Presence Of Critical Limb Ischemia Research Articles

Hospital Readmission in Patients With Diabetic Foot Ulcers: Prevalence, Causes, and Outcomes.

The aim of the current study was to evaluate the rate of readmission in patients affected by diabetes and foot ulcers (DFUs), and causes and outcomes of patients requiring a new hospitalization. The current study is a retrospective observational study including patients who have required hospitalization since January 2019 to September 2022 due to a DFU. Once patients were discharged, they were regularly followed as outpatients. Within 6 months of follow-up, the rate of hospital readmission for a diabetic foot problem was recorded. According to the readmission or not, patients were divided into 2 groups, readmitted and not readmitted patients, respectively. Hence, all patients were followed for 6 months more and outcomes of the 2 groups were analyzed and compared. Overall, 310 patients were included. The mean age was 68 ± 12 years, the majority of patients reported type 2 diabetes (>90%), and the mean diabetes duration was approximately 20 years. Sixty-eight (21.9%) patients were readmitted. The main reason for hospital readmission was the presence of critical limb ischemia (CLI) in the contralateral limb (6.1%), the recurrence of CLI in the previous treated limb (4.5%), and the onset of new infected DFU in the contralateral foot (4.5%). Readmitted patients reported lower rate of healing (51.5% vs 89.2%, P < .0001) and higher rate of major amputation (10.3% vs 4.5%, P = .2) in comparison to not readmitted patients. Critical limb ischemia resulted in the only independent predictor of hospital readmission. Hospital readmission is a frequent issue among patients with DFUs, and readmitted patients showed a lower chance of wound healing. Critical limb ischemia resulted in the main cause of new hospitalization.

Skeletal Muscle Bioenergetics in Critical Limb Ischemia and Diabetes

IntroductionMitochondrial dysfunction is implicated in the metabolic myopathy accompanying peripheral artery disease (PAD) and critical limb ischemia (CLI). Type-2 diabetes mellitus (T2DM) is a major risk factor for PAD development and progression to CLI and may also independently be related to mitochondrial dysfunction. We set out to determine the effect of T2DM in the relationship between CLI and muscle mitochondrial respiratory capacity and coupling control. MethodsWe studied CLI patients undergoing revascularization procedures or amputation, and non-CLI patients with or without T2DM of similar age. Mitochondrial respiratory capacity and function were determined in lower limb permeabilized myofibers by high-resolution respirometry. ResultsFourteen CLI patients (65 ± 10y) were stratified into CLI patients with (n = 8) or without (n = 6) T2DM and were compared to non-CLI patients with (n = 18; 69 ± 5y) or without (n = 19; 71 ± 6y) T2DM. Presence of CLI but not T2DM had a marked impact on all mitochondrial respiratory states in skeletal muscle, adjusted for the effects of sex. Leak respiration (State 2, P < 0.025 and State 4o, P < 0.01), phosphorylating respiration (P < 0.001), and maximal respiration in the uncoupled state (P < 0.001), were all suppressed in CLI patients, independent of T2DM. T2DM had no significant effect on mitochondrial respiratory capacity and function in adults without CLI. ConclusionsSkeletal muscle mitochondrial respiratory capacity was blunted by ∼35% in patients with CLI. T2DM was not associated with muscle oxidative capacity and did not moderate the relationship between muscle mitochondrial respiratory capacity and CLI.

Outcomes of biosynthetic vascular graft for infrainguinal femoro-popliteal and femoro-distal revascularization.

The aim of this study was to retrospectively analyze early and late outcomes of infrainguinal revascularization performed with the Omniflow-II® (LeMaitre Vascular, Inc., Burlington, MA, USA) biosynthetic vascular graft (BVG) for complex femoro-popliteal obstructive disease. Over a 10-year period, this BVG was used in 110 patients who underwent infrainguinal femoro-popliteal or femoro-distal bypass. Early (intraoperative and <30 days) results were analyzed in terms of death, thrombosis, amputations and reinterventions. Follow-up results were analyzed in terms of primary and secondary graft patency, and amputation-free survival. We performed 87 (79.1%) above-the-knee bypass, 20 (18.2%) below-the-knee bypass, and 3 (2.7%) tibial artery bypass. In-hospital mortality was not observed. Mean follow-up was 66±37 months (range, 3-150). Estimated primary patency rate at 1, 2 and 5-years of follow-up was 77%±4 (95%CI: 68-84), 73%±5 (95%CI: 63.5-83), and 59%±6 (95%CI: 47-70.5) respectively. Predictors of primary patency loss were the presence of critical limb ischemia (P=0.048; HR: 2.1; 95%CI: 1.01-4.28), and the necessity of below-the-knee bypass (P=0.012; HR: 2.4; 95%CI: 1.22-4.75). Aneurysmal degeneration of the BVG was detected in 4 (3.6%) patients, an infected BVG occurred in 3 (2.7%) patients. The amputation-free survival was 96%±2 (95%CI: 91-99), 93%±3 (95%CI: 86-96), and 76%±5 (95%CI: 66-84) at 1, 2 and 5-years respectively. In our experience, Omniflow-II® is a valid first-line alternative for infrainguinal revascularization when the ipsilateral autologous saphenous vein is not available. Aneurysmal degeneration was lower than previously reported with alternative BVGs, and the incidence of BVG infection was acceptably low.

