End-stage renal disease patients undergoing angioplasty and bypass for critical limb ischemia have worse outcomes compared to non-ESRD patients: Systematic review and meta-analysis.

BACKGROUND: End-stage renal disease (ESRD) is associated with increased morbidity and mortality following lower extremity amputation for critical limb ischemia (CLI). Angioplasty and bypass are used in ESRD patients with CLI; however, the treatment of choice remains controversial. We compared the long-term outcomes in patients with CLI undergoing angioplasty or bypass to evaluate the differences between patients with ESRD and those without ESRD. METHODS: Established databases were searched for observational studies comparing outcomes following bypass or angioplasty for CLI in patients with ESRD to those in non-ESRD patients. End points included survival, limb salvage, amputation-free survival (AFS), and primary and secondary patency at 1-year post-procedure. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random effect model. RESULTS: We included 20 studies with a total of 24,851 patients. ESRD patients compared to non-ESRD patients with CLI had significantly lower survival post-angioplasty (OR 0.51, 95% CI 0.36-0.72, p < .001) and post-bypass (OR 0.26, 95% CI 0.15-0.45, p < .001). ESRD patients had lower rates of limb salvage post-bypass (OR 0.33, 95% CI 0.21-0.53, p < .001) and post-angioplasty (OR 0.54, 95% CI 0.41-0.70, p < .001). AFS was significantly lower in ESRD patients compared to non-ESRD patients following angioplasty (OR 0.48, 95% CI 0.32-0.71, p < .001) and bypass (OR 0.28, 95% CI 0.16-0.47, p < .001) despite no significant differences in primary patency. ESRD patients had overall worse secondary patency post-angioplasty and/or bypass (OR 0.54, 95% CI 0.32-0.94, p = .03) compared to non-ESRD patients. A meta-analysis of four studies directly comparing survival in ESRD patients with CLI based on whether they underwent angioplasty or bypass showed no difference (OR 0.93, 95% CI 0.64-1.35, p = .69). CONCLUSION: ESRD patients have worse survival, limb salvage, and AFS outcomes following angioplasty and bypass for CLI compared to non-ESRD patients. Large randomized controlled trials comparing these two modalities of treatment in this patient population are needed for further clarity.

Correlation of Left Atrial Appendage Ejection Velocities with the CHADS2 and CHA2DS2-VASc Scores.

BACKGROUND: In patients with atrial fibrillation or flutter, a left atrial appendage ejection velocity measured via transesophageal echocardiography equal to or less than 40 cm/sec has been shown to correlate with an increased risk of developing left atrial appendage thrombus while velocities greater than 40 cm/sec are at lower risk. The CHADS2 and CHA2DS2-VASc scores calculated from clinical variables have been developed to risk stratify patients with atrial fibrillation/flutter in regard to the need for anticoagulation. This study was designed to assess whether a relationship exists between left atrial appendage ejection velocities and the respective CHADS2 and CHA2DS2-VASc scores, and whether this relationship is affected by the presence of atrial fibrillation or atrial flutter. METHODS: A retrospective chart review was performed on patients in the last 5 years who had undergone a transesophageal echocardiogram in which LAA velocity was measured. Once these patients were identified, relevant clinical information allowing for the calculation of the CHADS2 and CHA2DS2-VASc scores was also extracted from the medical record. RESULTS: Data from a total of 151 patients were included in the study. A statistically significant correlation between LAA velocity and CHADS2 score (P = 0.942) or between LAA velocity and CHA2DS2-VASc scores (P = 0.723) was not found. CONCLUSIONS: We could not identify a relationship between either the CHADS2 or CHA2DS2-VASc scores and LAA velocities. This was true regardless of whether patients were in sinus rhythm or AF at the time of the TEE. While reduced LAA velocities increase the risk of LAA thrombus, the development of stroke in patients with AF is secondary to a complex interplay of multiple clinical variables.