%, 43%, and 21%, respectively. Overall 1- and 2-year AFS was 40% and 17%. Mortality accounted for the primary mode of failure for both open bypass (78%) and endovascular interventions (80%) at two years. Survival, AFS, and freedom from major adverse limb event outcomes did not differ significantly between revascularization techniques. At 2years, endovascular patency was higher than open bypass (76% vs 26%; 95% confidence interval [CI], 0.28-0.71; P= .02). Multivariate analysis identified age ≥80years (hazard ratio [HR], 1.9; 95% CI,1.4-2.5; P< .01), indication of rest pain or tissue loss (HR, 1.8; 95% CI, 1.3-2.6; P< .01), preoperative wheelchair/bedridden status (HR, 1.5; 95% CI, 1.1-2.1; P< .01), coronary artery disease (HR, 1.5; 95% CI, 1.2-1.9; P< .01), and chronic obstructive pulmonary disease (HR, 1.4; 95% CI, 1.1-1.8; P= .01) as independent predictors of death. The presence of three or more risk factors resulted in predicted 1-year mortality of 64%. Overall survival and AFS among HD patients remains poor, irrespective of revascularization strategy. Mortality remains the primary driver for these findings and justifies a prudent approach to patient selection. Focus for improved results should emphasize predictors of survival to better identify those most likely to benefit from revascularization.

Dos años de seguimiento en la revascularización de extremidades inferiores basada en ultrasonografía

IntroductionTo compare the outcome of lower extremity revascularization with great saphenous vein (GSV) based exclusively on arterial Doppler mapping versus other diagnostic methods. Material and methodsA total of 91 patients were selected and followed-up for 2 years from the period November 2009 until December 2011, with the inclusion criteria; GSV bypass and no previous revascularization. Two groups were established; group A (n = 32) using only ultrasound Doppler as pre-surgical planning test and group B (n = 59) using other diagnostic methods. A historical cohort study was conducted, in which the results were compared (primary patency, secondary patency, major amputation-free rate and survival rate) in both groups. Statistical analyses were performed using survival curves of Kaplan-Meier and log-rank statistic. ResultsThe results in group A and B, respectively, in terms of: primary patency was 84% (95% CI: 72 to 96) vs. 76% (95% CI: 65 to 88); secondary patency was 93% (95% CI: 87 to 99) vs. 85% (95% CI: 76 to 95); the free of major amputation rate was 93% (95% CI: 87 to 99) vs. 92% (95% CI: 86 to 99), and the survival rate was 96% (95% CI: 90 to 100) vs. 85% (95% CI: 76 to 95).The results were also compared according to the receiver vessel (poplíteal or distal) and as a function of the risk factors, with no significant differences. ConclusionThe study shows that long term revascularization, based on a high reliability ultrasound test, has the same permeability as other imaging studies.

Outcomes of Lower Extremity Revascularization (LER) in Patients on Dialysis

Outcomes of Lower Extremity Revascularization (LER) in Patients on Dialysis

The impact of gender on outcome after infrainguinal arterial reconstructions for peripheral occlusive disease

The role of gender on the outcome of infrainguinal arterial revascularization (IAR) for peripheral arterial occlusive disease remains uncertain. This study analyzed the outcome of IARs performed over 15 years, stratifying the results by sex. Details of consecutive patients undergoing primary IAR for peripheral arterial occlusive disease from 1995 to 2009 at our institution were prospectively stored in a vascular registry. Demographics, risk factors, indications for surgery, inflow sources, outflow target vessels, types of conduit, and adverse outcomes were analyzed. Postoperative surveillance included clinical examination supplemented with duplex scans and ankle-brachial index measurements in all patients at discharge, 30 days, 6 months, and every 6 months thereafter. End points of the study, ie, patency, limb salvage, and survival rates, were assessed using Kaplan-Meier life-table analysis. The χ(2) or Fisher exact, Student t, and log-rank tests were used to establish statistical significance. Our sample consisted of 1459 IARs performed in 1333 patients, comprising 496 women (37.2%; 531 IARs), who were a mean 3 years older than the men (74 vs 71 years; P < .001) and had a higher incidence of diabetes mellitus (52% vs 46%; P = .03) and surgery for limb salvage (91% vs 87%; P = .02). An autogenous vein conduit (great or small saphenous, or both, spliced, arm, or composite veins) was used in 87% of the IARs. No deaths occurred perioperatively (30 days). The major and minor complication rates were comparable between men and women. At 10 years, the primary patency rate was 47% in women vs 49% in men (P = .67), the assisted primary patency rate was, respectively, 53% vs 50% (P = .69), the secondary patency rate was 61% vs 61% (P = .66), limb salvage rate was 93% vs 91% (P = .54), and survival rate was 43% vs 49% (P = .65). Stratifying by type of conduit revealed no differences in patency or limb salvage rates. Despite an older age and more advanced stages of disease on presentation in women, IAR performed in women can achieve patency and limb salvage rates statistically no different from those recorded in their male counterparts, supporting the conviction that sex per se does not influence the outcome of lower extremity revascularization.

Outcome of lower extremity revascularization for peripheral artery occlusive disease: is there a difference between men and women?

The incidence of peripheral arterial occlusive disease (PAD) increases with age. Women represent a growing percentage of the elderly population who present with PAD. While speculation exists that gender affects outcome after revascularization procedures, the literature is confusing and often conflicting. This review compares outcomes by gender after open surgical and endovascular lower extremity revascularization (LER) procedures including: demographic differences, patency rates, limb salvage rates, long-term survival, perioperative complications and 30-day mortality. This review summarizes the existing data and discusses current influences on outcome after LER.

Comparative results of open lower extremity revascularization in nonagenarians

The average lifespan in the United States continues to lengthen. We have observed a similar trend in our patients, with an increased number of nonagenarians presenting for evaluation of vascular disease. This study evaluated outcomes of lower extremity revascularization in patients aged >or=90 years. The vascular registry at Albany Medical College was retrospectively reviewed for all lower extremity bypasses performed between 1996 and 2006. We evaluated patient demographics, indications, procedure, patency rates, and complications. Patients were divided into groups based on age >or=90 years (>or=90 group) and <90 years (<90 group). Variables were evaluated by chi(2) analysis. Outcomes were prepared using life-table methods and compared with log-rank analysis. During the last 10 years, 5443 lower extremity bypasses were performed on patients aged <90 years and 150 on patients aged >or=90 years. The <90 group had significantly more men (61.4% vs 29.3%) and was obviously younger, at 68 years (range 7-89 years) vs 92 years (range, 90-101 years). The <90 group had more comorbidities in terms of diabetes, active tobacco use, and hypercholesterolemia. No significant difference was noted in coronary artery disease or chronic renal insufficiency between the groups. Critical limb ischemia as an indication was significantly higher in the >or=90 group (149 [99%] vs 4472 [82%]; P < .0.5). Strikingly, the primary patency was significantly higher in the >or=90 group at 4 years (77% vs 62%; P < .05). Complication and amputation rates did not differ between the groups. Perioperative (15% vs 3%; P < .05) and 1-year (45% vs 11%; P < .05) mortality rates were significantly higher in the >or=90 group. Lower extremity bypass for nonagenarians offers acceptable patency and limb salvage but at a significantly higher mortality rate.