Long-term clinical outcomes and cause of death after endovascular treatment for femoropopliteal artery lesions

BackgroundEndovascular treatment (EVT) for femoropopliteal artery disease is common in clinical practice. However, little is known about its prognostic factors, causes of death, and long-term clinical outcomes. MethodsTwo hundred eighty-five consecutive patients (mean age, 72±8 years, 73% men) undergoing their first EVT for de-novo femoropopliteal artery disease from 2009 to 2018 were studied. Patients were divided in two groups according to the presence of critical limb ischemia (CLI). We evaluated the incidence of major adverse limb events (MALE) including clinically driven target vessel revascularization and target limb major amputation, and all-cause death. ResultsThe procedure was successful in 97.9% of cases. The non-CLI group comprised 205 patients (72%), and the CLI group comprised 80 patients (28%). The CLI group exhibited higher high-sensitivity C-reactive protein (hs-CRP) levels and a higher rate of hemodialysis than the non-CLI group. During the median follow-up period of 3.5 years, there were 62 deaths (21.8%) including cardiovascular (32.3%), infection (32,3%), and malignancy-related (22.6%) deaths. Kaplan-Meier analysis revealed that the CLI group had a significantly higher incidence of MALE and all-cause death (log-rank, both p<0.001, respectively). The leading causes of death in the CLI group were cardiovascular- and infection-related death; the leading cause of death in the non-CLI group was malignancy-related. On multivariate Cox hazard analysis, hemodialysis, TASC II classification C/D lesions, and CLI were significant predictors of MALE (p<0.001, p=0.005, and p=0.012, respectively). Hemodialysis, age, higher hs-CRP levels, and CLI were significant predictors of all-cause death (p<0.001, p=0.003, p=0.009, and p=0.021, respectively). ConclusionsAlthough EVT for femoropopliteal artery disease appears feasible with a high rate of procedural success, a high incidence of MALE and all-cause death was observed. Further studies are needed to improve the outcomes in patients with CLI.

Comparative study between simultaneous and two-stage revascularization in patients with multi -segmental lower limbs arterial occlusive disease

Background: Peripheral arterial disease (PAD) is defined as a slowly progressing, occlusive vascular disease of the extremities primarily due to atherosclerosis which can involve vasculitis and thrombosis and diagnosed by an ankle-brachial index (ABI) less than 0.9. It may lead to intermittent claudication (IC) and with progression of the disease may lead to critical limb ischemia (CLI). Aim of the work: to compare the results between simultaneous revascularization of all level arterial lesions versus staged revascularization of the proximal or distal lesions regarding limb salvage rates, midterm primary patency rates, and secondary patency rates in multi-segment peripheral arterial disease Study Design and methodology: randomized comparative study. We randomly divided patients into two groups. Group A (20 patients: treated by total revascularization of all arterial lesions affecting the target limb) and Group B (20 patients: treated staged revascularization). Results: success rate after total revascularization (group A) reaching 82.5% success rate, success rate after staged revascularization (group B) reaching 65% success rate from inflow cases and 66.7% of the outflow repair. We achieved a limb salvage rate of 67.5% (27 patients). The difference between the groups was not statistically significant regarding amputation rates (P=0.99). Primary patency rate at 12 months was not significantly higher in group A than in group B (65% vs. 50%; P =0.98). Wound closure was statistically higher in group A than in group B (P=0.04). Reintervention was needed in 12 patients owing to restenosis or total occlusion of the treated lesions presenting with either lost pulses, rest pain, or deterioration of the wound healing. The secondary patency rates were non statistically significant between group A and group B at 12 months (3 patients 60%, 2 patients 28.6%) (P=0.56). Hospital mortality was 5% in Group A and 10% in Group B. Group A showed lower amputation rate but non-significantly different with group B (P=0.5). Conclusion: We conclude that multi-segmental reconstructions for multilevel occlusive arterial disease is a safe and effective method of treatment in the presence of CLI. Correction of the proximal lesions only cannot be considered satisfactory especially in patients presenting with tissue loss as it is usually associated with inferior patency rates and low overall limb salvage rates.

