Comparison of mortality and amputation after lower extremity bypass versus peripheral vascular intervention in patients with chronic limb-threatening ischemia and comorbid chronic kidney disease.

OBJECTIVE: Comorbid chronic kidney disease (CKD) is associated with worse outcomes for patients with chronic limb-threatening ischemia (CLTI). However, comparative effectiveness data are limited for lower extremity bypass (LEB) vs peripheral vascular intervention (PVI) in patients with CLTI and CKD. We aimed to evaluate (1) 30-day all-cause mortality and amputation and (2) 5-year all-cause mortality and amputation for LEB vs PVI in patients with comorbid CKD. METHODS: Individuals who underwent LEB and PVI were queried from the Vascular Quality Initiative with Medicare claims-linked outcomes data. Propensity scores were calculated using 13 variables, and a 1:1 matching method was used. The mortality risk at 30 days and 5 years in LEB vs PVI by CKD was assessed using Kaplan-Meier and Cox proportional hazards models, with interaction terms added for CKD. For amputation, cumulative incidence functions and Fine-Gray models were used to account for the competing risk of death, with interaction terms for CKD added. RESULTS: Of 4084 patients (2042 per group), the mean age was 71.0 ± 10.8 years, and 69.0% were male. Irrespective of CKD status, 30-day mortality (hazard ratio [HR]: 0.94, 95% confidence interval [CI]: 0.63-1.42, P = .78) was similar for LEB vs PVI, but LEB was associated with a lower risk of 30-day amputation (sub-HR [sHR]: 0.66, 95% CI: 0.44-0.97, P = .04). CKD status, however, did not modify these results. Similarly, LEB vs PVI was associated with a lower risk of 5-year mortality (HR: 0.79, 95% CI: 0.71-0.88, P < .001) but no difference in 5-year amputation (sHR: 1.03, 95% CI: 0.89-1.20, P = .67). CKD status did not modify these results. CONCLUSIONS: Regardless of CKD status, patients had a lower risk of 5-year all-cause mortality and 30-day amputation with LEB vs PVI. Results may help inform preference-sensitive treatment decisions on LEB vs PVI for patients with CLTI and CKD, who may commonly be deemed too high risk for surgery.

Evaluación de resultados en una serie de pacientes con reparación de aneurimas aórticos mediante endoprótesis fenestradas / Evaluation of results in a series of patients with repair of aortic aneurims by fenestrated graft stent

Resumen Introducción: el aneurisma de aorta tiene una prevalencia de 5,7%; sin tratamiento su desenlace final es la ruptura y en ocasiones la muerte. En la actualidad, existe el reparo endovascular mediante prótesis fenestradas para pacientes en quienes es inviable el procedimiento quirúrgico. Están diseñadas para adaptarse a la anatomía única de cada paciente y dan cabida al flujo de uno o más vasos viscerales logrando resultados satisfactorios. Objetivo: reportar una serie de casos de pacientes con aneurismas de aorta tratados mediante endoprótesis fenestradas en un centro de referencia cardiovascular de Medellín, Colombia, entre 2013 y 2017. Método: estudio descriptivo, restrospectivo, de una serie de casos, cuya información se obtuvo por medio de una fuente secundaria. Resultados: los resultados se presentaron como porcentajes y frecuencias. Se utilizó el programa SPSS versión 20.0. La mayoría de los pacientes fueron hombres, con promedio de edad de 69,5 ±7,9 años. La mediana del diámetro aneurismático fue de 6,0 cm (RIQ 5,0-8,25). La mayoría de las complicaciones fueron vasculares. El 80,0% de los pacientes tuvieron algún seguimiento radiológico al mes, 6 meses o a los 12 meses después de la intervención; el 100,0% requirió revascularización del o los vasos intervenidos. Conclusiones: se considera que el balance adecuado entre riesgos y beneficios que otorga la técnica hace que, para el grupo específico de pacientes cuyas características clínicas y anatómicas hacen poco factible la cirugía, el uso de las prótesis fenestradas sea seguro y tenga resultados clínicos y de supervivencia similares al compararse con la literatura.

Abstract Introduction: Aortic aneurysm has a prevalence of 5.7%. Its final outcome without is a rupture, and occasionally death. Endovascular repair can currently be carried out using a fenestrated stent graft in patients in whom a surgical procedure is not feasible. These grafts are designed to adapt to the unique anatomy of each patient, and makes room for one or more visceral vessels to flow, achieving satisfactory results. Objective: To report a case series of patients with aortic aneurysms treated with a fenestrated stent graft between 2013 and 2017 in a cardiovascular reference centre in Medellín, Colombia. Method: A descriptive, retrospective study was conducted on a case series, in which the information was obtained for a secondary source. The results are presented as percentages and frequencies. The statistics program SPSS version 20.00 was used. Results: The majority of patients were male, and the mean age was 69.5 ±7.9 years. The median aneurysm diameter was 6.0 cm (IQR 5.0-8.25). The majority of complications were vascular. Some type of radiological follow-up was carried out on 80% of the patients at one month, 6 months, and 12 months after the intervention. All of them (100%) required revascularisation of the vessels intervened. Conclusions: The risk-benefit ratio is considered adequate for this technique. It means that, for the specific group of patients that have clinical and anatomical characteristics that make surgery highly unlikely, the use of fenestrated stent grafts are safe, and have similar clinical and survival results when compared with the literature.