Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia.

BACKGROUND: Percutaneous transluminal angioplasty has been used with increasing frequency in the treatment of infrainguinal arterial occlusive disease. This meta-analysis aimed to assess the middle-term outcomes after crural angioplasty in patients with chronic critical limb ischemia and compare results with a meta-analysis of popliteal-to-distal vein bypass graft. METHODS: Data were retrieved from 30 articles published from 1990 through 2006 (63% of articles published between 2000 and 2006). All studies used survival analysis, reported a 12-month cumulative rate of patency or limb salvage, and included at least 15 infrapopliteal angioplasties. The outcome measures were immediate technical success, primary and secondary patency, limb salvage, and patient survival. Data from life-tables, survival curves, and texts were used. RESULTS: The pooled estimate of success was 89.0% +/- 2.2% for immediate technical result. Results at 1 and 36 months were 77.4% +/- 4.1% and 48.6% +/- 8.0% for primary patency, 83.3% +/- 1.4% and 62.9% +/- 11.0% for secondary patency, 93.4% +/- 2.3% and 82.4% +/- 3.4% for limb salvage, and 98.3% +/- 0.7% and 68.4% +/- 5.5% for patient survival, respectively. Studies with >75% of the limbs with tissue loss fared worse than their respective comparative subgroup for technical success and patency but not for limb salvage or survival. No publication bias was detected. CONCLUSION: The technical success and subsequent durability of crural angioplasty are limited compared with bypass surgery, but the clinical benefit is acceptable because limb salvage rates are equivalent to bypass surgery. Further studies are necessary to determine the proper role of infrapopliteal angioplasty.

An updated meta-analysis of infrainguinal arterial reconstruction in patients with end-stage renal disease.

BACKGROUND: A previous meta-analysis reported on the mid-term outcomes of infrainguinal bypass grafts in patients with critical limb ischemia and end-stage renal disease. Given the competing interest in endovascular procedures, the results of bypass surgery must be assessed as precisely as possible for future comparison. In this study, the original meta-analysis was refined and updated by increasing the number of studies reviewed, estimating primary graft patency, extending follow-up time, and investigating the problem of early amputation despite a patent graft. METHODS: Studies published from 1987 through 2005 were identified from two electronic databases. Two investigators independently extracted the survival data from life tables, survival curves, and texts. Pooled survival curves were then constructed for graft patency, limb salvage, and patient survival according to a random-effects protocol for meta-analysis. RESULTS: Of 28 articles included, 18 reported amputation despite a patent graft in 84 (10%) out of 844 limbs, and 25 described a perioperative mortality of 88 (8.8%) out of 996 patients. The 5-year pooled estimate (SE) was 50.4% (15.4%) for primary patency, 50.8% (19.0%) for secondary patency, 66.6% (11.2%) for limb salvage, and 23.0% (11.7%) for patient survival. No publication bias was detected. CONCLUSIONS: Limb salvage can be achieved in most end-stage renal disease patients who undergo bypass surgery for critical ischemia, but survival is poor. To avoid early amputation despite a patent graft, bypass grafting should not be offered to patients with a great amount of tissue loss or extensive infection.

Meta-analysis of popliteal-to-distal vein bypass grafts for critical ischemia.

BACKGROUND: Several studies have described the use of popliteal-to-distal bypass grafts, mostly in patients with diabetes mellitus who show tissue loss and represent a high-risk population. The study objective was to conduct meta-analysis to assess the long-term primary and secondary patency and foot preservation after popliteal-to-distal bypass grafts. METHODS: Data was retrieved from studies published from 1981 through 2004 that were identified from an electronic database. Thirty-one series that used survival analysis reported a 1-year graft patency rate and included at least 15 bypasses. Data from life tables, survival curves, and texts were used to calculate an interval success rate for each month in each series of grafts. Monthly success rates were combined across series to obtain a pooled estimate of success for each month, according to a random-effects protocol for meta-analysis. Pooled survival curves were then constructed for graft patency and foot preservation. RESULTS: The 5-year pooled estimate +/- standard error was 63.1% +/- 4.3% for primary patency, 70.7% +/- 4.6% for secondary patency, and 77.7% +/- 4.3% for foot preservation. There was a superiority trend favoring reversed vein grafts and tibial bypasses that became more apparent in sensitivity analysis. No publication bias was detected. CONCLUSION: The popliteal-to-distal vein bypass is a tool of high efficiency in the treatment of severe, chronic critical ischemia in the lower extremity.