Results of infra-inguinal bypasses with cryopreserved arterial allografts for critical ischemia

In presence of critical limb ischemia (CLI), the material of choice for peripheral revascularization is the greater saphenous vein (GSV) when its quality is satisfactory. In the absence of GSV, the use of a cryopreserved arterial allograft (CAA) is possible. We evaluated the results of CAA infra-inguinal bypasses in patients with CLI.

Cell therapy of critical limb ischemia in diabetic patients - State of art.

In this review we report on the state of cell therapy of critical limb ischemia (CLI) with respect to differences between diabetic and non-diabetic patients mainly from the clinical point of view. CLI is the most severe form of peripheral arterial disease and its diagnosis and treatment in diabetic patients is very difficult. The therapeutic effect of standard methods of CLI treatment is only partial - more than one third of diabetic patients are not eligible for standard revascularization; therefore, new therapeutic techniques such as cell therapy have been studied in clinical trials. Presence of CLI in patients with diabetic foot disease is associated with worse clinical outcomes such as lack of healing of foot ulcers, major amputations and premature mortality. A revascularization procedure cannot be successful as the only method in contrast to patients without diabetes, but it must always be part of a complex therapy focused not only on ischemia, but also on treatment of infection, off-loading, metabolic control of diabetes and nutrition, local therapy, etc. Therefore, the main criteria for cell therapy may vary in diabetic patients and non-diabetic persons and results of this treatment method should always be assessed in the context of ensuring comprehensive therapy. This review carries out an analysis of the source of precursor cells, route of administration and brings a brief report of published data with respect to diabetic and non-diabetic patients and our experience with autologous cell therapy of diabetic patients with CLI. Analysis of the studies in terms of diabetes is difficult, because in most of them sub-analysis for diabetic patients is not performed separately. The other problem is that it is not clear if diabetic patients received adequate complex treatment for their foot ulcers which can strongly affect the rate of major amputation as an outcome of CLI treatment.

A comparison between aortobifemoral bypass and aortoiliac kissing stents in patients with complex aortoiliac obstructive disease

ObjectiveThe aim of this study was to retrospectively compare early and late results of aortobifemoral bypass and endovascular recanalization with the kissing stent technique in the management of TransAtlantic Inter-Society Consensus II (TASC II) C and D lesions in the aortoiliac district in a multicenter study. MethodsFrom January 2006 to December 2013, 210 open and endovascular interventions for TASC II class C and D aortoiliac obstructive lesions were performed at three Italian teaching hospitals. In all the cases, the intervention was performed for aortic and bilateral iliac involvement. An aortobifemoral bypass was performed in 82 patients (group 1); in the remaining 128, an endovascular recanalization with the kissing stent technique was carried out (group 2). Early results in the two groups were compared with the χ2 test. Follow-up results were analyzed with Kaplan-Meier curves and compared with log-rank test. Univariate and multivariate (forward Cox regression) analysis to identify potentially significant predictors of primary patency in the whole study group was performed. ResultsPatients in group 2 were more frequently female and more frequently had diabetes and arterial hypertension than patients in group 1. The indication for surgical intervention was the presence of critical limb ischemia in 29 cases in group 1 (35%) and in 31 cases in group 2 (24%; P = .07). Technical success in group 2 was 98.5%; two patients required immediate conversion to open surgery for iliac rupture. There was one perioperative death in group 1 (mortality rate, 1%; P = .2 in comparison with group 2). Four perioperative thromboses occurred, two in group 1 and two in group 2 (in one case requiring conversion to open surgical intervention), and no amputations at 30 days were recorded. Cumulative postoperative local and systemic complications occurred in 17 patients in group 1 (20.5%) and in 9 patients in group 2 (7%; P < .001). Mean duration of follow-up was 38 months (range, 1-96 months). Survival rates at 6 years were 65.5% (standard error [SE], 0.08) in group 1 and 83.5% (SE, 0.08) in group 2 (P = .08; log-rank, 2.2). At the same time interval, primary, assisted primary, and secondary patency rates were similar; reintervention rates were 6% in group 1 (SE, 0.05) and 11% in group 2 (SE, 0.04; P = .3; log-rank, 0.8). Univariate and multivariate analysis showed that only the presence of critical limb ischemia was independently associated with poorer primary patency during follow-up (hazard ratio, 2.4; 95% confidence interval, 0.9-6.4; P = .05). ConclusionsIn this multicenter experience, endovascular repair of aortoiliac complex lesions with the kissing stent technique provided similar satisfactory early and late results to those obtained with open surgery.

Rearfoot Transcutaneous Oximetry is a Useful Tool to Highlight Ischemia of the Heel.

To demonstrate the usefulness of rearfoot transcutaneous oximetry to assess the peripheral arterial disease in diabetic patients with heel ulcer. From our database of 550 critical limb ischemia diabetic patients followed after a percutaneous transluminal angioplasty, we have selected patients with below the knee arterial disease. Patients were grouped according to the dorsal transcutaneous oximetry value (Group A<30mmHg; Group B≥30mmHg). Patients of Group B had a second oximetry performed at the rearfoot, close to the lesion localized in all cases at the heel. Finally, the analysis of the arterial pattern disease has been done. We selected 191 patients: Group A (151 patients), dorsal transcutaneous oximetry of 11.8±0.7mmHg; Group B (40 patients), dorsal transcutaneous oximetry of 44.2±10.1mmHg. In Group B, rearfoot oximetry was 20.5±5mmHg, significantly lower than dorsal oximetry (p=0.0179). The anterior tibial artery was involved in all patients of Group A. In Group B, the anterior tibial artery was involved in 15 subjects and never alone; the posterior tibial artery was involved in 20 subjects and in 11 cases alone. The peroneal artery was affected in 20 subjects and in 14 patients alone. When a heel lesion is present and the transcutaneous oximetry recorded on the dorsum of the foot does not confirm the presence of critical limb ischemia (not ≤30mmHg), a second oximetry recorded on the rearfoot is useful to point out ischemia of the peroneal artery and/or of the posterior tibial artery.

Plasma Levels of Advanced Glycation End Products Are Related to the Clinical Presentation and Angiographic Severity of Symptomatic Lower Extremity Peripheral Arterial Disease.

Evidence implicates a role of advanced glycation end products (AGEs) in the development of atherosclerosis. The present study examined the relationship between plasma levels of AGEs and the clinical and angiographic characteristics of patients with symptomatic peripheral arterial disease (PAD). A total of 40 consecutive patients with symptomatic lower extremity PAD undergoing invasive evaluation were enrolled. Clinical history, angiographic data, and plasma levels of total AGE (tAGE), N'-carboxymethyllysine (CML), and high-sensitivity C-reactive protein were obtained. In multivariate analyses, there were independent relationships noted between tAGE levels and the presence of critical limb ischemia (CLI) (r (2) = 0.195, p = 0.003), Rutherford stage (r (2) = 0.351, p < 0.001), and the average below the knee (BTK) score (r (2) = 0.119, p = 0.006). Presence of CLI (r (2) = 0.154, p = 0.012) and the Rutherford stage (r (2) = 0.194, p = 0.003) were associated with CML levels. We demonstrate a relationship between tAGE and the symptom profile of patients with PAD and an association between tAGE and infrapopliteal angiographic disease severity. Both tAGE and CML levels were related to the presence of CLI. These data suggest that AGE levels may reflect the severity of PAD and may be of importance in CLI.

Increasing Obesity Adversely Affects Limb Salvage Following Lower Extremity Revascularization in a 20-Year Population-Based Study