Meta-analysis of alternate autologous vein bypass grafts to infrapopliteal arteries.

BACKGROUND: Several studies have described acceptable results for infrapopliteal bypass surgery that uses an autogenous vein other than the greater saphenous vein but is still no reliable prediction of outcomes. The objective of this study was to use meta-analysis to assess the long-term outcomes after infrapopliteal bypass grafting done with alternate autologous veins. METHODS: Studies published from 1982 through 2004 were identified from electronic databases and pertinent original articles. Thirty-two series were selected, all of which had used survival analysis and had reported a 1-year graft patency rate, with at least 15 bypasses. An interval success rate was calculated for each month in each series of grafts by using data from life tables, survival curves, and texts. Monthly success rates were combined across series to obtain a pooled estimate of success for each month. Pooled survival curves were then constructed for graft patency and foot preservation. RESULTS: The 5-year pooled estimates were 46.9% (95% confidence interval [CI] = 35.5%-58.3%) for primary patency, 66.5% (95% CI = 54.9%-78.2%) for secondary patency, and 76.4% (95% CI = 68.0%-84.8%) for foot preservation. These results were far superior to those reported for nonautologous grafts. Intensive duplex surveillance had a favorable impact on graft patency and foot preservation. No publication bias was detected. CONCLUSIONS: When the greater saphenous vein is unavailable, alternate autologous veins are preferable to other graft materials in bypass surgery to infrapopliteal arteries.

Meta-analysis of polytetrafluoroethylene bypass grafts to infrapopliteal arteries.

CONTEXT: Reports of polytetrafluoroethylene (PTFE) bypass grafting to the infrapopliteal arteries have often used survival analysis of acceptable quality to describe a wide range of long-term results. In theory, these results may be combined if variability between series and time intervals is considered. OBJECTIVE: Meta-analysis was performed to gain insight into long-term graft patency and foot preservation after PTFE bypass grafting to infrapopliteal arteries. DATA SOURCE: Studies published from 1982 through 2001 were identified from the PubMed database and pertinent original articles. STUDY SELECTION: Three investigators selected 43 studies that used survival analysis, reported 2-year patency rates, and included at least 15 bypass procedures. Data extraction and transformation: Based on standard life-tables or survivor curves, an interval success rate was calculated for each month in each series. The monthly success rates were combined across series, enabling construction of pooled survivor curves. DATA SYNTHESIS: Random-effects meta-analysis yielded 5-year pooled estimates (SE) of 30.5% (7.6%) for primary graft patency, 39.7% (5.5%) for secondary graft patency, and 55.7% (5.0%) for foot preservation. During the entire follow-up, pooled estimates were slightly higher for series of PTFE grafts with adjunctive procedures compared with series of PTFE grafts only. Sensitivity analysis: A simulation using only unfavorable assumptions showed a decrease of less than 5% at 5 years for all outcomes, and smaller differences at subgroup meta-analysis. Funnel plots suggested that publication bias was unlikely. CONCLUSION: This meta-analysis indicated moderate success for PTFE bypass grafts to infrapopliteal arteries, but the role of adjunctive procedures at the distal anastomosis remains uncertain.

Censo Escolar: controle de qualidade

Apresenta presumidamente a metodologia desenvolvida para a pesquisa de Controle de Qualidade do Censo Escolar, cuja importancia se ampliou a partir da promulgacao da Ementa Constitucional numero 14, que estabeleceu uma relacao entre a alocacao de recursos federais e a quantidade de alunos matriculados no Ensino Fundamental. Descreve a metodologia e a estrutura da pesquisa, indicando os procedimentos amostrais adotados, descrevendo, ainda, os instrumentos de coleta de dados utilizados e os procedimentos propostos para sua auditagem. Conclui com comentarios e recomendacoes sobre as informacoes coletadas.