We have previously reported trends of decreasing amputations along with increasing endovascular interventions for peripheral arterial disease (PAD) in a defined population between 1990 and 2009. The aim of this study was to analyze preoperative risk factors affecting outcomes in these patients. A retrospective cohort study of residents of a single county was conducted. Procedures were identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)/Current Procedural Terminology codes and data collected through record review. Study end points were major adverse limb events (MALE), major amputations (AMPU), amputation-free survival (AFS) and mortality. Statistical analysis was performed using the Cox-proportional hazards model. A total of 1906 lower extremity procedures were performed in 957 limbs with PAD; 622 patients (males, 363; females, 259) with a mean age 67.8 years, (range, 27-98). These included 713 open, 610 endovascular), and 75 hybrid revascularizations; and 192 primary and 340 secondary amputations. Half the procedures (52%) were performed for critical limb ischemia (CLI) and 7% were emergencies. The study population was predominantly white (96%); comorbidities included dyslipidemia in 62%, coronary artery disease in 47%, 26% with a prior intervention, current smoking in 42%, diabetes mellitus in 37%, and renal insufficiency (serum creatinine >2.0 mg/dL) in 8%. On univariate analysis the most significant risk factor associated with MALE and AMPU was presence of CLI (hazard ratio [HR], 3.1/7.1), followed by renal insufficiency on dialysis (HR, 3.2/5.2), emergency procedure (HR, 3.0/2.5), diabetes mellitus (HR, 2.0/3.9), and congestive heart failure (HR, 1.9/3.4). The prevalence of significant obesity (body mass index >35 kg/m2) increased from 6% in the 5-year interval of 1990 to 1994 to 12% in 2005 to 2009, and was also significantly associated with MALE, AMPU, and AFS (HR, 2.4/4.3/1.5). In addition, factors associated with AFS and mortality included, age >75 years (HR, 2.4/2.8), anemia (HR, 2.7/2.8), and coronary artery disease without intervention (HR, 1.6/1.8). Table I summarizes multivariate analysis for factors significantly associated with all end points. This population-based study confirms the traditional risk factors for adverse outcomes following revascularization for PAD. Severe obesity is emerging as an important risk factor not previously reported especially in light of increasing incidence in the population.TableMultivariate analysis of preoperative factors affecting outcomes with lower extremity revascularization proceduresMALE (n = 217), HR (95% CI)P valueAmputation (n = 85), HR (95% CI)P valueAFS (n = 466), HR (95% CI)P valueMortality (n = 301), HR (95% CI)P valueRace Nonwhite2.0 (1.02-3.9).04––– White1.0 (reference)Chronic dialysis Yes2.0 (1.1-3.4).012.7 (1.4-5.0).0022.2 (1.4-3.6)<.0012.0 (1.2-3.4).01 No1.0 (reference)1.0 (reference)1.0 (reference)1.0 (reference)Diabetes mellitus Yes1.5 (1.1-2.1).0082.4 (1.3-4.1).0031.5 (1.2-1.9).0021.4 (1.1-1.8).007 No1.0 (reference)1.0 (reference)1.0 (reference)1.0 (reference)Type CLI2.4 (1.8-3.3)<.0015.0 (2.6-9.5)<.0012.1 (1.7-2.7)<.0012.0 (1.5-2.6)<.001 Claudication1.0 (reference)1.0 (reference)1.0 (reference)1.0 (reference)Urgency of procedure Emergent2.3 (1.5-3.6)<.001–1.7 (1.1-2.7).011.7 (1.1-2.6).009 Elective1.0 (reference)1.0 (reference)1.0 (reference)Congestive heart failure Yes–1.7 (1.01-3.0).0482.2 (1.6-3.0)<.0012.3 (1.7-3.2)<.001 No1.0 (reference)1.0 (reference)1.0 (reference)Age >75––2.1 (1.6-2.7)<.0012.3 (1.8-2.9)<.001 ≤751.0 (reference)1.0 (reference)BMI ≥35––1.5 (1.01-2.1).04– <351.0 (reference)COPD/emphysema Yes––1.3 (1.01-1.8).041.4 (1.1-1.9).02 No1.0 (reference)1.0 (reference)Hematocrit ≤30 Yes–––1.6 (1.07-2.3).02 No1.0 (reference)Coronary artery disease/intervention CAD with intervention–– CAD with no intervention1.1 (.85-1.5).381.2 (.87-1.6).30 NO CAD1.4 (1.04-1.8).021.6 (1.2-2.1).0031.0 (reference)1.0 (reference)BMI, Body mass index; CAD, coronary artery disease; CI, confidence interval; COPD, chronic obstructive pulmonary disease; HR, hazard ratio. Open table in a new tab

Independent Predictors of Readmission After Femoral-to-Popliteal Artery Bypass Grafting in Diabetics

A database review was performed to determine which factors contribute to hospital readmission for diabetic patients within 30-days of femoral-to-popliteal artery bypass (FPB) surgery. The National Surgical Quality Improvement Program (NSQIP) database was queried from the years 2005 to 2011 to identify diabetic patients who underwent FPB. Patients groups by those who were readmitted (RA) ≤30 days of operation and those who were not readmitted (NRA). Patient demographics, comorbidities, perioperative data, and outcomes were compared. Of the 5523 patients identified, 334 were in the RA group and 5189 were in the NRA group. There were 208 vein bypasses in the RA group and 2949 vein bypasses in the NRA group. The rest were prosthetic conduit. Difference in bypass conduit approached but did not achieve statistical significance (P = .051). The RA group had a higher proportion of patients with medical comorbidities, including ventilator dependence (2.1% vs 0.1%; P < .01), congestive heart failure (8.7% vs 3.1%; P < .01), recent myocardial infarction (4.5% vs 2%; P < .01), and insulin dependence (59.6% vs 53.6%; P = .03) compared with the NRA group. Preoperative vascular disease was more severe in the RA group as well, with rest pain/gangrene (50.9% vs 39.1%; P < .01) and history of amputation (73.1% vs 49.8%; P < .01) both higher in the RA group. The RA group also had a higher proportion of emergency procedures (11.4% vs 4.4%; P < .01), longer operative time (226 ± 11.5 minutes vs 208.4 ± 2.6 minutes; P < .01) and longer prior hospital length of stay (16.5 ± 1.8 days vs 8 ± 0.3 days; P < .01). The RA group also was taken back to the operating room more frequently during the index admission (36.2% vs 15.3%; P < .01) than the NRA group. Preoperative hypertension (odds ratio, 46.7; 95% confidence interval, 34.6-62.9) and rest pain/gangrene (odds ratio, 50.1; 95% confidence interval, 36.4-69.1) were the only independent predictors of RA on multivariate analysis. Insulin dependence and preoperative cardiac comorbidities are not predictive of readmission rates after FPB in diabetic patients. The presence of critical limb ischemia is the most predictive factor for 30-day readmission after FPB in diabetic patients.

Preoperative smoking is associated with early graft failure after infrainguinal bypass surgery

Smoking has been implicated as the single most important risk factor for the development of peripheral arterial disease. Whereas previous studies have found poor long-term outcomes in smokers undergoing lower extremity bypass, there is a lack of consistent reports describing the effects of persistent tobacco abuse on early outcomes after infrainguinal bypass. The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2011 was queried for primary infrainguinal bypasses. A bivariate analysis was done to assess preoperative and intraoperative risk factors for the primary outcome of 30-day graft failure comparing active smokers with nonsmokers, defined as patients who did not smoke within the 12 months before surgery. Multivariable logistic regression was conducted to assess the independent association of active smoking with graft failure. In 6614 (40.0%) active smokers and 9920 (60.0%) nonsmokers, 16,534 infrainguinal bypasses were performed. Active smokers were more likely to be younger, male, and of nonwhite race and to have a history of chronic obstructive pulmonary disease (P < .001, all). Nonsmokers were more likely to be functionally dependent and had significantly more comorbidities (ie, hypertension, diabetes, obesity, congestive heart failure, history of previous cardiac surgery or intervention, and dialysis; P < .001, all). The presence of critical limb ischemia was similar in both groups (53.1% of active smokers vs 53.5% of nonsmokers; P = .61). More nonsmokers received a tibial-level bypass than did active smokers (47.8% vs 33.9%; P < .001). There was a trend toward increased early graft failure in active smokers compared with nonsmokers (5.3% vs 4.7%; P = .08). With adjustment for other variables, especially bypass level and graft type, there was an independent association between active smoking and early graft failure (adjusted odds ratio, 1.21; 95% confidence interval, 1.02-1.43; P = .03). Although nonsmokers were significantly older, had more comorbidities, and required more distal revascularization, active smokers still had an increased risk for development of early graft failure. These results stress the need for immediate smoking cessation before lower extremity bypass. Further research is warranted to determine an optimal period of abstinence among smokers with peripheral arterial disease to reduce their risk for early graft failure.

Influência da agressividade do tratamento da Doença Arterial Periférica na cessação tabágica

ObjectivesTo determine in patients with Peripheral Arterial Disease (PAD) whether if the type of treatment and the degree of ischemia influences smoking habits. Material and methodsFrom January 2010 to December 2011 317 smokers were treated, 304 men and 13 women, mean age 66±9,7 years. Of these, 44% were medically managed, 22% underwent endovascular revascularization and 34% surgery. We studied the demographic characteristics of the population, presence of risk factors and cardiovascular events, indications for treatment and smoking cessation after revascularization or during follow-up. ResultsStatistical analysis revealed a higher proportion of patients who stopped smoking when they underwent endovascular procedure compared to those undergoing medical treatment (66% vs. 51%, p=0,036) and also higher when undergoing surgery (66% vs 80% p=0,021). In the endovascular treatment group, 65% of ex-smokers were claudicants and 69% had critical limb ischemia (p=0,36). In the surgical group, the percentage of patients who quit smoking was higher among those with critical limb ischemia compared to claudicants (86% vs 72%, p=0,039). ConclusionsPatients with Peripheral Arterial Disease who are undergoing more invasive revascularization procedures such as surgery, are more likely to quit smoking than those subjected to endovascular or medical treatment. The presence of critical limb ischemia during surgical treatment influenced, in a statistically significant way, smoking cessation. Therefore, the moment of surgical proposal is crucial to promote smoking cessation.

Current efficacy of open and endovascular interventions for advanced superficial femoral artery occlusive disease

There has been a marked paradigm shift in the treatment of symptomatic femoro-popliteal disease with a shift from open to endoluminal therapy. The consequence of this shift in therapy is poorly described. The aim of this study is to examine the clinical efficacy of this shift in treatment strategies. A database of patients undergoing open (OPEN) and endoluminal (ENDO) intervention for TASC II C and D femoro-popliteal lesions between 1990 and 2010 was retrospectively queried. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a multivariant Cox proportional hazard model for time-dependent variables. A total of 2593 limbs underwent either OPEN or ENDO treatment for symptomatic and anatomically advanced femoro-popliteal disease over a 20-year period. There was a two-fold rise in endovascular interventions between the first and second decade. In the first decade, 80% of the interventions were OPEN, while in the second decade, 61% of the interventions were ENDO. There were equivalent comorbidities in both groups, and survival was also equivalent. Endoluminal therapy was more commonly performed on claudicants. Thirty-day mortality was equivalent, but major morbidity was higher in OPEN compared with ENDO. Cumulative patency was equivalent in both groups with a similar reintervention rate. In contrast, clinical efficacy (freedom from recurrent symptoms, maintenance of ambulation, and avoidance of major amputation) was significantly higher in the OPEN group (P= .002). The presence of critical limb ischemia, diabetes, end-stage renal disease, and poor tibial runoff were predictors of poor anatomic and functional outcomes in both groups. There has been a marked shift in treatment modality for advanced femoro-popliteal disease with a lowering of the symptomatic threshold for intervention over 2 decades, likely spurred by the ease of endoluminal interventions. Although peri-procedural and anatomic outcomes for both procedures are equivalent, it appears that open surgery carries a superior long-term clinical efficacy. This superiority is negatively influenced by poor preoperative ambulation status, high modified Cardiac Risk Score, worse presenting symptoms, the occurrence of major adverse cardiovascular events, poor tibial runoff, the absence of hemodynamic success, and occlusion of the original bypass.

Preoperative Smoking Cessation is Essential in Preventing Early Graft Failure after Infrainguinal Bypass Surgery

Smoking has been implicated as the single most important risk factor for the development of peripheral arterial disease (PAD). While previous studies have found poor long-term outcomes in smokers undergoing lower extremity bypass, little data exists as to the effects of persistent tobacco abuse on the early outcomes of infrainguinal bypass on a national level. The American College of Surgeons-National Surgical Quality Improvement Program database from 2005-2011 was queried for all patients undergoing infrainguinal bypass. A bivariate analysis was done to assess pre- and intraoperative risk factors for the primary outcome of 30-day graft failure stratified by current smoking status. The American College of Surgeons-National Surgical Quality Improvement Program considers patients to be nonsmokers if they did not smoke for 12 months prior to surgery. Multivariable logistic regression was conducted to assess the independent association of active smoking status with graft failure. 17,147 infrainguinal bypasses were performed in 7008 (41%) active smokers and 10,139 (59%) nonsmokers. Active smokers were more likely to be younger, male, black race, and have a history of chronic obstructive pulmonary disease (P < .001; all). Nonsmokers were more likely to be functionally dependent and had significantly more comorbidities (ie, hypertension, overweight or obese, diabetes, congestive heart failure, history of previous cardiac surgery or intervention, and dialysis (P < .001; all). The presence of critical limb ischemia was similar in both groups (47% of active smokers vs 46% of nonsmokers; P = .54). More nonsmokers received a tibial level bypass than active smokers (47% vs 34%; P < .001). There was a trend toward increased early graft failure in active smokers compared with nonsmokers (5.5 vs 4.8%; P = .06). When adjusting for other variables, especially level of bypass, there was an independent association between active smoking and early graft failure on multivariable analysis (adjusted OR, 1.22; 95% CI, 1.04-1.42; P = .01). Although nonsmokers were significantly older, had more comorbidities, and required more distal revascularization, active smokers still had an increased risk for developing early graft failure. These results stress the need for smoking cessation prior to lower extremity bypass. Further research is warranted to determine an optimal period of abstinence among smokers with PAD to reduce their risk for early graft failure.

Determinants of intermediate term clinical outcome after endovascular below-knee interventions

To determine predictors of clinical outcome after endovascular interventions of crural arteries in patients with peripheral arterial disease. We prospectively followed 154 limbs in 147 patients treated with below the knee endovascular interventions for critical limb ischemia (52 %) and severe claudication (48 %). Patient-immanent, hemodynamic-procedural and anatomic determinants of outcome were analyzed. Outcome was defined as event-free survival from the combined endpoint freedom from re-intervention, major amputation and death. Cumulative event-free survival after 12 months was 65.1 %. During follow-up 42 patients (27.3 %) required re-intervention, 8 (5.2 %) underwent major amputation and 5 (3.2 %) died. In univariate analyses, the presence of critical limb ischemia, multilevel disease, age > 72 years, impaired renal function, and long lesions (> 65 mm) were significant determinants of the study endpoint. The anatomic location of the lesion, distal patency of treated artery below the ankle, cardiovascular risk factors or concomitant cardiovascular diseases, and the type of postinterventional antithrombotic treatment did not influence outcome. Below-knee interventions resulted in acceptable procedural mid-term results and high rates of amputation free survival. Multilevel disease, long lesions and impaired renal function were indicative of a worse outcome.

Arterial Duplex Imaging of Lower-Extremity Arteries and Interventions

The application of duplex ultrasound for the evaluation of patients with lower-limb arterial occlusive disease provides the clinician with detailed information on its location, extent, and severity. Duplex scanning from the visceral aortic segment to the tibial arteries allows the detection of aneurysms and occlusive disease with a classification of its severity, including the presence of critical limb ischemia. Testing should be performed in conjunction with limb pressure measurements to accurately categorize arterial hemodynamics and functional impairment. Interpretation of duplex-acquired velocity spectra recordings is fundamental to successful clinical evaluation, including the characteristic features of normal versus and abnormal lower-limb arterial flow and hemodynamic changes associated with stenosis both at the occlusive lesions and its impact on distal limb perfusion. Duplex testing is accurate both before and after intervention for the diagnosis of occlusion and stenosis severity allowing decisions regarding treatment (medical, open surgical repair, endovascular therapy) to be made. Scanning can provide an arterial map of occlusive or aneurysm lesions analogous to magnetic resonance or computed-tomography angiography. An important duplex ultrasound application is for the surveillance of lower-limb bypass grafts and peripheral angioplasty for the development of stenosis that is their common mode of failure. The detection of high-grade stenosis in an arterial repair allows for pre-emptive treatment before thrombosis and improves long-term patency.

PREDICTORS OF EARLY MORTALITY IN PATIENTS WITH CRITICAL LIMB ISCHEMIA CAUSED BY ISOLATED BELOW-THE-KNEE ARTERY DISEASE

It has already been reported that presence of critical limb ischemia (CLI) associated with high mortality. In this study, we sought to investigate the predictors of early mortality in patients with CLI caused by isolated below-the-knee (BTK) artery disease. This study was multicenter retrospective

Technique, Complication, and Long-Term Outcome for Endovascular Treatment of Iliac Artery Occlusion

The aim of this study was to report technical details, procedure-related complications, and results of endovascular treatment in chronic iliac artery occlusion. Between 2001 and 2008, endovascular treatments of 127 chronic iliac artery occlusions in 118 patients (8 women and 110 men; mean age, 59 years) were retrospectively reviewed. The study was based on Ad Hoc Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery Standards). All occlusions were treated with stent placement with or without preliminary balloon angioplasty. Kaplan-Meier estimators were used to determine patency rates. Univariate and multivariate analyses were performed to determine variables affecting successful recanalization, major complications, early stent thrombosis (<or=30 days), and primary and secondary patency rates. Initial technical success was achieved in 117 (92%) procedures. Successful recanalization was obtained by antegrade approach in 69 of 77 (90%) procedures and by retrograde approach in 52 of 105 (50%) procedures (p < 0.001). Complications were encountered in 28 (24%) patients [minor in 7 patients (6%) and major in 22 patients (19%)]. One death occurred in the operative period secondary to iliac artery rupture. Early stent thrombosis was seen in eight (7%) patients. Presence of critical limb ischemia (p = 0.03), subintimal recanalization (p = 0.03), and major complication (p = 0.02) were the independent predictors of early stent thrombosis on multivariate analysis. Primary and secondary patency rates at 5 years were 63 and 93%, respectively. Presence of critical limb ischemia, TASC type C iliac lesions, combined occlusions of both common and external iliac arteries, and major complications were associated with decreased patency rates on univariate analysis, whereas these factors were not independent predictors of stent patency on multivariate analysis. In conclusion, endovascular treatment of iliac artery occlusion has a high technical success rate with favorable long-term patency rate. Success of recanalization increases with use of the antegrade approach and with the presence of a stump of artery before the occlusion.